Development of Supervision Model based Experiential Learning for the Implementation of Patient Safety Goals at Teaching Hospital in Surabaya

Introduction: Patient safety is one of the demand of people who need health services. The hospital is required to fulfill the patient's safety goals. Nurses as health care providers have a risk of making mistakes and it can result in harm to the patient. The purpose of this research was to develop model of supervision based on experiential learning in the implementation of patient safety goals. Method: This research used explanatory survey. The samples were some of nurses who assigned to the ward of UNAIR hospital. The samples were selected by using stratified random sampling technique with total of 100 respondents. The variables in this research are supervision based on experiential learning and the implementation of patient safety goals. The data collection used questionnaires. The data were analyzed by using Partial Least Square (PLS). Result : The results of this study indicate that organizational characteristics and individual characteristics influence supervision based on experiential learning. Characteristics of the organization contruct by two indicators namely rewards and leadership systems. For individual characteristics, there are also two indicators that contribute on it, they are the ability and motivation. Supervision based on experiential learning affects the implementation of patient safety goals. Discussion: Supervision based on experiential learning uses four stages: concrete experience, reflective observation, abstract conceptualization and active experimentation. Supervision affects the implementation of patient safety goals by nurses in the hospital.


INTRODUCTION
Patient safety is a global issue as the community of health-care users is expecting a safe and convenient services.Improving quality and patient safety is a concern for all health care facilities, especially hospitals.The World Health Organization (WHO, 2007) issued a policy on the Nine Life Saving Patient Safety Solution as a system designed to prevent or reduce patient injury and improve patient safety.Some institutes report incidents of patient safety due to errors that could have been prevented through the implementation of patient safety.The data from Patient safety Committee of Hospital in Indonesia September 2006-2011 based on incident type revealed 249 reports of adverse events and 283 reports of near miss events.
Factors contributing to the occurrence of patient safety incidents include individual characteristic factors, the characteristic of work, the physical environment, the interaction between the system and human, organizational and social environment, management, and external environment (Lucian, Of, & So, 2010).According to the study from Sumarni (2013), the most dominant directive function in patient safety implementation is supervision.McKimm (2010) stated that supervision can basically improve patient safety and quality of care.Therefore, supervision is required to improve the hospital staff performance in patient safety.Harmatiwi (2017) in her study found that the disobedience of supervisors on the protocol of supervision was quite high (60%) and the majority of supervisors do with indirect supervision.There are several factors related to the implementation of nurse unit manager's (NUM's) supervision.Zulfikar (2015) in his research reported that leadership style and work experience have a relationship with nursing supervision.The results of Sulastri's study (2002) showed that the characteristics of the organization have a significant relationship with the ability of supervision.
Clinical supervision can improve the quality of nursing services, reduce errors, improve efficiency, improve staff performance, and reduce burnout rates (Cruz, Carvalho, & Sousa, 2014).
Suyanto ( 2009) also explained that a nursing supervisor in carrying out his/her daily duties should have the ability to provide guidance and clear instructions, so that, it can be understood by nurses.Clinical supervision is a facilitative process of professional development, contributing to the quality of practice, promoting the safety of care and protection of clients in clinical complex situations.In the supervision process, it is essential that clinical supervisors use appropriate clinical supervision strategies in order to facilitate the development of the supervisee (Pires, Reis, Pereira, & Rocha, 2016).Nurses will comprehend more easily when supported to directly implement the right patient safety goals.
Experiential learning emphasizes a holistic learning model in the learning process.In the reflective observation phase, the learner closely observes the actions performed by others, then reflects the results obtained, hence facilitating ease of understanding.Giving direct examples can encourage the nurse to perform patient safety according to the required standards.The aim of this study was analyzing the effect of organizational characteristics on supervision, analyzing the effect of individual characteristics on supervision, analyzing the effect of work characteristics on supervision, and analyzing the effect of supervision on the implementation of patient safety goals.

MATERIALS AND METHODS
The population in this study was nurses who work in the inpatient ward of the teaching hospital.They were 112 nurses.The number of sample in this research were determined using a rule of thumb formula.There was 20 variable in this study, so the number of a sample was 100 nurses.The sampling technique in this study using stratified random sampling, it is a sampling method in which the population is first divided into strata, then a simple random sample is taken from each stratum so that it can reach a representative sample.The grouping of strata used in this study is based on the length of work in the hospital.The strata were divided into, less than 1 year, 1-3 years, and more than 3 years.The study was conducted in the inpatient ward of teaching hospital in Surabaya from March -April 2017.
The variables in this research are, organizational characteristic, individual characteristic, work characteristic, supervision based experiential learning and the implementation of patient safety goals.Organizational characteristic consists of two sub-variables, they are reward system and leadership.Individual characteristics consist of two sub-variables, namely capability and motivation.The work characteristic of this study is job design and work schedule.In the variable of supervision, the four experiential learning stages are observed in the implementation of supervision.The four stages consist of concrete experience, reflective observation, abstract conceptualization, and active experimentation.The patient safety implementation variables consist of sub-variables, identifying patient correctly, improving effective communication, improving the safety of high-alert medications, ensuring safe surgery, reducing the risk of healthcare-associated infections, and reducing the risk of a patient from falls.The data were collected by using questionnaire made by the researcher.The test of validity and reliability of the questionnaire were done, and the question which was not valid have been removed from it.The data analysis used Partial Least Square (PLS).

