Nurses’ Viewpoints on the Quality of Care: A Qualitative Study in Timor-Leste

Research on quality of care revealed nurse-to-patient ratio and skill mix as key elements in quality of care. However, those studies were done in countries where the nursing workforce had a higher proportion of professional nurses with bachelor degrees. The ndings of the research studies may have overlooked health system challenges such as the auxiliary nursing services found in lesser developed small island countries with higher proportions of auxiliary nurses. Working in under-resourced places, nurses in Timor-Leste might have differing viewpoints on the aspects that contribute to quality of care perspectives. used to improve quality care policies. Our study portrays both the uniqueness and the breadth of the nursing profession in a prolonged conict country. This data enriches factors that are important to quality care in under-resourced places and can be used to improve quality of care measurements. Our study implies that suffering and hardship faced by the least developed small island countries could impede their to achieve universal coverage Thus, data from this study can international to their long-term to these to a strong health thereby supporting access to quality of care.


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Background The nursing workforce in Timor-Leste dominated by nurse assistants, known also auxiliary nurses (91%), who graduated from a high-school nursing course [1] and work as staff nurses in health care facilities [2].
While the majority of professional trained nurses graduated from a three-year diploma in nursing course (8%), only small percentage of them (0.1%) graduated from a bachelor degree. This low percentage of professional trained nurses, illustrates a skill-mix gap [3]. In addition, a lower ratio of nurse-to-1,000 population (0.9/1,000) [4] contributes to the low density of skilled healthcare workers (physicians, nurses, and midwives) per 1,000 population in the country, which is below the minimum threshold of 2.28 [5]. This ratio implies a sta ng inadequacy further contributing to health system ine ciencies [6][7][8][9], impacting patient outcomes [3,6,10], thus in uencing key aspects de ning facility quality of care.
Quality of healthcare service concerns in uence the care provided to the population. Information regarding service insu ciencies (i.e. oxygen de ciencies) and negligence [11] as well as reports of nurses experiencing unsafe working conditions and patient behaviors of impoliteness and unfair business practices were indicated in the literature [12]. These concerns may suggest that it is possible that nursing services become a stumbling block to quality care improvement efforts, given that nurses comprise 45% of healthcare providers; the backbone of Timor-Leste's health system [4]. These nurses justify signi cant contribution to the overall healthcare services performance. A similar situation was found in many other lesser developed small island countries and under-resourced facilities [13]. However, serving as the backbone of a health care system, comes with additional responsibilities in which the nurses frequently are obliged to assume extended roles without proper preparation and adequate organizational supports [14][15][16]. A prolonged period of con ict in Timor-Leste that impacted health workers development has exacerbated nursing competence and performance [18].
A low performance could impede progress toward achievement of universal health coverage (UHC). Thus, improving nursing performance will eventually lead to quality care improvement helping the country to improve access to quality of care [19].
Since 2001, measurements of quality of care have been directed toward better outcomes [20]. Mostly, the key measures of quality of care have used Donabedian's SPO framework that links three quality care dimensions of Structure (S), Process (P), and Outcomes (O) [21][22]. Structure describes the elements of healthcare settings. Process describes an interaction between healthcare providers and patients.
Outcomes include changes as a result of activity of care that encompasses patient satisfaction and health outcomes [22]. In high-income countries, many studies have moved toward measuring sensitive patient outcomes, including hospital readmission [21], morbidity and mortality rates such as decubitus ulcer [23][24]. But, in middle and low-income countries, most studies measured the dimensions of structure that include sta ng in nursing, in addition to facilities and supplies as part of an effort to achieve service readiness and su ciency [21].
Some studies highlighted that better skill mix proportion and patient-to-nurse sta ng ratio were associated with outcomes improvement [3,[25][26][27]. However, these studies were done in countries with at least 10% of the nursing workforce had bachelor degrees and hospital nurse skill mix was above 40%. Therefore, ndings from these studies may not capture sta ng related problems in countries such as Timor-Leste. Little is known about the quality of care where the nursing profession is dominated primarily by auxiliary nurses. Given the vast number of auxiliary nurses and the nature of nurses' roles in challenging circumstances, these nurses may be exposed to a variety of health care activities, suggesting that they may have different views on the quality of care construct. Achieving quality of care and UHC goals requires an understanding of the primary workforce perspectives as nurses address contextual challenges in the work environment.

