1. Suba, Sukardi BSN
  2. Scruth, Elizabeth Ann PhD, MPH, CCNS, CCRN, FCCM

Article Content

The regulation of nursing varies widely in many parts of the world. In Indonesia, nurses for many years have campaigned and demanded a legislative act that specifically addresses the science and practice of nursing. Last year (September 2014), the House of Representatives passed a new Nurses Act.1 The Nurses Act is considered legal protection for nurses in Indonesia and defines their scope of practice.1 The Act was developed and passed with the specific aim to improve professional quality and the quality of nursing care. For the public in Indonesia, it is also viewed as contributing to improving public health.



Indonesia defines its nurses as vocational or professional.1 Vocational nurses have a basic education that consists of a 3-year diploma program. Successful completion of the program is required for the designation of a vocational nurse. The title of professional nurse is broken down into 2 tiers: the first tier are nurses with a bachelor of nursing degree involving clinical placement rotation, and the second tier are nurse specialists with a master's degree involving clinical residency in designated specialty focus area.1


The Nurses Act also extrapolates higher education in nursing into 3 sections: diploma, academic, and professional.


The academic-educational program consists of bachelor of nursing, master of nursing, and doctorate of nursing programs. Professional educational programs refer to both professional clinical placement programs included in the bachelor degree program and nursing specialist program after completion of the master's degree.1


Since 2013, the Indonesian government has required all healthcare practitioners other than physicians, dentists, and pharmacists to register with the Indonesia Healthcare Profession Board.1 The Registration Certificate is mandatory for nurses to practice both in clinical settings and nonclinical settings. In late 2013, a national competency examination for vocational and baccalaureate nurses graduating after August 1, 2013, was implemented based on a mandate from the Higher Education Directorate of Ministry of Education.1 The implementation was marked with controversy as many nurses in Indonesia were critical of the new policy as there was not sufficient legal precedence regarding the execution of the examination. More importantly, nurses voiced their concern as the Nurses Act was still in draft at that time. The voice of the nurses in Indonesia was heard, and in early 2014, the competency examination was postponed. With the Nurses Act legalized, the competency examination is now mandatory for all nurses at the completion of their education program. The certificate is required to register with the National Nursing Council to receive a nursing registration certificate. The certificate is valid for 5 years.


After 5 years, in order to continue to be registered, nurses in Indonesia are required to actively serve their community and participate in healthcare services, education, training, and/or other scientific activities. Details about the specific requirements will be regulated and directed by a nursing council, which is not established yet in Indonesia.


Foreign nurses who intend to practice in Indonesia are required to pass a competency evaluation. The evaluation consists of an administrative process involving verification of educational credentials and the competency examination. Nurses who meet the criteria are granted a Temporary Registration Certificate and Temporary Nursing License to practice in Indonesia. An Indonesian citizen who has completed his/her nursing education outside the country is granted a nursing license for 5 years and is eligible to renew after 5 years.1


Nurses in Indonesia practice in a variety of settings including private clinic and public healthcare facilities. Nurses are authorized to perform medical treatments based on physicians' delegation or mandated orders. Based on local government/agency policies in areas where physicians are limited in number, nurses are legally permitted to prescribe limited medical treatment for common diagnoses, order a patient referral, and perform pharmacy services. In addition, in life-threatening situations, nurses can perform medical actions and administer medications. All of these actions will be regulated by codes from the Ministry of Health, which will be derived from the new Nurses Act and with consideration of the nurse's competencies to perform such specific interventions.


The Indonesian National Nurses Association (Persatuan Perawat National Indonesia) is the national nurses' organization in Indonesia.2 The organization aims to increase and develop knowledge, skills, dignity, and professional ethics. It functions to unify, foster, develop, and supervise nursing in Indonesia. Within the organization, the Nursing Collegium will be formed as an autonomous body with the specific aim to develop nursing specialty branches and higher education standards for professional nurses in Indonesia. The nursing council will be established to improve the quality of the nursing practice and to provide legal protection for nurses. The nursing council will be a part of the Indonesian Healthcare Professions Council and will be located in the capitol city of Indonesia. Specific duties of the council will include nursing registration, guiding nursing practice, guiding and directing advanced nursing education, developing a standard of nursing practice and competencies, and establishing disciplines in practicing. As both the council and the collegium have not been established yet, the constitution mandates the organization to establish ones within 2 years from the passing of the Nurses Act in late 2014.



Prior to the passage of the Nurses Act last year, there had been master's degree-prepared nurse specialist programs developed by the University of Indonesia, commencing in 2003 with Maternity Nursing and Community Nursing Specialist programs.3 Currently, the University of Indonesia is the only school that provides the nurse specialists program in Indonesia, with 5 specialty programs (community, maternity, medical-surgical, psychiatric, and pediatric) in addition to the leadership and nursing management program. There is no official regulation around the scope of practice and standard of competencies for the nurse specialist practicing in Indonesia. Considering that the Nurses Act has just been legalized, it is clear that the authority bodies, specifically the Ministry of Health and professional organizations, need additional time to develop outlines and specific codes for advanced practice-level nurses based on the Nurses Act.


