INDICATORS OF COMPLIANCE PRESSURE FOR NURSE IN IMPLEMENTING PROCEDURES : A QUALITATIVE APPROACH

ABSTRACT


INTRODUCTION
Safety is a fundamental principle of patient care and a critical component of quality management. Health care service providers contribute to the occurrence of errors threatening the client's safety. Nurse compliance in the application of the standard procedure is the success parameter in nursing services and one of the most important goals in human resource management (Hall, 2003).
Even though every hospital already had its own standard procedure regarding patient safety, some work behavior shown by nurses suggests that they are still lacking in complying with the administering of measure procedures. Hospital's Patient Safety Committees in Indonesia reported 145 patient safety incidents, 11% of which were in East Java (Systems & City, n.d.). The result of initial research at Islamic Hospitals in March 2018, suggested the happenings of phlebitic (6.6%), wound infection (5.3%) at several wards exceeded the minimum standard of ≤ 1,5%.
Nurse behavior in performing compliance with the standard procedure is affected by many factors, both internal from personal characteristics like intelligence level, experience, attitude, or external factors like others' influence, environment, leadership, organizational culture, and system. Both factors are affecting each other in shaping one's behavior (Werder & Ees, 2007).
Interligi (2010), describing that the process of employee compliance is developed upon the interaction between the environment and the organization as well as the interaction between the organization and the employees, where the purpose of the organization is to influence and shape their employees' behavior. The organization applies various policies, rules, processes, and procedures as well as norms in influencing employee behavior (Anthony, Johnson, & Anthony, 2009).
An organization needs to develop other mechanisms to complete the existing rules, guidelines, and procedures to improve employee awareness to comply with the procedure of patient safety. The Mechanism should not be obtained through policymaking or pressing regulation, but instead, it is developed from the basis of values applied in the organization of which can be positive pressure to employees when they are made habits in the working process (Ciancio, 2004).
Pressure, not always assumed negative. The organization is obliged to establish mechanisms that are based on rules and work culture, so that something that is considered negative by employees if implemented positively, will be able to change one's work behavior. Behavioral change and compliant habituation can be encouraged by growing an individual's internal values, feeling comfortable, feeling autonomy, and recognition from the organization. The strengthening can be obtained from the leadership of the head of space at the smallest level and management at the organizational level. It is undeniable that the role of the leader and the values that are implanted are closely related to encouraging employee performance achievement (Amenta, Ramsey, Amenta, & Ramsey, 2010).
Previous explanations show that building compliance behavior is not easy. Compliance pressure from organizations perceived as positive pressure and internalized will be a strong basis for compliance. Finally, the researchers focused on new things in this study is to find what indicators are the basis for building nurse's compliance in carrying out procedures

METHOD
The design of the study was using a qualitative study with a phenomenological approach. This type of research design provides a thick description of the phenomenon what indicators are the basis for building nurse's compliance in carrying out procedures. The study was conducted at Islamic Hospitals and Public Hospitals in Mojokerto. This qualitative study used the purposive sampling method to choose participants to contribute to the research. The study used 20 respondents, taking into account the selection criteria of respondents, namely senior nurses, having experience as team leaders, working for a minimum of 5 years, having good qualifications based on the results of leadership monitoring. The data collected in this study used in-depth interviews with open-ended and semistructured questions to all participants by the primary author. All data were recorded to a tape recorder for verbal data and field notes for non-verbal expressions. The interview terminated when the data attained the information depth justified by the researcher as the instrument itself. Afterward, the data were listened to repeatedly and shifted into a verbatim transcript. The transcripts and field notes were combined to complement the suitability of the data collected. The transcripts were then sorted to find significant statements of the participants. These were then classified into categories, which were grouped into themes and sub-themes. The themes were written in a thoughtful and representative narrative form, to make them easy to understand. The analysis and the results were obliged to the qualitative data validities by ensuring credibility, transferability, dependability, and conformability. This research strictly provides autonomy, beneficence, non-maleficence, confidentiality, and justice.  Table 1 shows, the majority of respondents, female sex, middle age, three diploma education, working period span >5 years, and have attended training 2-3 times. In addition to the characteristics of the respondents, the results of in-depth interviews obtained 8 dimensions of compliance pressure for nurses in implementing procedures as follows: 1. Guidelines in the form of rules and policies.