Aim and study design
This study was designed to use descriptive qualitative research utilizing focus group discussions (FGDs) to capture diverse viewpoints from participants [28][29][30]. This study aimed to explore staff nurses' roles and their contributions to quality of health service. This article attempts to answer a broad-based question on aspects contribute to the quality of care perceived by staff nurses.

Participant and setting
The participants were categorized into two groups, staff nurses (SfNPs) and senior nurses (SeNPs) who had worked continuously at least a year at the healthcare facility. The SfNPs were nurses who graduated from high school level nursing course and with no supervisory responsibilities. The SeNPs were nurses with management responsibilities, graduated at least from diploma three in nursing. The participants were purposively recruited from three healthcare facilities located in three districts: a national hospital, a regional hospital, and a community health center (CHC). The three districts (out of 13) were chosen based on the density of the nursing workforce and the availability of healthcare facilities.

Instruments and ethical consideration
The open-ended questions were prepared for each group of nurses. Probes were used to clarify information provided by the participants. The guide questions that were written in Indonesia were translated to Tetun and then were translated back to Indonesia by different individuals to ensure that meaning and semantics consistent [31]. All researchers spoke the two languages uently. After the Human Right Ethics Committee of Ministry of Health approved the study proposal, a pilot test was held before initiating the actual data collection procedures.

Data collection
Procedures for recruitment, informed consent, and FGDs sessions were de ned. A formal letter to the head of healthcare facilities was sent to help identify candidates for each group of nurses. Each candidate was chosen purposively and was informed about the nature of the study. The candidates, who voluntarily agreed to participate in a FGD, were asked to read an informed consent form before signing the consent. They were asked to complete demographic data without included their name. The candidates were informed that should they feel uncomfortable, at any time, they could withdraw from the FGD.
Six FGDs were held in three districts over a 2-month period in 2017. Each FGD lasted for two hours at most. All FGDs were audio-recorded and data were transcribed verbatim. Thirty-three participants were recruited, with an average of 42 years of age, with the majority of them were male (51.5%). A majority of SfNPs worked at national hospital (58.3%) while most SeNPs worked at CHC (58.3%). SfNPs work experience was longer than SeNPs with an average of 18 years versus four years respectively.

Data analysis
Data from FGDs were analyzed using content analysis method [32][33][34][35]. To maintain data accuracy, two different persons translated each transcription into Indonesia and then, all translated data were compared with the original transcription. Some errors and omissions of data were identi ed and corrected. All transcriptions were treated as a complete data set. A word table was used to organize all the categories. Codes identi ed from the groups were input separately before organizing into categories and themes to comprehend the similarities and differences between the two groups and corroborate the information. The distinctive viewpoints from each group were highlighted in the study results unless implied otherwise.

Data quality assurance
Rigor of this study was maintained through several ways. First, multiple sources of data were used; from two different groups of nurses who worked in three different health facilities [34]. Second, discussions and re ections were done continuously before data collection and during analysis procedures [35][36].
Notes were compared and discussed before labeling and sorting of codes, categories, and themes [37][38]. Third, transcriptions and translated data were read at least three times to comprehend the meaning [33,39]. Fourth, comments from participants and experts were sought [34].

