Nursing education in Indonesia has developed significantly in recent decades from initial programs to diploma and bachelor's degree programs. However, nursing education faces challenges in keeping up with societal changes such as globalization, changing patient demographics due to aging populations and longer lifespans, and advancements in healthcare technology. To prepare nurses for these future trends, nursing education must reform curricula to incorporate topics like cultural competence, community health, research, and technology skills to ensure nurses can provide relevant care.

1. NURSING EDUCATION IN INDONESIA: TODAYS AND FUTURE TRENDS
Nursalam1, Ferry Efendi1, Lan Thi Ngoc Dang2, Yuni Sufyanti Arief1
1 Faculty of Nursing
Airlangga University Indonesia
2Vietnam Development Information Center,
Global Development Learning Network Vietnam
E-mail: nursalam_psik@yahoo.com, fefendi@gmail.com, lanitavn@gmail.com, yuni_psik@yahoo.com
Abstract
Societal and health care changes have presented many challenges for nursing. The challenge for nursing education is to ensure that professional education remains relevant and keeps in track with the needs of the market. These challenges include globalization, changes of patient characteristics, impacts of technology information, migration, future tendencies and other current issues in nursing development in Indonesia. A desk study was performed from relevant published materials. Literature was reviewed from means and databases of the International Council of Nurses, Indonesian Nurses National Association and electronic journals. The aim of this paper is to consider possible future societal and healthcare changes and how they may impact the development of future nursing education. A clear understanding of these factors is critical to face tomorrow challenges within global context.
Keywords: nurse, education, curriculum
History of Nursing Education
In line with the rapid economical growth and technological development, nursing education in Indonesia has also been developed positively over the last decades, starting with the issues of "The doctor‟s servant" and "Nurses as the second class". Nurses want their voices heard together with their profession more highly recognized.. As the result, in some urban provinces of the country a Diploma Program in Nursing was set up in the 1970s. In 1982, Indonesia University opened a Bachelor degree in nursing science as a pilot project. Since then, several medical faculties followed the step of Indonesia University and provided Bachelor‟s Degree Program in Nursing. Moreover, Self-study Education Program in Nursing started in Indonesia and, this type of education quickly spreads to other cities, which included Diploma Program, Diploma IV at the beginning and Bachelor's Degree Program after several years.
In addition, a continuing education program called “Program Khusus” leading to a diploma was also established, which is a 3-year part time program for clinical nurses with professional training education background. This program provides good opportunities for clinical nurses in pursuing higher education while working and overall, in improving their professional knowledge and skills. With the increasing number of higher nursing education programs, there is lack of nurse educators who have higher educational background.
Recognizing the necessity, the Ministry of Health has sent a number of nurses to study abroad to get higher education, master and doctoral degrees. However, that effort seems to be insufficient compared to the actual requirement. More importantly, competencies of nurse educators need to considerably improved, in accompany with

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increasing the number of qualified nurse educators. The diversified levels of nursing education programs and also increased nurse students number have resulted in an over workload for nurse educators. This unfortunately creates a challenge for them in renewing and gaining more knowledge. Not only more nurse educators with Master's and doctoral degree are needed, but also each educator would put more attention to researches and theoretical development and the development of cognitive skills in teaching and clinical practice as well. The current situation of Indonesia is that most of nurse educators have only Bachelor‟s degree; this has caused constraints in taking roles of teaching, guiding and coaching their students. Meanwhile, this situation is not an issue for many western countries, where most of nurse educators possess their PhD or Master's degree.
With the development of nursing science and the constant influence of modern education notions, continuing reforms in nursing education have been made since 1982. Nursing education has changed from a biological paradigm to a humanistic or holistic paradigm. The reforms covered a wide range of areas, from curriculum development, contents, teaching methods to human resource aspects. More efforts have been made in curriculum design and development for courses related to sociology, psychology, psychoneurotic immunology; researches in nursing science have been put more emphasis. Contents of different courses, especially those relating to clinical nursing and community setting have been adjusted with strong focus on consumers‟ needs. As to the teaching methods, besides traditional class teaching, multi-media teaching have been used widely. In addition, internet teaching has also attracted more and more interests (Nursalam & Efendi F, 2008).
Globalization
Globalization is the process by which people around the world are unified into a single society and functioning together. Globalization is often used to refer to economic globalization: the integration of national economies into the international economy through trade, foreign direct investment, capital flows, migration, and the spread of technology (Bhagwati J, 2004). The process of unifying into single society and functioning together has an impact of the movement of people, information, capital and commercial goods. The free inflow of people, animals and goods across national borders forms a rapid spread of new threats in the form of infectious disease. Examples are spread of the HIV virus, avian influenza virus (H5N1) and currently swine flu (H1N1). At the moment, more than 70 countries have reported cases of novel influenza A (H1N1) infection and there are ongoing community level outbreaks of novel H1N1 in multiple parts of the world (CDC, 2009). Bythe end of July 2009, the Ministry of Health of Indonesia declared that Swine Influenza become an outbreak in the country. Reemerging diseases in the developing world (including Chagas‟ disease, dengue, filiariasis, leishmaniasis, malaria, schistosomiasis, trypanosomiasis,) (DaSilva & Iaccarino, 1999) are likely to spread across the world as western aid workers and migrants move freely (Lee, 2004).
In order to response to the multiple forces of globalization, nurses face the challenge of embracing a global perspective and protecting health of people for all framework. The dynamics of revolutionary communications technologies, global migratory movements and transnational economies are making traditional boundaries and borders increasingly flexible. As a result, professional roles and responsibilities are being redefined. To bring

