402 | pISSN: 1858-3598  eISSN: 2502-5791 Jurnal Ners Vol. 14, No. 3, Special Issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17216 This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License Systematic Review Why We Have to Develop Instruments of Our Caring Measurement Based on an Indonesian Perspective Candra Panji Asmoro1,2, Rr Tutik Sri Hariyati1, and Andri Setiya Wahyudi2 1Faculty of Nursing, Universitas Indonesia, Depok, Indonesia 2Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia ABSTRACT Introduction: Caring is the core or focus in nursing as a form of professional nursing practice. The current caring instrument is an original instrument that measures the attitudes or behavior of nurses, has not paid attention to the administrative and environmental aspects of the hospital. The use of an instrument that does not yet contain certain characteristics gives rise to improper measurement results. The purpose of this study was to explain the importance of developing caring measurement instruments with an Indonesian perspective. Methods: Systematic reviews were carried out from database articles on ScienceDirect, Scopus, Google Scholar, SpringerLink, Wiley online, Proquest, and EBSCOhost. Criteria for articles were articles published in the last 10 years, national and international research locations, and in Indonesian and English. 15 references were obtained from 2100 references that met the predetermined criteria. The development of a caring behavior instrument based on an Indonesian perspective does not yet exist. Results: The results found that development on the basis of linguistics, cultural adjustment, and according to the prevalence of disease in a country because the epidemiology of the disease differs on the climate region. Conclusion: Specific caring instruments in an Indonesian perspective is expected that the research results will be more accurate. ARTICLE HISTORY Received: Dec 26, 2019 Accepted: Dec 31, 2019 KEYWORDS caring; linguistics; cultural adjustment CONTACT Candra Panji Asmoro  candra .panji.a@fkp.unair.ac.id  Faculty of Nursing, Universitas Indonesia, Depok, Indonesia Cite this as: Asmoro, C.P., Hariyati, R.T. S., & Wahyudi, A.S.. (2019). Why We Have to Develop Instruments of Our Caring Measurement Based on an Indonesian Perspective. Jurnal Ners, 14(3si), 402-407. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17216 INTRODUCTION Caring is at the core of humanity. The basis for providing nursing care for patients by nurses is caring behavior (Alligood, M.R. Tomey, 2014). Nurses who meet caring criteria in attitudes and behaviors will guarantee excellent nursing services at the hospital (Fawcett, 2005). Nurse caring behavior can influence patients in quality services (Prompahakul, C., Nilmanat, 2011). In some previous studies, there were still caring attitudes and behaviors that nurses perceived were lacking by patients or by other nurses in the hospital. The current caring instrument is an original instrument that measures the attitudes or behavior of nurses, this has not paid attention to the administrative and environmental aspects of the hospital. The use of non-specific instruments results in incorrect measurement results. Research on caring instruments has given birth to instruments that can measure caring according to the desired dimensions and aspects (Suroso, 2016). The development of caring instruments based on the characteristics of the Indonesian nation has never been done. The results of the literature study conducted by researchers found a study of developing caring instruments to be used in emergency nursing services. Meanwhile, most of the research on caring in Indonesia adopts instruments from other countries, of course, there are elements that are different from ours, for example, language. In addition to language, there are aspects that need to be considered to develop caring instruments in Indonesia, namely nurse career paths, which are systems to improve performance and professionalism in the field of work through competencies that produce professional performance (Kementrian Kesehatan RI, 2017). By https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:dopaminsirup@gmail.com http://dx.doi.org/10.20473/jn.v14i3(si). JURNAL NERS http://e-journal.unair.ac.id/JNERS | 403 developing caring instruments that are tailored to the characteristics of the Indonesian nation, it is expected that caring measurements carried out in Indonesia can be more specific and unbiased. Several studies on caring nurses have been carried out with various caring parameters used or various kinds of caring questionnaires themselves. Chen, S. Y. conducted a validity study of the caring questionnaire namely the Caring Assessment Report Evaluation Qsort (CAREQ) in China. Chen compared the level of nurse caring behavior seen from two sides, namely based on nurses' perceptions themselves and patient perceptions. This study provides information that there are significant differences in the level of caring between the assessments made by nurses and patients (Chen, S.Y., 2018). The validity and reliability study of the caring behavior questionnaire was also conducted by Ayala, R.A. and Calvo, M.J. This study examines the reliability of the Asset Assessment Caring Behavior (CBA) questionnaire to be used in Chile in Spanish (Ayala & Calvo, 2017). Fleming, R. developed a Japanese version of the Care Planning Assessment Tool (J-CPAT) whose original instrument was developed in Australia for people with dementia (Fleming, Nagashio, Kanegae, Ichimaru, & Koizumi, 2009). Instrument development was carried out because then 2 million Japanese people experienced dementia. A comprehensive assessment is vital in providing appropriate services and for improving the quality of life for elderly people with dementia. J- CPAT is valid and reliable for