Experience of Nurses in Providing Emergency Services in Ponelo Island: A Qualitative Study

Received 13 February 2021 Accepted 4 August 2021 Published 5 September 2021 An emergency involves many aspects, such as health workers, families, medical equipment and adequate health service facilities. The nurse is a health worker who can save a patient's life. Emergency services in remote areas allow nurses to face several threats and challenges. The community has the view that a nurse must be able to provide all health services in a complete manner, including treatment. This study aims to explore the experiences of nurses in emergency services in the Ponelo Islands, North Gorontalo district. The research design used was qualitative with an interpretive phenomenology approach. In-depth interviews with informants, which involved 3 participants who acted as implementing nurses at the community health center in Ponelo Island area. This study resulted in four themes, namely having concern for patients who need help, the helplessness of nurses to perform first aid in emergency cases, feeling anxious when referring patients and the importance of developing quality resources and medical center service facilities. The conclusion of the results of this study is that the limited number of nurses, the lack of development through training in emergency services and inadequate public health center service facilities causes the implementation of emergency services to be not optimal. Keyword:

The Ponelo community health center which is located in Ponelo Village, Kepulauan District of North Gorontalo Regency, is a community health center that provides services to the community in four villages, namely Ponelo Village, Malambe Village, Otiola Village and Tihengo Village. Preliminary studies show that the development of community health center services is increasingly complex, but the fact is that these developments are not accompanied by adequate facilities and human resources. The executive nurse coordinator said that the number of nurses was still lacking, the training that was attended was still lacking, especially training in emergency service management, and the workload of being a program holder in a community health center. In addition, the facilities are still lacking. This dual role and limited personnel and facilities can make emergency services less optimal.
Another problem that was found was the difficulty of access to the community health center, which made the community not get treatment, so that the nurses provided direct care to each of the inter-island houses around the Ponelo community health center. Based on the description of the problem above, the researcher wants to explore the experience of nurses through a qualitative study using a phenomenological approach to emergency services in the Ponelo Islands.

METHOD
This research is a qualitative study using an interpretive phenomenology approach. This research was conducted at Ponelo Medical Center, North Gorontalo District. The participants of this research were the executive nurses. Data were collected using in-depth interviews. The transcripts of the interview results were then analyzed using the hermeneutic analysis method (Polit& Beck, 2012). The stages of data analysis include: The researcher reads the entire text of the interview results to gain understanding, the researcher interprets each text of the interview summary results, analyzes the selected interview transcript, returns the analysis results to the original text if there are differences in data interpretation, identifies the main meaning by comparing meanings main or theme with the text of the interview results, linking emerging themes.

RESULTS AND DISCUSSION
The results of the study are based on the research objectives, namely exploring the experience of implementing nurses in emergency services in the Ponelo archipelago, North Gorontalo Regency, the researchers found five research themes including: 1) Having concern for patients who need help, 2) The helplessness of nurses in carrying out first aid in emergency cases , 3) Feelings of anxiety when referring patients, 4) The importance of developing the quality of resources and public health center service facilities. The description of the themes and sub themes is as follows: 1.Having concern for patients who need help The theme of having concern for patients who need help is conveyed in categories including: feeling proud to be able to provide help to others, feeling happy to help overcome health problems experienced by others. The theme of having concern for patients who need help was conveyed by three participants with the following statements : "..I am proud to be able to serve the community, because I already have a registration certificate, so I am proud to be able to serve them .." (P1) "..I am happy to help other people, overcome their health problems .." (P2) ".. Actions of hecting wounds, wounds caused by machetes, ..., due to traffic accidents, .., some were stepped on by sharp rocks, .., fishermen were stabbed with hooks, .., some were hit by fish punctures. .. "(P3).
Contextually, having concern for patients in this study means that participants take actions taken by participants on patients during the emergency service process so that they continue to get good service. The theme of having concern for the patient in this study shows that the participants have characteristics in accordance with Caring's theory which was initiated by the nursing figure, Jean Watson. The nature of caring shown by the participants appears in the sub-themes that build this theme, namely, feeling happy in providing help to patients to overcome health problems suffered, where the relationship built by nurses as caregivers and patients as recipients of nursing care is aimed at increasing ability. the patient as an individual to recover is influenced by the efforts of the nurse to protect the patient. The nurse is also responsible for helping patients to gain knowledge and try to improve their health as the essence of the nurse client relationship in nursing. In addition, Watson also argues that the essence of nursing is caring, that is, in providing health services, a nurse must be able to realize all the Caring factors for the client as someone who needs help (Alligood, 2017).
Watson also revealed that nurses as health workers who provide services in their efforts to help patients regain inner harmony by providing knowledge, self-control and patient readiness for recovery. Watson further said that nurses must be able to demonstrate their quality as professionals by Experience of Nurses in Providing Emergency Services in Ponelo Island: A Qualitative Study providing nursing services based on science and a code of ethics as a commitment to Caring's character.
The caring process that the participants showed in this study was not only by providing the best possible service for the safety of patients who needed emergency care, but also by the participants trying to bring their heart into each service. This is reflected in the sub-theme of feeling proud in providing services to the community. This is also in accordance with what Watson expressed that each individual is unique and gives different responses to the suffering he is experiencing so that an understanding of a nurse is needed when providing nursing care to the various responses that the patient displays, both current and future (Alligood, 2017). In addition, as an interpersonal relationship between a nurse and a client, caring must be shown in the form of attention and intervention that can maintain the client's health and provide positive energy in their relationship.