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global perspectives to local practices, nurses must be willing to challenge conventional roles, values and boundaries. A fundamental shift to address the current worldview is needed if nurses are to take leadership in reorienting local and national health care systems toward principles of primary health care and Health for All. „Health for All‟ continues to be a call for equity and social justice, a global issue that must be dealt with at the local level in communities around the world. Playing dual roles as health professionals and citizens, nurses can advance the notion that global health is indeed a local concern. By embracing a global vision of health and linking it with local action, nurses can be active participants in advancing the goal of health for all entire world‟s people (Messias, 2001).
Globalization has also created a challenge in healthcare delivery to a variety of diverse populations. Patients need a nursing workforce that can tailor knowledge and skills to provide culturally competent care (RCN, 2004). Provision of culturally appropriate interventions, through the use of advanced communication skills and awareness of cultural diversities, is one aspect of nurses‟ moral and ethical obligation to provide a high standard of nursing care (Duffy, 2001). Thus, nursing curricula must change to fulfill global needs and demands.
Changing Patient Characteristic
Demographic changes affect the profile of patients presented at healthcare services. Advances in public health, science, and clinical care mean that people are living longer and more frequently have dementia and other conditions associated with aging (Heller et al., 2007). For example, it is stated that stroke becomes the third killer in Indonesia and many of stroke survivors live in residual disabilities. Further, the increased longevity of people with intellectual disabilities together with their associated complex needs has created a need for acute and community care services (MOH, 2008). Nurses of the future will need the skills and ability to influence policy formulation and the development of creative solutions to respond to changing demographics and the ageing chronically ill. Review of regulatory requirements for nursing may be needed to broaden nursing students‟ clinical placement exposure, thus enhancing the diversity of experience gained (Hegarty J et al., 2009).
Nurses of the future will need the skills to influence policy formulation and the development of creative solutions to respond to changing demographics and the ageing chronically ill. Review of regulatory requirements for nursing may be needed to broaden nursing students‟ clinical placement exposure, thus enhancing the diversity of experience gained (Hegarty J et al., 2009).
The Impact of Technology Information
Nurses in the future will need to be knowledgeable and skillful in using computer technology because of ongoing information technology advancements (Gugerty, 2007). Medical equipments are continuously being updated and paper records are being replaced by electronic medical records. Future nurses need to be confident to use medical equipments and technology effectively. This is an important and urgent agenda for nurse education worldwide. Moreover, advanced science requires nurses to constantly remain abreast of advances in illness treatments and new drugs. Whilst it is acknowledged that nurse educators cannot update every new drug, disease and treatment in the nursing curriculum; the challenge is to awaken the curiosity in students for life-long learning. The

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skills of critical thinking, problem-solving, and clinical decision-making are essential for nurse to function effectively in complex health care environments and to be life-long learners (Dalley et al., 2008).
Recent years have seen two substantial changes in heath care provision: the increasing technological application in the area and a higher demand for nurses on a global scale. Nurses are front line staff in most health systems, and their contribution is recognized as essential to the success of planning and implementing technological application. As such, one of the most important educational tasks of Indonesia is to develop capacity of nurses in effectively using technologies applied for health care. Higher education institutes in nursing will then play a significant role in meeting this demand (Efendi F, Nursalam & Indarwati R, 2009).
Furthermore, advanced knowledge in information technology will facilitate the process of life-long learning because computers are educational catalysts in the retrieval of nursing and healthcare literature and health information generally. Arguably, proficiency in information technology literacy will be as important as curriculum content to the nurses of the future.
Migration
International recruitment and migration of nurses has been a growing feature of the global health agenda since the late 1990s (Oulton, 2004). Nurses have always taken the opportunity to move across national borders in pursuit of new opportunities and better career prospects; however, the fact that nurse migration has grown significantly over the past few years, which potentially undermines attempts to achieve health system improvement in some developing countries. Meanwhile, in many developed countries, a new tendency in demography – a growing and ageing population and an ageing nursing workforce – make it mostly likely that many of these countries will need to encourage an inflow of nurses from other countries (Buchan 2002). In fact, an emerging pattern is that there is a trend of increasing nurses provided to developed countries from a wider range of developing countries, due to these countries become more active in using international recruitment to combat nursing shortages. Shared language, common educational curriculum, and post colonial relation as well as large diasporas or trans-national communities tend to be the factors determining which developing countries are being targeted as sources of nurses providers (ICN, 2005).
There are two main indicators of international migration of nurses to a country: the "inflow" of nurses into the country from other source countries (or "outflow" to other countries), and the actual "stock" of international nurses (as compared to the home- educated nurses) in the country at a point in time. To undertake an accurate assessment of the impact and policy implications of migration of nurses, it is necessary to assess the level of migration within the broader context of trends and dynamics in the national nursing workforce (ICN, 2005).
There are no accurate data of Indonesian nurses in destination countries. In fact, Indonesians are going to USA, UK, Australia or any other country that provide them with a better income. Indonesian Nurses National Association (INNA) (2009) stated that more and more nurses attracted to work overseas and predicts that there will be an increased number of migration from Indonesia. Most possible reasons for leaving Indonesia come from financial conditions, poor working environment and limited opportunities to advance career. Buchan and Dovlo (2004) identified several factors considering