Results
Patients as the center focus of the service Patients seen as family members Participants described similar viewpoints on how view their patients. While showing respect to the patients both participants felt "as though I took care of my own family member" (C1) said SfNPs. To support their stands, SeNPs philosophically explained that it was because they saw their patients as "God's creation human being who possess bio-psycho-spiritual dimensions… and before God human beings are equal" (Z2). Hence, providing good quality of care to the patients was seen as a way of deifying God. This belief enthused them even when facing a dilemma while performing their tasks in challenging situations such as in the absence of other health care providers or while working in remote areas. SfNPs modestly believed that "Although the case was di cult for me and beyond my responsibility, I knew God would help me" (C1). A participant stated, "I took the risk and handled it. That's my responsibility before God" (C1). Consequently, "Patient should not be abandoned. We need to serve them equally and not base it on family relationship, skin color, or race" (C1).

Medicines are not exclusive indicators of the quality care
Believing that medicines were not the sole determinant of the quality of care, the SfNPs stated, "Medicines [drugs] alone do not work" (C1). A participant offered an opinion:"…. When we did not serve them kindly, even though we provided them with a plastic full of medications, it was not effective to help them getting well or be satis ed" (C1). Appreciation toward hospitality, politeness, and treatment provided by nurses went beyond the number of medicines or drugs received by the patients. Being fully present with the patients was perceived as a remedy. In this regards, SeNPs stated: "…we communicated with the patients for hours. That was a therapeutic action toward the patients" (E2). They always made time available to their patients and noticed that their patients grew closer and trusted them. They said, "When our patients complained or wailed, we were ready by their side" (Z2). Thus, building a professional relationship with the patients was critical: "If our service was only by giving pills [medications], and nurses and doctors were not that close with the patients, they became di cult to cure" (E2).
Quality care is more than being kind Most participants accentuated nurse's personal character and behaviors as an important aspect to quality care. SfNPs described some demeanors: "We took care of our patients not only through our technical actions, … by showing our kindness" (Y1). Nurses' good mannerisms also indicated: "We also … loved and acknowledged them, shook their hands, all of which could help them get well quickly" (X1). While con rming that notion, SeNPs added that they showed their respect to others by at least "offering a supportive greeting" (E2), an effortless action, yet a worthy way of maintaining a therapeutic relationship with their patients and colleagues. They believed that quality care should be more than offering politeness in caring: "Quality of service that is… we are capable of displaying our responsibilities, being alert, and knowing how to manage our job well" (F2).
SeNPs believed that nurses needed to be accountable for their action and "give more of our time to nursing care" (F2). They voiced some concerns that due to social demands, many nurses were more interested in carrying out medical interventions rather than doing nursing care activities. The quality of nursing care could be improved if all nurses applied "nursing care plans [NCP]… by planning, treating, observing, and monitoring patient's conditions" (E2). They believed that nurses had to use some indicators stated in the NCP so that "our performance can be assessed and we have to be brave in being evaluated" (E2). Some SfNPs a rmed that they would adjust to changes in nursing care standards required by the nursing profession "because we chose this profession intentionally" (C1).
Working extra time to help others Participants stated that working overtime has been a norm in healthcare facilities. SfNPs who worked in hospitals conceded that they sacri ced their time by taking double shifts and "working long hours" (Y1) to keep health services running. SeNPs believed that nurses played an important role in helping cure patients because "we are with the patients for 24 hours a day" (E2). Relatively, SfNPs who worked at CHC, emphasized that, "We worked overtime, even on Sundays" (C1). SeNPs at CHC a rmed that nurses who visited families in remote communities had long walks of approximately 2-3 km from the main road.
These nurses "made an effort to improve public health services" (F2) by ensuring that people "have access to health information and health promotion" (F2).
We are happy when our patients get well SfNPs believed that patient satisfaction and recovery become the ultimate goal in nursing care because "when the patients went home [recovered], we succeeded" (C1) and "we were happy because we saved patients' lives… and family members were also satis ed" (X1). They highlighted more on promptness and exibility as two important aspects in saving a patient's life. For example, regarding the delivery and care of a baby, "… even if we were only a little late, it could risk the life of mother and child" (C1). While SfNPs implied on a personal level, SeNPs stressed more on a broader level, connections between organizational performance and patient satisfaction: "When we did not reach 85% of our target performance, surely people were dissatis ed… claiming our attitudes were poor" (Z2). Both groups also implied that "providing service e ciently" (Z2) could save even more lives. Furthermore, participants inferred that it was important for them to embrace nursing values especially in a case where patients treated them unkindly, in return "we would stay calm because our profession is about caring" (X1).