RESULTS
Most of the nurses stated that reward system was in moderate category (79%, n=100), and leadership also in moderate category (73%).These two indicators were included in organizational characteristics.Individual characteristics consist of capability and motivation.This study found that capability in moderate category (62%), and motivation also in moderate category (72%).For the work characteristic, most of the nurses that job design was in moderate level (70%).The model in this study determined that the indicator is valid if the value of outer loading is more than 0.4 (Vinzi et al in Sofyani, 2010).

Invalid indicator includes work schedule on work characteristics variable (X3.1).
The other indicators were declared valid, it were reward system, leadership, capability, motivation, job design, supervision, and implementation of patient safety included: identifying patient correctly, improving effective communication, improving the safety of highalert medications, ensuring safe surgery, reducing the risk of health care-associated infections, and reducing the risk of patient harm resulting from falls.
The analysis of hypothesis testing used PLS, and the results as in table 1.The result of the analysis shows that there was significant affect of organizational characteristics, individual characteristics and work characteristic to the supervision based on experiential learning with the p-value were 0.005, 0.011 and 0.003.Supervision based on experiential learning also had affected the implementation of patient safety goals with the p-value 0.000.That patient safety goals consist of identifying patient correctly, improving effective communication, improving the safety of high-alert medications, ensuring safe surgery, reducing the risk of health careassociated infections, and reducing the risk of patient harm resulting from falls.

The influence of organizational characteristics on supervision based on experiential learning
Organizational characteristics consist of rewards systems and leadership.In this study, organizational characteristics contributed to the implementation of supervision based on experiential learning by the NUM.
The rewards is defined as a stimulus to improve nurse's performance in providing nursing care.Giving reward is a statement that explains what hospital wants to give to the staff in the long term to develop and implement policies, practices and reward system process that support the achievement of goals and needs (Brown, 2001in Nursalam 2016).In this study, nurse's perceptions about the hospital's reward system were mostly in quite satisfaction level.The organization or employer should reward the staff by award presentation, advancement or promotion (Mangkunegara, 2005).This study, that most of the nurses had perceived moderately about the reward system.The result of this study was consistent with Mandagi (2015) that stated the reward system had affected to the nurse's performance, and the reward could become the effective motivator to the nurses work.
The definition of leadership is the activity or art that affects others to work together based on the ability of the person to guide others in achieving the organizational goals.Leadership is one of the most important in the management function, especially in directing and controlling functions.Melo (2015) in his study stated that a NUM who apply all of the management roles can improve the nurse's satisfaction in supervision done by NUM.

The influence of individual characteristics on supervision based on experiential learning
The indicators that contribute to individual characteristics include capability and motivation.This characteristic influence on supervision based experiential learning is done by the NUM The higher capability and motivation caused the better supervision by NUM.A person's motivation is very influential on the performance that can be achieved in his job because the support will make the person doing the thing for achieving their goals (Suyanto, 2009).Motivation level of nurses in this study is found to be in a moderate category.the NUMis motivated to conduct supervision based on experiential learning in order to achieve the task and management functions and vice versa.
Many aspects can be assessed from the variables of capability, including cognitive, affective, and psychomotor abilities.This study also found that motivation level influences the ability to supervision implementation done by the NUM.This is consistent with the study conducted by Wahyuningsih (2015), which states that the ability to work has a significant positive influence on the nurse's performance, and also for the NUM.

The Influence of supervision model based on experiential learning in the implementation of patient safety goal
The result of this study stated that supervision model based experiential learning was significantly affected the implementation of patient safety goals.In this supervision, the supervisor observed implementation of patient safety goals done by nurses based on responsibility, accountability and authority aspects.Each aspect followed by experiential learning process consists of concrete experience, reflective observation, abstract conceptualization, and active experimentation.
Supervision can influence nurse's performance on implementation of patient safety goals.This is in accordance with the previous study by Hastuti (2014), which reported a significant relationship between nurse's perception about supervision with nurse's performance.This is also consistent with the study conducted by Amsrud et al (2015), which revealed that clinical supervision definitely influences the development of important skills for patient safety care, Brunero et al (2010) also asserted that clinical supervision promotes professional accountability, skill, and knowledge development.Clinical supervision was more positive evaluation where the sessions running for over one hour and took place on at least a once a month (Edwards, Hannigan, & Fothergill, 2005).Previous research, show there was a relationship between the NUM conducting supervision of the nurse in the implementation of patient safety, the nurse will be able to implement patient safety well if they are given optimal supervision by NUM (Ernawati et al, 2014).

CONCLUSIONS
The supervision model based on experiential learning was affected by the reward system, leadership, capability, motivation, and job design.Supervision based on experiential learning improved the implementation of patient safety goals by nurses included identifying patient correctly, improving effective communication, improving the safety of highalert medications, ensuring safe surgery, reducing the risk of healthcare-associated infections, and reducing the risk of patient harm resulting from falls.This supervision model is expected to be applied in hospitals to improve performance in the implementation of patient safety goals and prevent the error incident of patient safety.

Table 1 .
The Result of Analysis Picture 1. Outer loading factor results analysis using Partial Least Square (PLS)