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International Journal of Nursing Practice 2013; ••: ••–••

RESEARCH PAPER

Person-centred care in the Indonesian

health-care system
Wan Nishfa Dewi RN BN MNg
PhD Student, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia
Lecturer, School of Nursing, University of Riau, Pekanbaru, Riau, Indonesia

David Evans RN DipN BN MNS PhD

Senior Lecturer, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia

Helen Bradley PhD MEdSt GrCertIntHlth BEd RN RM

Senior Lecturer, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia

Sandra Ullrich PhD BSc (Hons) Grad Dip (Gerontology) BN RN

Researcher/Consultant, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia

Accepted for publication April 2013

Dewi WN, Evans D, Bradley H, Ullrich S. International Journal of Nursing Practice 2013; ••: ••–••
Person-centred care in the Indonesian health-care system

Person-centred care (PCC) is defined as the health-care providers selecting and delivering interventions or treatments that
are respectful of and responsive to the characteristics, needs, preferences and values of the individual person. This model
of care puts the person at the centre of care delivery. The World Health Organization suggests that PCC is one of the
essential dimensions of health care and as such is an important indicator of health-care quality. However, how PCC is
implemented differs between countries in response to local cultures, resources and consumer expectations of health care.
This article discusses person-centred care in the Indonesian health-care system.
Key words: health-care system, Indonesia, nursing, person-centred care.

INTRODUCTION he or she receives to becoming actively involved in deci-

Person-centred care (PCC) is defined as health-care pro-
viders, such as nurses, selecting and delivering interven-
tions or treatments that are respectful of and responsive to
the characteristics, needs, preferences and values of the
person or individual.1–5 The essence of PCC is to shift the
person from having a passive role in the health care that
Correspondence: Wan Nishfa Dewi, School of Nursing and Midwifery,
University of South Australia, GPO Box 2471, Adelaide, SA 5001,
Australia. Email: wan.dewi@mymail.unisa.edu.au
sions about his or her care. It moves away from an empha-
sis on disease to a model that integrates the biological,
psychological and social dimensions of illness.6,7 The
application of PCC in a clinical setting implies that nurses
will assess the person’s needs, values and preferences, and
then select and implement interventions that are consid-
ered and responsive to their client’s needs.
PCC has become an established approach to the deliv-
ery of health care, and a growing number of organizations
are starting to adopt a PCC model of care.8,9 In the UK,
Australia, Europe and the USA, there has been substantial
development of the PCC model of care. In the USA PCC