Gaps in providing quality care
We don't have a chief nurse All participants uttered their concern toward the absence of the highest-ranking nurse particularly within hospital organization structure. For SfNPs, the absence of a chief nurse limited efforts to make progress on implementing standardized nursing care, which led to care variation. For example, many problems that occurred in care settings were associated with an unclear standard operating procedures (SOP). Subsequently, "Most nursing care activities are not consistently provided" (C1). A lack of a wound care SOP forced nurses to treat a patient's wound guided by personal experience however limited those experiences may have been. SeNPs recounted that "the most di cult one was the lack of monitoring nursing activities" (Z2) as it complicated and obscured their functions in managing nursing activities.
Hence chaos and disorder were hard to avoid. Participants described, "Everything is mixed together. Patients were sent to a ward not in accordance with their medical diagnosis… people have argued with each other over many things" (Z2).

The young nurses surpass us in all aspects
All participants voiced concerns about the employment system adequacy with regards to recruitment and placement, job evaluation and promotion. On recruitment and placement, SfNPs stated, "They do placement… but without enough knowledge about that person's competency" (X1). As a result, "All activities become impassable and ineffective" (E2), as they experienced the chaos, said SeNPs. They considered three aspects that contributed to their satisfaction and performance: "job evaluation, overtime compensation, and incentive and reward" (Z2). They believed that inadequacy in these aspects could harm nurses' motivation and compliance in carrying out their duties. Additionally, performance evaluations should also be applied to employees who earn a degree after pursuing a higher education program while working full time, saying, "it would serve as a stimulus … increase their motivation to work" (Z2). For them, "motivation affects staff spirits to carry out their tasks" (Z2). There were resentments among nurses and it happened because the fresh college graduates "came and surpassed us in all aspects, in income and position" (X1), said SfNPs. This problems of reward and remuneration systems also affected doctors and "we pity them" (Z2), said SeNPs. Accordingly, experience should be considered as a critical aspect to the reward system, otherwise workers' morale was at stake, as they said: "A staff member who was diligent, became lazy and a staff member who obeyed the code of conduct, became troublesome and not motivated anymore" (Z2). Examining this situation, SfNPs allusively demanded for a change: " For how long do we have to tolerate and bear people with this kind of attitude?" (X1).