2.The helplessness of nurses in carrying out first aid in emergency cases
The theme of the helplessness of nurses in performing first aid in emergency cases consists of three sub-themes, namely: lack of training, feeling tired of doing aid, fear of lawsuits. The first sub-theme of the lack of training that was followed was conveyed by the participants including: many patients who experienced emergencies, such as cardiac arrest but were not helped because the nurses did not know how to do help. The sub-theme of the lack of training that was followed was conveyed by two participants with the following statement : ".. Many patients undergo cardiac arrest, but it is not helped because I do not know how to handle it .." (P3) "... later yesterday, after I attended the training, it turned out like that helping patients in cardiac arrest .." (P2) The second sub-theme is feeling tired of doing the help conveyed by the participants, including: handling in emergency services to the community is only done by one nurse who has a registration certificate, besides that the nurse directly handles the patient's house in four villages in one sub-district. This sub-theme was conveyed by one participant with the following statement: "..Sometimes, because I have served four villages in one sub-district, I feel tired .." (P3) "... the family of the community told me, I did help, I still had time to do cardiopulmonary resuscitation, but because I was alone, I felt tired, even though I had done CPR, there was still a response, because I was tired, the patient was. could not be saved .. "(P3) "... the patients only do services in their own homes, I feel so tired ..." (P3) The third sub-theme is the fear of lawsuits submitted by the participants, including: giving treatment outside their authority, but the community has the view that a nurse must be able to provide all health services including treatment. This sub-theme was conveyed by one participant with the following statement : "... the services I provide are in the form of injection and hecting .." (P3) "... when I do not have the authority of nurses, I feel insecure .." (P3).
In this study, one of the causes of the helplessness of nurses to perform first aid in emergency cases is the lack of training in providing emergency assistance. The importance of training for nurses can increase the self-efficacy of nurses in handling emergency services. The results showed that training in the form of educational workshops could increase the self-efficacy of nurses. Self-efficacy is an individual's selfperception of a person's ability to perform competently and to achieve tasks or goals effectively (Sheikhbardsiri et al., 2019).
Another cause of the nurse's helplessness is feeling tired of doing help. The cause of nurses feeling tired, namely the lack of nurses and services provided by nurses who come directly to patients' homes after the implementation of services at medical centers. The results showed that nurses who worked more than 12 consecutive hours and exceeded their work capacity could have a fatigue effect on nurses, and could have an effect of insufficient sleep which could endanger health (Rogers, 2008).
Handling outside the authority of the nurse, raises fear of lawsuits, but the view of the community that a nurse, must be able to provide all health services including treatment. Despite increasing attention to the quality of health care services, there are still many threats to patient safety in health care settings. Because patient safety is multidimensional and based on ethical and legal imperatives, ethical and legal challenges must be considered. This can be facilitated by encouraging multidisciplinary collaboration for transparent reporting of medical errors as well as active participation of patients and their families in detecting medical errors. In addition, the provision of emotional support and legal protection to staff by the organization is essential to encourage voluntary incident reporting. In addition, training and an emphasis on professional codes of ethics can be effective in deepening understanding and belief in the moral foundation of patient safety (Kadivar et al., 2017).