Since the nurse specialist program at the University of Indonesia has been established for a decade, there has been a small number of graduates who have started to work throughout communities in the country. The majority, however, work in the academic setting. The small numbers of nurse specialists is likely due to the limited regional scholarships available for nurses to undertake the program. Another factor is the low salaries for nurses practicing in clinical settings and also because there is no clear definitions of the scope of practice for the nurse specialist in the field. There have been many questions not only from the community as consumers of nursing care, but also from institutions (eg, hospitals, clinics, and other public health centers), about what the nurse specialists really do and their roles, especially in clinical settings. Nurse specialists are still viewed as performing bedside level nursing care, and thus, there is no clear distinction between vocational nurse- and general professional nurse-level practice. Therefore, the existence of a clinical nurse specialist is not clearly defined or perceived as a specialty by both the public and hospital systems.


Looking at the future of the clinical nurse specialist in Indonesia, there are several issues that need attention in order to develop the scope of practice. For this purpose, the authors will try to compare and contrast the nurse specialist-level graduates in Indonesia with that of the clinical nurse specialist model from the United States.


The nurse specialists are master's degree-prepared nurses who complete an academic program (graduate degree) and an additional 2 semesters of a clinical residency program based on an area of specialty.4 The main goal is to fulfill the biopsychosociospiritual needs of the patient. It is also expected that the nurse specialist graduate maintain the following roles: take preceptorship role; take consultation role; apply legal, ethical, and humanistic practice; and take an active part in developing the profession based on his/her expertise.


Looking back in 2012, in fact, there had been an effort from the Higher Education Directorate of Ministry of Education, in collaboration with the profession organizations and educational institution association, to develop standard competencies for all levels of nurses practicing in Indonesia.5 Based on the draft written at that time, there are main aspects of competencies for nurse specialists: professional practice, legal and ethics; nursing care and management; and professional, personnel, and quality development.5 In the nursing care and management competency, there are several subsections defined: health promotion, nursing process, therapeutic communication, leadership and management, interprofessional services, delegation/supervision, and environment safety. These competencies require the nurse specialist to utilize their knowledge, skills, and critical thinking and clinical judgment. In addition, all actions taken by the nurse specialists should consider patient safety and comfort. The nurse specialists are also expected to perform clinical evidence-based research in answering scientific problems, utilizing technology based on area of specialty, and be able to collaborate with other professionals and team members. The education for nurse specialists also puts them as referral resources for other nurses. However, this draft has not been finalized yet and will need more additional time to be regulated by related authority bodies.



In comparing the CNS program in the United States, there are several differences in Indonesia relating to expert clinical practice, research, consultation, and leadership roles.6 In Indonesia, it is not fully clear if the nurse specialist program correctly encompasses the following: advanced physical assessment, advanced pathophysiology, and clinical pharmacology, which are mandated for advanced practice nurse (APN) programs in the United States (APN includes clinical nurse specialist, nurse practitioner, nurse-midwives, and certified registered nurse anesthetist).6 In addition, the nurse specialist program does not prepare students with diagnostics and therapeutics courses.


The specialist-prepared graduates in Indonesia are not empowered with conducting nursing research, including the initiation of evidence-based practice in their practice setting. The nurse specialists are not prepared to conduct research findings analysis, evidence integration, and application of EBP principles and its role in improving quality of care.


For the consultation role, nurse specialists function as a resource for nursing consultation with nursing colleagues and/or the lower-level nurses. However, they are not prepared to provide consultation in the broader setting that involves patients, other medical staff and interdisciplinary colleagues, and system. In leadership competency, nurse specialists are mostly prepared in providing leadership role as a team leader in a team of care, delegation of team members and available resources, and contribution to policy and procedure in their specialty area, as well as in the development of professions and specialty education. It is not clear if they are prepared for advocacy and policy involvement in the wide-system level.



Finally, it is clear that the future of the nursing profession in Indonesia will need further development in the coming years. With the new Act, the government regulatory bodies, professional organizations, and educational institutions are now in alignment of how the profession will need to progress. Indonesia will be challenged to bring the nursing profession from a current state to a desired future state that will include defining the role of the clinical nurse specialist. All stakeholders will need to be engaged to develop the role and scope of the APN.




1. Indonesian Nursing Act.-38 year- 2014. Accessed May 2, 2015. [Context Link]


2. The Indonesian National Nurses Association (INNA) homepage. Accessed May 2, 2015. [Context Link]


3. University of Indonesia: Nursing Science Programme ( home page). Accessed May 2, 2015. [Context Link]


4. Program Magister Fakultas Ilmu Keperawatan. Universitas Indonesia. Brosur program S2 FIK-UI. [brochure]. Accessed May 2, 2015. [Context Link]


5. Persatuan Perawat Nasional Indonesia, Asosiasi Institusi Pendidikan Ners Indonesia, & Asosiasi Institusi Pendidikan Diploma Keperawatan Indonesia. Standar kompetensi perawat Indonesia [draft]. 2012. Accessed May 2, 2015. [Context Link]


6. Clinical Nurse Specialist Core Competencies. Accessed May 2, 2015. [Context Link]