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migration such as low salary and remuneration, limited career prospects, feelings of lack of respect/value placed in health workers by country/system, concerns about poor governance and management of the health system and anxiety about poor retirement benefits and prospects.
Further action should be focused on the development of nurses to response to the challenges caused by limited access to capital to build an appropriate nursing education infrastructure in meeting Western standards and by the emigration of nurses in faculty and hospitals of Indonesia.
Recent Issue in Nursing Society
Nurses across the country are pushing for the government and the House of Representatives to speed up deliberation of the Nursing Practice Bill, which is to recognize this profession as a main component in the national health system (The Jakarta Post, 2009). The purpose of the bill is to clarify the rights and duties of nurses. The author believes that nurses have the right to a safe work environment, to practice in a manner that assures the provision of safe care through adherence to professional standards and ethical practice, and to advocate freely for themselves and their patients. The draft bill was submitted to the House in 2005 and has since been revised 20 times.
Indonesia is still implementing the Ministry of Health Decree No. 1239/2001 as a legal basis for nurses‟ jobs. However, the decree is not sufficiently clear in defining nurses' rights and duties; this has resulted in misunderstanding and misperception of nurses jobs. In fact, nurses‟ legal position is not protected adequately. Evidently, nurses in East Java, West Java and Central Java have been detained by authorities or harassed by locals for providing emergency assistance, which they believed that only doctors could do. In fact, the decree states nurses are allowed to give medical treatment if they have approval from the doctors in charge. However, the majority of people still believe (misbelieve actually) that all medical treatments, even as simple as giving injections should be done by doctors and only doctors.
This problem has definitely hampered nurses‟ job which basically doing dependent job. To resolve the problem, Indonesia needs a specific law regulating nursing practice and defining nurses' responsibilities. The bill under discussion covers nurses' competence and protection during practice, which means they are defined as professional practitioners. If the bill is passed into law, it will be Indonesia's first national standard for nurses.
Conclusion
A summary of today, future challenges and the curriculum implication are listed in the table below.
Table 1. Today and future trends in nursing education
Challenges
Today’s
Curriculum Implications
Globalization
 Delivery of care to diverse people
 Rapid spread of emerging
and re-emerging communicable diseases
 Adoption of an international approach to research and the
 Increased focus on infection
control and risk management
 Increased focus on transcultural nursing
 Focus on transferable skills
 Mutual recognition of qualifications across

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implementation of evidence based practice necessary
 Global mobility of nurses
 Promotion of a global perspective
 Global economic downturn
jurisdictions
 Incorporation of the following perspectives: principles of health, global- local connections, intentional caring, justice, challenging indifference, transcultural and transnational, relationships
 Potentially less capital available for investment in health and education
Changing Patient Characteristic
 Patients more aware of their rights as consumers
 Patients more informed about own health status.
 Increased emphasis on patients‟ views
 Increased longevity resulting in increased morbidity associated with chronic illness
 Increased focus on patient orientated learning and person centered education
 Increased focus on self management of chronic illness
 Potentially the development of long term care services
The Impact of Technology Information
 Improvement in nurses‟ IT competency required (nurse informatics)
 Critical thinking, problem solving and clinical decision making skills
 Essential to assess evidence through systematic reviews to use standardized clinical; practice guidelines
 Embedding of digital literacy in the curriculum
 Promotion of life-long learning
 Ensuring that students can access and interpret evidence such as that presented in systematic reviews
Migration
 Growing number of nurses who want to work overseas
 Big opportunity for better future
 Issues for domestic demand for nurses
 Increased focus on migration issue
 Increased on international standard of competency
 Problem-based learning methodology applied
Recent Issue in Nursing Society
 The urged of nursing bill draft
 Greater aware and concern on nurses right
 Dissemination of Rights and Responsibilities to Nurses and community
Many potential challenges lie ahead for the profession of nursing and consequently for nurse educators, particularly in developing curricula in order to meet the demands associated with a changing healthcare environment. Firstly, changes associated with socioeconomic factors such as globalization and the changing patient profile will undoubtedly affect the practice of nursing in the future. Advancements in science and

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information technology are rendering healthcare increasingly complex. Indonesian nurses migration and the issue of creating nurses with global standards will continue to affect the education of nurses. It is imperative that in developing nursing curricula, academics need to consider these challenges in order to prepare graduates to meet the challenges associated with a changing healthcare environment.
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