RESULTS
Obligation to obey the rules and policies implemented by the hospital is a concern that is the basis for the emergence of compliance in implementing SPO.

DISCUSSION
Compliance is a critical management function in the organization. Compliance management contains organizational rules and processes for complying with rules and policies. Management must be able to monitor the implementation of the stability of policies, procedures, and responsibilities for employee performance. The presence of internal and external pressures has an impact on changes that policies, procedures, and controls added to the management structure will affect employee compliance (Chen, 2004).
Implementation of quality services requires employees and leaders who are proactive and willing to contribute to investigations, problem-solving, and continue to strive to perform well. One important thing is culture, which impacts proactive behavior. Employees will be motivated to comply if they work in a culture where there is trust, good relations between leaders and employees, effective communication, and a process of control with integrity. A culture of obedience is very much needed to create conditions where everyone will work by understanding the goals, communicating clearly and consistently, effective reporting and monitoring, and efficient corrective actions (Dan, Uji, & Teori, 2007).
The description of various compliance pressure indicators that contribute to building nurse compliance in implementing standard procedures is as follows: 1. Rules and policies Rules and policies are legally binding guidelines, including written guidelines, performance indicators, and sanctions (Organizations, n.d.). Rules and standards form the basis for organizations and employees about how to behave. The rules must be perceived by employees as behavioral retention and used as a standard at work (No Title, n.d.); (Isbehavior in, n.d.) . Individuals need to understand the importance of compliance with rules, while management is obliged to see compliance as a mandate. The main health service activities that guarantee patient safety requires compliance with formal and informal rule, so the rules set by management become an indicator of compliance pressure for employees (Quality Management Theory and Application, n.d.).

Standard procedure
Determination and implementation of standard operating procedures can maintain consistency in performance levels, minimize failures, errors, and omissions, parameters for assessing performance quality, ensure efficient and effective use of resources, explain task flow, authority, and responsibility, direct adequate documentation and accurate (Morris & Epes, n.d.).

Communication
Every task, rule must be communicated, and the way of communication gives different values to each person, meaning that the form and mode of communication become an important element in an organization (Amenta et al., 2010). Leaders' communication with employees is a form of compliance pressure. At the leadership level in the organization, norms, values, rules, policies, procedures must be communicated to all personnel, and every employee must accept every policy (Ciancio, 2004). The leadership has a role in ensuring procedures are carried out correctly. One of the influential factors is communication. The communication process here is expected to take place both ways, supportive, giving positive and constructive feedback. This means that communication delivered by the leader can be a stimulus or verbal reward and ultimately build nurse compliance (Anthony et al., 2009); (Systems & City, n.d.). When the reward is in the form of positive information, they will feel satisfied and feel more competent and give rise to intrinsic motivation. The verbal reward can be an unconscious control mechanism because subordinates will experience positive and good interpersonal experiences with their leaders (Werder & Ees, 2007).

Corrections and confirmations
In addition to communication, the leadership mechanism that has influences as pressure is correction and confirmation. (Wendt & Wendt, n.d.). Confirmation of every action and document that has been implemented is a way to increase compliance with employees. The important thing that must be considered is the way or procedure in conducting confirmation should be done while respecting employees and supported by the use of competent language (Tallberg, 2002). Sieburg and Larson (1971) state that confirmation should be a behavior that should cause others to feel they have more value. Confirmation occurs when participants in a system do not understand something and that requires proper communication and confirmation processes to make people feel competent (Ramus & Oppegaard, 2007); (Scott, 2004). Positive feedback cannot change behavior directly, but will slowly build self-compatibility and empowerment of personal qualities (Price & Cambas, 2012).

