While nursing is a global profession, it has multiple iterations and variations, many of which have developed in relation to local, regional and national policies, politics, norms and traditions. Regardless of the path taken by the profession in any one country, nurses are committed to maintaining the health and wellbeing of the public they serve. Nurses strive to assure care and comfort for their patients by preventing or reducing risk of disease and harm, relieving distressing symptoms, promoting physical and cognitive functioning and maximising quality of life (Fulton and Holly, 2021).
In this era of globalisation, compliance with international standards is an absolute prerequisite for nurses who wish to compete with, and work alongside, others from other countries. This requires nurses to have a professional understanding of the interpersonal and technical aspects of such international standards, as well as a sensitivity to socio-cultural differences, a broad knowledge base and an ability to use technology (Oktaviani and Santoso, 2018).
Early development of nursing
In 1900, Indonesia was a Dutch colony and known as the Dutch East Indies. Over time, and in response to nursing workforce shortages, Dutch colonists trained local Indonesians to become nurses. Colonists offered training to both women and men, the latter of whom were known as Mantri nurses or hulpgeneesheeren (ancillary doctors) (Hesselink, 2015; Juanamasta et al, 2021).
Nursing in Indonesia was still developing when the country gained its independence. While there were 20 different types of practicing nurses, hospital-based nursing education was aimed more at meeting the needs of local hospitals and nurses worked under the supervision of other healthcare staff. The services provided lacked strong scientific-based practice and the workforce lacked accountability. The situation prompted the Indonesian Ministry of Health to establish an academy of nursing in Jakarta in 1962 (Lestari, 2014). Subsequent developments included, but we were not limited to, the implementation of the Indonesian Nursing Act (2014). The Act defined the scope of nursing practice in relation to education, research and practice, and officially certified nurses as government-recognised health professionals (Juanamasta et al, 2021).
Specialist nursing
Specialist nursing education has evolved in response to the rapidly changing health problems and progressively complicated health situations. Specialist nursing is an extended education programme categorised as a MSc programme designed to prepare nurses with specific advanced knowledge, skills and competencies beyond the level of a nurse generalist to deliver safe, good-quality patient care (Jokiniemi and Miettinen, 2020). The advanced competencies emphasise scientific and evidence-based skills, which should be used to enhance the quality of nursing care. The advanced competencies also stress the importance of systematic problem-solving skills, research, the application of scientific principles and areas of specialisation (Persatuan Perawat Nasional Indonesia et al, 2013).
To meet the needs of specialist nurses, several Indonesian public universities pioneered specialist nursing education programmes. Several variations of nursing specialist programmes have emerged across the country (McKenna et al, 2023). Specialist nursing programmes were first established in 1999 by the University of Indonesia, which formed the postgraduate Master of Nursing, Nursing Leadership and Management programme (McKenna et al, 2023). Between 2003 and 2007, the University introduced maternity, community, medical surgical, psychiatric and paediatric specialist nursing programmes. The most recent of these specialist nursing programmes at the University of Indonesia are oncology and gerontic nursing, which opened in 2020 and 2021, respectively.
In 2009, Padjajaran University released its own specialist programmes in community nursing and critical care nursing; it then went on to expand into paediatric and maternity nursing in 2011 (Casman et al, 2020). In the same year, Gadjah Mada University proposed an advanced nursing programme that specialised in pediatric, medical-surgical and maternity nursing. Airlangga University launched a similar programme that focused on medical-surgical specialists in 2020 (Efendi et al, 2018).
In Indonesia, becoming a clinical nurse specialist, as part of advanced practice nursing, can be achieved in two ways:
Clinical nurse specialist candidates should apply for a nurse specialist education programme and take a clinical residency for 2 or 3 semesters, based on their specialty area. It is expected that a nursing specialist graduate will take a consultation, supervisor and preceptorship role after they have graduated. The nursing specialist programme aims to produce graduates who can:
Develop the profession by mastering and understanding approaches, methods and scientific principles
Advanced practice nursing creates a path for nurses to effectively respond to the complexities and changes in healthcare. Though the effectiveness and professionalism of specialist nurses, patients will directly reduce their medical costs. For example, nurse specialists will provide comprehensive nursing care to patients, including their consultation, treatment and education, which will reduce the amount of required referrals, eliminate unnecessary administration and streamline time for patients (Nugraeni, 2022).
Challenges
Although many specialist nursing programmes have emerged and the number of clinical nurse specialists has increased, there are still some unaddressed challenges in Indonesia. Government policies on the planning and use of nursing personnel in service settings, both in terms of levels, types, numbers and distribution, are still not in line with the demands of society, scientific challenges and the development rate of technology and education. This has resulted in nursing specialist graduates preferring to work in educational institutions as lecturers and educators, rather than in hospital settings.
In addition, many clinical nurses with extensive clinical experience and high clinical competency qualifications—equivalent to specialist qualifications—are not recognised as specialist nurses, because they have not undertaken a formal specialist education programme (Casman et al, 2020). Despite the need, the nursing education sector has not yet been able to produce an effective recognition scheme that appropriately addresses this issue; therefore, the differences between general nurses and specialist nurses in the workplace remain unclear. In addition, the clinical career path system for hospital nurses still focuses on work experience and a general nurse education background as a basis for promotion (Ministry of Health of the Republic of Indonesia, 2017); this needs to be expanded to include the education background specialist nurse.
Other limiting factors are also at play. First, the training and working conditions of specialist nurses in Indonesia are not favourable. For example, specialist nurses have to study for an extended time, which also incurs a high financial cost; these factors reduce the desire of the nursing workforce to specialise (Oktaviani and Santoso, 2018; Nugraeni, 2022). In addition, specialist nurses can be assigned to assist general nurses in the workplace. While this is predominantly because of labour shortages, and is not a comment on specialist nurses' capacity and knowledge base, it can make some feel that they are no different from general nurses, and have needlessly gone through an expensive specialisation process (Oktaviani and Santoso, 2018; Nugraeni, 2022).
Moving forwards
While Law No. 38/2014 on nursing has been passed, specialist nurses are still employed as general nurses, and there continues to be no clear distinction between the two roles. The existence and duties of specialist nurses are not clearly defined in the eyes of the public or hospital systems. The development of nursing specialisation has not been well publicised over the past two decades, and it is not possible to assume that scope of practice, educational standards and nursing practice have been uniformly implemented throughout Indonesia (Oktaviani and Santoso, 2018).
Therefore, it is essential that the development and demand for specialist nurses are established and clarified on a national level. Government regulatory bodies, professional organisations, educational institutions and healthcare facilities must work together to determine policies that can benefit specialist nurses and positively impact the nursing workforce in Indonesia. Government and hospitals must ensure that specialist nurses receive salaries and workloads that suit their respective capacities and specialities. Public education is also needed to normalise holistic and complete treatment from specialist nurses, in accordance with their scientific fields.