3.Feelings of anxiety when referring patients
The theme of feeling anxious when referring patients is presented in categories including: the difficulty of the vehicle to use when referring to it and the time taken during the trip is approximately 1 hour 20 minutes. This theme was conveyed by one participant with the following statement : ".. Likewise when I refer, there is a feeling of anxiety, not if there are no vehicles, sometimes if the water recedes it can't be .." (P3) "... usually it takes 1 hour from the public health center to the Kwandang port, from the port to the hospital it might have arrived 20 minutes .." (P3).
In this study, one of the causes for nurses to feel anxious when referring patients is the lack of transportation facilities and equipment used in emergency services for the community. Transfer of patients from medical centers to other facilities or hospitals is an important matter to note. The decision to move a patient is based on a more complete care facility against the potential risks that will occur. There are many risks that need to be considered in transferring critically ill patients, namely in the form of medical care facilities, transportation and time for referrals. Disorganized patient transfer can significantly contribute to the morbidity and mortality of referred patients (Kulshrestha & Singh, 2016). Improving the referral system to improve patient safety is one of the top five priorities as standardized in saving patients before arriving at the hospital. Designing an appropriate environment, providing adequate equipment, recruiting the appropriate workforce, and clarifying all the needs needed in emergency services, into several strategies to increase good and standard patient referrals (Kalyani et al., 2019).

4.The importance of developing the quality of resources and public health center service facilities
The theme of the importance of developing the quality of resources and public health center service facilities consists of three sub-themes, namely: increasing the number of nurses, road access, and completeness of facilities in community health center services. The first sub-theme of increasing the number of nurses delivered by the participants included: additional nurses who were divided into each village, making it easier to provide services to the community. This sub-theme was conveyed by one participant with the following statement : "... if the actions are the same as the CPR, only myself will do it .." (P3) ".. if possible, plus health workers such as nurses, which can be divided into one nurse in each village there is one nurse .." (P3) The second sub-theme is road access delivered by the participants, including: no road access from the community's house to health facilities, the journey is only walking distance, besides that, there is no sea ambulance access. This sub-theme was conveyed by three participants with the following statements : "..because there are no roads, only footpaths, during the rainy season you cannot use a motorbike, only on foot .." (P1) ".. It's difficult, there are no roads, it's still forests .." (P2) "... there's only a path ..." (P2) "..The first obstacle is no road access .." (P3) "... actually the patient should come, but the road is not good, so patients are also prevented from coming to the community health center ..." (P3) "... it takes a complete marine ambulance ..." (P3) The third sub-theme was the completeness of facilities at the community health center services conveyed by the participants including: the absence of oxygen facilities, Bag Valve Mask, hecting sets and other equipment needed in emergency services. This sub-theme was conveyed by one participant with the following statement : ".. the facilities in the community health center are still lacking, oxygen is not even available .." (P3) "... BVM, still help with that, Alhamdulillah the patient was safe, because at that time two people were helped, but the equipment was below from the health department ..." (P3) "..The treatment of wounds in a community health center, sometimes there are no tools, the instruments are incomplete, so just situational .."(P3).
Optimal emergency care is difficult, due to a lack of nurses, quality development of health personnel and lack of facilities in community health center services. The number of appropriate nurses will be significant with the services provided, this is in accordance with a literature study conducted by (Griffiths et al., 2018), it was found that seventy-five percent or more, nurses could not perform optimally in service, due to the lack of nurses. Adequacy of nursing staff can improve health services properly and optimally.
In addition, the development of the quality of health personnel can significantly provide good service to patients or the community. This is in accordance with research by (Worsley et al., 2016), it was found that training could improve the quality of employment of all health professionals. Through training, it can improve the ability of health workers to respond effectively, improve the right skills in handling patients effectively.

CONCLUSIONS AND RECOMMENDATION
The description of the experience of nurses in carrying out emergency services in the Ponelo islands area is not optimal, due to limited nursing personnel, lack of development through training in emergency services and inadequate community health center service facilities.

Recommendation
Recommendation for further research who are interested in the topic of emergency services in the archipelago, namely to be able to continue similar research, assess in detail the needs of facilities and infrastructure and assess the effectiveness of emergency services.