doi:10.1111/ijn.12213 © 2013 Wiley Publishing Asia Pty Ltd

2 WN Dewi et al.
is considered to be a health-care priority,10 and in the UK
PCC has been embedded in many policy initiatives.9
However, PCC is not widely used in the health-care
systems of developing countries. It is likely that PCC is
contrary to some of the current approaches to care deliv-
ery in these countries.1,11 It might also be that the philoso-
phy that underpins PCC is different from those that
inform health care in some developing countries. In addi-
tion, different countries and institutions have different
understandings of what PCC means and different ways of
translating it into care delivery. This article will explore
the nature and characteristics of PCC with a particular
focus on its introduction into developing countries and
specifically to the Indonesian health-care system.
TERMINOLOGY
In the literature, the word person in person-centred care is
used interchangeably with patient, client, individual and
resident.12 The variation depends on the context in which
care is provided. In the hospital setting the term patient-
centred care is most commonly used, whereas in aged care
it is resident-centred care. Different terms are used inter-
changeably in the literature to reflect the concept of
PCC. These include client-centred care, individualized care,
self-directed care, patient-centred care, relationship-centred
care and family-centred care.1,13–16 However, the intent of
the care delivery is consistent across all of these terms:
that PCC care should be individualized and responsive
to the needs of the client.
DEFINITIONS
Definitions of PCC in the literature differ. McCormack
defines PCC as ‘the formation of a therapeutic narrative
between professional and patient that is built on mutual
trust, understanding and a sharing of collective knowl-
edge’.17 Suhonen, Leino-Kilpi, and Välimäki18 define PCC
as being comprehensive care that fulfils patients’ physical,
psychological and social needs. Kitwood describes it as a
status that is given to one person by another and involves
recognition, respect and trust.19
From a slightly different perspective, Nolan et al.20 con-
siders it to be relationship-centred care because all parties
involved in the care must experience relationships that
promote a sense of security, belonging, continuity, goals
and achievements.20 One of the first international organi-
zations to introduce PCC into the health-care system to
improve care by considering the totality of the experience
through the ‘eyes of the patient’ was the Picker Institute.21
© 2013 Wiley Publishing Asia Pty Ltd
The Picker Institute defines PCC as a partnership between
informed and respected patients and their families and the
health-care team to achieve quality health care.22
The nursing literature is consistent in the view that
being person-centred requires the formation of a thera-
peutic relationship between care professionals and
patients and other significant persons. McCormack and
McCance proposed a definition of person-centred care
within a nursing context:
Person-centredness is an approach to practice established
through the formation and fostering of therapeutic relation-
ships between all care providers, older people and others
significant to them in their lives. It is underpinned by values
of respect for persons, individual right to self-determination,
mutual respect and understanding. It is enabled by cultures of
empowerment that foster continuous approaches to practice
development.13
PCC makes the client and his or her family an integral
part of the care team, and as such they collaborate with
health-care professionals in the decisions that impact on
the care that they receive.
CHARACTERISTICS
It is not just the terminology and definitions that are open
to interpretation; the characteristics of this model of care
are also viewed differently. There have been many
attempts to characterize the attributes of PCC. Contem-
porary views of PCC are based largely on research con-
ducted by the Picker Institute.23 This early work identified
seven characteristics:
• Respect for patient values, preferences and expressed
needs
• Coordination and integration of care
• Information, communication and education
• Physical comfort
• Emotional support relieving fear and anxiety
• Involvement of family and friends
• Transition and continuity
Some authors, such as Mead and Bower,24 Radwin25
and Poochikian-Sarkissian et al.,26 have also attempted to
describe the characteristics of PCC. Although there are
some differences in the characteristics reported, three
common themes emerge:
• Participation and involvement of patient and relatives
• Respect for patient values, preferences and needs
• Information and education and sharing knowledge
Person-centred care in Indonesia
Importantly, these three characteristics emerge as the
principles of PCC and are in line with the concept that
nursing care is individualized.4,25,27
Patient and family participation and involvement is an
important component of delivering PCC, particularly in
nursing care.28 In PCC, the traditional view of caring has
been substituted with one that actively engages patients in
their own care. Sharing information and shared decision-
making in PCC is a dynamic process in providing better
care. Information, education and counselling are needed
in the PCC model of care, as is health-care practitioners’
providing trustworthy information that is responsive and
tailored to the patients’ individual needs.29
IMPACT ON HEALTH CARE
There are a number of benefits related to the implemen-
tation of PCC into health-care practice, including
increased satisfaction with care, improved independent
self-care, better team performance, organizational effec-
tiveness and efficiency, and an enhanced quality of health