Value
Values are strategies, goals, principles or qualities, passion as a result of creativity in organizational behavior. (Dajani, 2009). Values are often associated with work and organization including prestige, control, authority, pleasure, independence, creativity, tolerance, respect that is the culture in the workplace (Lynham & Chermack, 2006). The results of the review journal that the values applied and culture in both hospitals are family, togetherness, spirituality, and empathy (Chen, 2004). These four values produce conclusions of meaning, that the value of family and togetherness at work makes the work atmosphere more comfortable and conducive. Spiritual value, giving multidimensional meaning in work. Empathy in patients who are nurses, encouraging more positive work attitudes, increasing moral awareness, triggering the desire to provide the best service, maintaining the quality of service with the hope that does not add to the burden on patients (Umit, 2004). Beliefs and values developed as organizational culture specifically increase willingness to comply with safety procedures (Gupta, 2011). 6. Professional Standards Professional standards are a minimum expectation in providing safe, effective, and ethical nursing care. The obligation to provide nursing services properly and appropriately in terms of service and administration becomes one of the drivers of compliance because of the professional obligations that have been listed in professional standards (Hall, 2003). Professional standards set by the organization are mandatory signs that guide nurses in implementing nursing services to patients (Lou & Judith, 1997).

Accreditation Standards
Accreditation is an attempt by the government to provide a tool that encourages hospitals to continuously improve quality and safety services (Trisnantoro & Bachtiar, 2010). Rules and indicators of accreditation standards are some of the drivers for nurses in complying with procedures. Hospitals that obtain international accreditation must apply several conditions set for patient safety, namely six patient safety targets (Martin & Julius, 2005). 8. Co-worker support Co-worker support is the ability of coworkers to make the work environment pleasant or unpleasant when spending time at work (Terry, Steve, Beth, & Marshall, 2000). Co-worker support is an important component of compliance pressure for participants. The support of co-workers will also encourage colleagues to work better, with appropriate procedures (Elanain, 2008). Sheng & Chen (2010), the influence of coworker support is to build motivation and self-efficacy. The motivation here is focused on the formation of internal motivation. This is in line with the theory of "Self Determinant Theory" from Deci & Ryan (1985), where with support for autonomy and competence, they will feel more capable and will try to do their jobs better (Bishop, Scott, 2000). Effective safety behavior and positive feedback will increase interpersonal trust between co-workers. The feedback comes from friends, it will build self-confidence in ability, making pressure and motivation for self-improvement (Ronald & Shelby, 2000). Vincent (2007), "Social support at work and affective commitment to the organization", support becomes a positive pressure that will affect employee commitment to the organization primarily affective commitment (Ajzen & Ajzen, 2011); (Barry, 2000).
Employees will feel more valuable as individuals, feel meaningful as part of service success, and be more motivated when leaders give positive appreciation when they do the job right (Richard & Paul, 1986). Another culture that also has a contribution as an indicator of mimetic pressure is the correction and confirmation of the leadership. Monitoring and evaluation conducted by the leadership should refer to clear supporting evidence, not just assumptions. When stating true wrong work employees must use the same checklist and get an amplifier from the document. What has happened so far is often to blame without referring and listening to the evidence first. How to do the correction also does not judge but still provides support to employees (Cameron, 1996); (Organizations, n.d.). Many organizations implement obedience by establishing rules, rewards, sanctions, and policies that serve as controls for employees. But actually, it is just an initial driver, it is hoped that an internalization response will emerge from the employee as a form of internal pressure that will affect the employee in acting. The findings of the 8 indicators of compliance pressure above are appropriate controls and complement the regulatory pillars and normative pillars in building nurse compliance in carrying out procedures.

CONCLUSIONS
Qualitative results of the eight indicators can be used by managerial as one of the alternatives in managing quality improvement and enhancement of service satisfaction.