Not enough knowledge impedes care
SfNPs seemed to have a similar understanding that "little or not enough knowledge could impede our performance" (C1), thus might interrupt nurses' contribution to a good quality level of care. Also, "level of educations that greatly vary among health workers" (C1) hindered the provisioning of good quality levels of care. They believed that "with enough experience, with higher levels of education, with a well-trained team, we can provide high quality of health services that gives high bene ts to the patients" (Y1). While acknowledging that "staff nurses' technical skills are excellent" (E2), many SeNPs posed a question, "If the majority of nurses graduated from a high school level, can we expect more?" (E2). A concern came from SfNPs: "Our capacity with current medical knowledge is limited" (Y1). Thus, aside from inadequacy in scienti c reasoning while applying nursing care, they had limited chances to advance up-to-date knowledge on diseases, diagnosis, and treatments needed for improving case management activities. They believed that efforts to increase their knowledge could improve their "spirit in working" (X1), hence "nursing services can run better" (E2). SeNPs blatantly said that if nurses failed to increase their competency, "we will get stagnant even until 10 years from now" (E2).
We work more that it should be.
SeNPs believed that "inadequacy in number and distribution of health professionals" (E2) caused increased workloads among nurses. In fact, "Two or sometimes three nurses took care of 30 patients in a shift" (Z2). While SfNPs implying that heavy workloads among nurses caused fatigue because "nurses did not have time to take a leave" (C1), SeNPs asserted that, "Our service became unfocused, a person was handling this, and then was taking care of that… we worked more than it was supposed to be. So, there was no a quality in our services at all" (Z2).
We treated the wounds using sewing needles Supplies, drugs, and equipment were considered supportive challenges. SeNPs mentioned that "often we have no drugs or … it is far from enough" (Z2). SfNPS indicated: "… many expensive broken medical devices, but no technician is available" (C1). SeNPs thought that ine ciency in other departments such as an absent mechanic to take care of medical equipment could impede the healthcare providers performance. Participants also commented on medical supply insu ciency. For example, there were many instances where syringes or wound care supplies were not available in CHC. Some nurses in hospitals creatively recycled infusion bottles and then used them "as needles containers" (X1). It was unavoidable that nurses in rural settings "treated wounds using sewing needles" (C1). In addition, nurses who had attended clinical training often found it di cult to implement what they had learned from a training session because their units lacked equipment as taught by the trainers.
Blaming each other is common Participants suggested that functioning teamwork and good communication skills were important to nursing. Nonetheless, their work atmosphere was challenged in building a solid teamwork as SfNPs said, "… blaming each other among nurses was common and affected the patients" (Y1). They highlighted the importance of working together in teams to "complement each other" (X1). Comparatively, SeNPs re ected that "our good communication and solid teamwork" (E2) approaches mattered to the patients.
Participants believed that a cultural-based approach was an important approach to gain patient trust. SfNPs from CHC said, "we had to visit our patients in their houses, spoke to them using their mother tongue so that … they had a desire to visit us in health facilities" (C1). As language plays a crucial role in communication and teamwork, SeNPs highlighted that using a wide variety of languages in hospital became a burden in their daily routine. This concern appeared in relation with language barriers due to the presence of many foreign medical doctors. They said, "If we are not clear about the instructions [from doctors], we can end up injecting a wrong drug" (E2).

Discussion
Preserving values to uphold patient-centeredness In general, nurses believed that care should be delivered safely, equitably, e ciently, and in a timely manner. In particular, they endorsed the importance of putting the patients in the center of care provision.
These aspects of quality of care are linked to the health care quality concept of the Institute of Medicine (IOM) [20,40). They also discussed viewpoints related to the concept of patient-centeredness such as promptness, respect, watchful, total presence as a remedy, and efforts used to meet patient's need. The IOM de nes patient-centered as providing care that is respectful of and responsive to individual patient preferences, needs, and values while ensuring that patient values guide all clinical decisions [20].
Our ndings indicate that nurses employ their own value system to guide their attitudes and behaviors towards their patients. Some moral values such as respect, integrity, responsibility, and equality navigate nurses' reasoning, actions, and preferences concerning right and wrong or good and bad [41,42]. They also underlined a cultural aspect in caring resonated by Timorese culture that recounts on collectiveness, kinship, connectedness, and relationship [43][44]. These aspects of culture allow nurses to build strong attachments with their patients for better caring relationship and recovery [45].
The value of the nursing profession also emerged from our study. Our participants insinuated that care for their patients must go beyond good etiquette, politeness, joyous, and a smiling face. They prevailed over challenges around their efforts in seeing patients as the whole entity to foster nurse-to-patient relationships [46], while solidifying their connection to professional values. They underlined the importance of being accountable to their patients while utilizing standardized nursing practice to foster the quality of care. Our study emphasizes some nursing values such as compassion, self-sacri ce, and dignity [42] and indicates that nurses' professional values serve as beliefs and ideals in guiding their collaboration with colleagues and their interaction with patients and families they serve [47].