care.2,3,7,27,30–32 PCC can also increase consumers’ satisfac-
tion with outcomes of health-care delivery.30 A study by
Stewart et al.2 on the impact of PCC in healthcare showed
PCC contributed to improved recovery and a reduction in
diagnostic tests and referrals.2 Hook examined the rela-
tionship between PCC and quality of care and found that
a good partnership between patients and health-care pro-
viders supported patients having a greater say about their
care and improved outcomes such as patient independ-
ence in self-care and improved health-care utilization.31
Sidani27 and Wolf et al.7 found PCC contributed to
increased self-care ability, improved functional status, sat-
isfaction and quality of care received. These authors
suggest that patient satisfaction and quality of care in
wards using a PCC model of care rated more highly than
wards that did not use PCC.
Few developing countries have implemented PCC.
However, the impact of PCC in countries such as Lebanon
and Jordan has been investigated.32,33 PCC improved
patient satisfaction, efficiency, competence and attitudes
in both countries.32,33 Implementing PCC also brought a
range of benefits for patients by enhancing their independ-
ence18 and improving quality of care.27,34
INTERNATIONAL EXPERIENCES
Recent policy developments across developed countries
have highlighted the importance of a PCC approach within
3
health-care services.9,35,36 In the UK, USA, Canada, Aus-
tralia and some European countries such as the Nether-
lands and Denmark, PCC has become an expected
dimension of high-quality care. In 1997, the National
Health Services in the UK started to develop a PCC envi-
ronment. From that time the implementation of this
model became an agenda to be delivered and achieved by
all health services in the UK.36,37
In the USA, the concept of PCC has become more
popular since the Institute of Medicine in 2001 reinforced
this concept of care in the new health system for the 21st
century. This new model of care delivery considers that
good quality care should be safe, effective, patient-
centred, efficient and equitable and considers PCC a fun-
damental practice for high-quality care in the USA.38 In
Canada and Denmark PCC provides highly accessible care
for patients and families by health professionals.8 Both
Australia and the Netherlands have also implemented a
PCC model of care. The Dutch associate PCC with
responsiveness,8 whereas in Australia PCC is grounded in
mutually beneficial collaboration among health-care
professionals, patients and families.39
THE HEALTH-CARE SYSTEM
IN INDONESIA
Indonesia is one of the world’s most densely populated
countries, consisting of 33 provinces and home to many
different cultures, religions and racial clusters, resulting
in many different views of health. The diversity of
Indonesia’s environment and population poses enor-
mous challenges to effective health-service delivery.40,41
The health-care system consists of two sectors: public (or
state) and private. The government funds public hospitals
and Puskesmas, or primary health-care clinics, across Indo-
nesia, and private hospitals and clinics are run by private
companies and individual organizations.42 The public
system has different levels of care, from Class 1 to Class 3.
Class 1 patients usually have some health insurance and
receive the maximum resources that a public health
system can provide. Class 2 patients receive a lower level
of service but still incur costs. Class 3 covers the poorest
people, who have free health care but minimal access to
resources. This group is covered by the central and local
government health-care cards, or jamskesmas and jamkesda.
Currently, most health-care services in Indonesia are
based on a conventional model of care. Conventional care
is related to the delivery of care based on routine activities
and tasks.43 The conventional care implemented in most
© 2013 Wiley Publishing Asia Pty Ltd
4 WN Dewi et al.
of the hospitals is such that the caregivers expect that their
patients will be compliant—that is, follow their instruc-
tions according to Indonesian social norms. Health-care
providers do not normally consult patients, nor do they
deliver care that is based on individual patient prefer-
ences. Socially, patients do not expect that their concerns
will come first or that they will have a voice in decisions
related to their care delivery.
In Indonesia, health-care professionals are highly
respected and commonly come from the higher class of
society. Doctors have a higher status than nurses. This
difference in social status can serve as a barrier between
the provider and the recipient of health care. Patients
have little opportunity to discuss or consult with medical
practitioners, who hold a higher social status than them-
selves.43 This hierarchy of social status also influences
nursing practice in Indonesia, because nursing has a social
status that is lower than that of other health professions.
As a consequence, nurses have little independence in how
they deliver nursing care and determine patient needs.43
Introducing PCC into the Indonesian health-care system
could challenge this traditional approach to care with a
new and unfamiliar model that could also challenge health
practitioners.
PERSON-CENTRED CARE IN
INDONESIA
There is very little information about the use of PCC in
Indonesia. One study on family-centred care (FCC) found
that implementing FCC in Indonesia encountered diffi-
culties related to an insufficient number of health
workers.44,45 However, there is little further evidence
related to PCC in the Indonesian healthcare system.
While PCC is a new concept to Indonesian nurse practi-
tioners and researchers, it is possible to identify barriers to
and enablers of PCC.
BARRIERS
Although there has been an investment in resources to
improve the quality of health-care delivery in Indonesia,
some barriers still exist. These include decentraliza-
tion, workforce issues, health education and social
stratification.5,8,37,41,45–47 These barriers all influence the
implementation of PCC in the Indonesian health-care
system.
The general decentralization process implemented in
2001 has had many impacts on the health system. New
responsibilities have been given to local governments,
© 2013 Wiley Publishing Asia Pty Ltd
which are poorly prepared for planning new health poli-
cies, and some public health institutions and hospitals now
have a focus on profit.46 As stated, workforce issues are
also considered an important barrier to the implementa-
tion of PCC in Indonesia. Human resources for health have
been affected by the decentralization policy. Health work-
force issues are grounded in long-standing policies about
central planning and deployment, budget limitations and
ceilings on workforce numbers in Indonesia.41,48 Existing
civil service regulations constrain central and local govern-
ments in addressing the problems.40 These workforce
issues might serve to limit any further changes to care
delivery because the system is already struggling to come
to terms with the changes related to decentralization.
Although PCC has been introduced through the
nursing curriculum, nurses have not been able to influ-
ence its introduction into the clinical area because of their
lack of clinical authority. However, the existing nursing
and medical workforce have a limited understanding
of PCC. A lack of education about PCC in this group
has been identified as a barrier in the literature.5,49,50
Therefore, this is likely to be an important barrier to the
implementation of PCC in Indonesia.
Social and economic differences between the health-
care professionals and patients are also a barrier to PCC.
As previously discussed, in Indonesia health-care
professionals have a higher social status than their
patients. This difference in social status can serve as a
barrier between the health-care professionals and the
patients. Similarly, the social status of nurses within the
health system in Indonesia is lower than that of other
health professionals, especially medical doctors, so this
impacts on their autonomy in clinical practice. As a con-
sequence, these two factors have acted as barriers to
PCC implementation.
ENABLERS
There are also enablers that could support the implemen-
tation of PCC in Indonesia. Decentralization has also had
a positive impact because it has accelerated change in the
health sector and in the nursing profession. Decentraliza-
tion can increase the responsiveness of a system to local
conditions by encouraging the growth of decision-making
capacity and by developing the skills, abilities and moti-
vation of local officials who work in the health sector.51
Therefore, local governments can be more flexible in
determining health sector priorities to better meet the
needs of their region.
Person-centred care in Indonesia
The need to have nursing recognized as a profession in
Indonesia has prompted the Indonesian National Nurses
Association to request the government to acknowledge
their identity as a health profession. They are developing
a credentialing system which will provide a legislative
framework within which nurses will practice. Efforts are
currently underway to develop and implement competen-
cies to strengthen nursing as a self-regulating, accountable
and professional body with a code of ethical conduct and
a ‘Nursing Act’.48 Professional nurses play an important
role in promoting quality of care in health systems.
Having more qualified, skilled and scholarly nurses is
likely to foster the transformation of nursing in Indonesia,
not only in practice but also in education.
DISCUSSION
Studies have demonstrated the many benefits that accom-
pany a person-centred approach to health-care delivery.
However, there are few studies of PCC in the developing
world and none in Indonesia. To improve the provision of
health care and to implement PCC as a new model of care
in Indonesia there are challenges still to be addressed.
The challenges for PCC in Indonesia identified in this
paper are the lack of nursing authority, decentralization,
workforce issues and social stratification. Nursing has a
lack of authority and has been unable to influence the use
of PCC in the hospital or clinical setting. Although edu-
cation of nurses will assist in the change to care delivery
processes, more is needed to ensure a sustained imple-
mentation of PCC. The workforce issue can be resolved
by refining the deployment of staff and analysing the skill
mix to support the implementation of this new model of
care.52 Consequently, skilled, qualified and scholarly
nurses would improve care and help support the imple-
mentation of the PCC model in the Indonesian health-care
system.
CONCLUSION
A person-centred approach to health care can improve the
quality of patient care and increase satisfaction and adher-
ence to care programs. PCC is now considered by many
to be an important dimension of quality in health care.
However, its implementation internationally might be
impeded by a lack of understanding. Implementation of
PCC in the health systems of developed and developing
nations might encounter quite different challenges reflect-
ing the unique cultural views, health-care practices and
5
social norms of individual countries. Implementation of
PCC in a developing country such as Indonesia will
require changes in attitudes and skills to accommodate the
differing view of health that PCC demands.
ACKNOWLEDGEMENT
The first author would like to thank the Directorate
General of Higher Education, Ministry of Education and
Culture, Republic of Indonesia, for her PhD scholarship.
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