Quality care milieu
Our participants strongly believed that health-care quality depends on multiple aspects, many of which were beyond the realm of nursing care. They had strong apprehension toward the structural dimension of Donabedian's quality care framework such as facility infrastructure and sta ng [22]. Like many small island countries, Timor-Leste has a collection of problems in service delivery including health supply inadequacy [14,[48][49]. With total gross domestic product (GDP) of $1.6 million [50] and total expenditure on health is around 1.48% of total GDP [13,51], Timor-Leste is struggling to improve the essential services in health sector focusing mostly on the structural dimension of quality of care [21]. Thus, a long-term nancial support is indispensable for Timor-Leste to rebuild a steady health service delivery system [52].
Our participants also indicated that health system performance affects their clinical competence. They implied how health system inadequacy incapacitates nurses in their ability to maintain patient safety and to some extent overthrows their personal desire to improve quality of care. A poor health system could defeat nurses' overall performance and decrease their motivation to advance their academic quali cations, thus affecting their clinical skills [15,53] and subsequently impacting patient safety [54]. Hence, in order for nurses to provide quality care, health system needs to operate as optimal as possible.
Our participants implied that heavy workload affects their performance. They indicated that a heavy workload has to do with two aspects; a low nurse-to-patient ratio and a limited number of higher skill nurses with whom they can consult with. Their concerns on these two aspects indicate a pressing demand for health systems to meet adequate sta ng levels. Nurses who worked with heavy workloads often failed to perform proper nursing procedures and became psychologically overburdened that inevitably led to patient mistreatment [15,[55][56][57]. Nevertheless, nurses often decided to choose their patients over the limitations in front of them [16,[57][58]. Our ndings denote that a strategic approach that includes efforts to build a strong HRH policy and nursing regulatory system [59,60] is needed to improve Timor-Leste health system such that enables nurses to function properly.
Our participants revealed an absence of nursing leadership in the hospitals and other healthcare facilities. Their concerns seemed to suggest that career advancement was also problematic. But these problems of career advancement are not solely found in Timor-Leste. Elsewhere, nurses frequently have little chance to move into higher leadership roles [61]. A lack of an effective leadership leads to adverse patient outcomes, such as medication errors [62], but the presence of nursing leadership improves patient safety [63] and affects how society regards nursing professionals. So, improving nursing leadership in the country will improve interaction between nurses and the patients thus stimulating process dimensions for better outcomes.
We indicated some limitations in this study. This study did not include nurses in academic settings. These nurses may have different experiences and perceptions on quality of care thus improving triangulation and would comprehend understanding of quality of care. However, some faculty members were invited to discuss the ndings of the study. The results were also discussed with some experts in nursing services and disseminations were held to include nurses from hospitals and CHCs and other healthcare professionals. All discussions indicated an agreement with the ndings. However, this study included only some districts in Timor-Leste, thus ndings from this study should be used cautiously.

Conclusion
The results of our study show that nurses in Timor-Leste face many di culties in the provision of care. Despite having low nursing skill mix proportion, nurses exercised their value system and embraced the concept of patient-centeredness to promote quality of care. The results of our study provide an important fact that both an inadequacy and a de ciency of various structural and environment factors of healthcare delivery, gives a negative impact to nurses' competence and performance that in turn incapacitates them to improve the quality of care. Consequently, improving the quality of care requires health system restoration such that allows nursing profession development reaching its full potential. Enhancing nursing leadership becomes urgent for stimulating excellence in nursing care that subsequently helps the health system to progress beyond quality of care's structural dimension. Our ndings can inform many actors ranging from researchers, health facilities' administrators, leaders of national health system, and international nongovernmental organizations (NGOs) and donors. For example, leaders of national health system can use information from this study to develop a comprehensive assessment of healthcare facilities, the results of which can be used to improve quality care policies. Our study portrays both the uniqueness and the breadth of the nursing profession in a prolonged con ict country. This data enriches factors that are important to quality care in underresourced places and can be used to improve quality of care measurements. Our study implies that nancial suffering and hardship faced by the least developed small island countries could impede their progress to achieve universal coverage [UHC]. Thus, data from this study can inform international NGOs and donors to include in their long-term strategies to support these countries to institute a strong health system, thereby supporting access to quality of care.