planning care in Japan (Fleming et al., 2009). This shows that there are differences in the assessment of caring behavior between countries so that adjustments are needed so that the questionnaire is more representative in its use. According to Jean Watson, caring is central to nursing practice because caring is a dynamic approach, where nurses work to further raise their concern for clients. The key to the quality of nursing care services is caring, empathy and caring. This is in accordance with the demands of the community at this time, namely to expect quality nursing services (Muhlisin, 2008). With the caring instrument in accordance with the conditions and characteristics in Indonesia, researchers in Indonesia do not need to adopt caring instruments from other countries. It is hoped that more research on caring will result in better results because the instruments are more specific. The results of the literature study conducted by researchers obtained articles that developed caring instruments according to the conditions or characteristics of the nation or country. Ayala Research, R.A., and Calvo, M.J develop caring instruments by prioritizing linguistic and cultural adjustment aspects (semantic disambiguation, morphosyntax, and language). One example of the difference in the original instrument at the different CBA if applied in Spanish is the parameter "know what they are doing" by analysis of the far difference. Meanwhile, in Fleming's research, the CPAT adaptation process in Japanese included: translation into Japanese, item evaluation and modification if necessary, re-translation and comparison with the original, creating final results, assessing validity and reliability. There are additional items "The person interacts with the family" needed on the Social Interaction sub-scale. Family interaction is an important care factor in Japan where traditional family-based care is still expected. Based on preliminary studies conducted by researchers through interviews with the Nursing Committee regarding the implementation of credentials in a large hospital, information was obtained that they had difficulty assessing nurses' caring behavior. According to them, caring evaluation parameters between clinic nurses and patients are sometimes in the instrument, but there are other activities from the nurse which are not caring behaviors but which are not in the instrument. While from the nurses' side when they filled out a questionnaire about caring behavior it stated that some of their caring activities were not on the instrument, such as doing caring by adjusting the ethnicity of the patient's culture. This states that caring assessment parameters do not reflect the actual conditions in the field. Besides that, there is also no caring instrument that matches the characteristics of Indonesian people which can be used for caring assessment. The nursing assessments are that the skills of nurses do care for patients increasingly trained with a large number of cases and patients and varied. Based on the description above it is understandable the importance of developing caring instruments with an Indonesian perspective. MATERIALS AND METHODS Systematic reviews or reviews are more widely used than descriptive reviews because they use systematic, explicit methods and reduce the effects of bias. The quality of the studies conducted can also be assessed and concluded based on the methodology used and the most votes (B’Far, 2005). In this study, a systematic review methodology was used to identify, assess and compile evidence from research to develop caring measurement instruments; Indonesian perspective. The stages in conducting a systematic review consist of 5 stages, namely (Fling, 2009) are (1) question mapping. The problem to be analyzed must be specific, clear and the researcher prepares structured questions before the review. Why do we have to develop caring instruments according to the Indonesian perspective? What is the appropriate caring instrument to be applied in Indonesia? How can the development of caring instruments be accepted and applied directly to Indonesia?, (2) Identification of relevant publications. A comprehensive literature search for literature published between 2009 and 2019 was carried out using several search engines including ScienceDirect, C. P. ASMORO, ET AL. 404 | pISSN: 1858-3598  eISSN: 2502-5791 Scopus, Google Scholar, SpringerLink, EBSCOhost, ProQuest, Wiley Online. Other criteria in search are articles with English and Indonesian, accredited journals, theses, and dissertations. The search term is broadly determined with the aim of finding as much relevant literature as possible. The inclusion of one or more keywords or text terms is also determined with the aim of focusing the results on the desired topic. The keywords used are caring instruments, development of an instrument to measure care. Of the 2100 articles obtained in the search results, researchers determined 15 articles that met the inclusion criteria, (3) Assessing the quality of research. Preparation of research questions (stage 1) and study selection criteria (stage 2), the next step is to describe the minimum acceptable design level. Study designs were received from observation to experiment. Another article is a book, domestic legislation that supports a systematic review of why we should develop caring measurement instruments with an Indonesian perspective, (4) Summarize the evidence. Data synthesis consists of a tabulation of study characteristics, quality and results and also statistical methods to explore differences between studies and combined results. In this study, the search results were categorized in themes related to the development of caring measurement instruments with Indonesian perspectives to be concluded based on the evidence found, (5) Interpretation of findings. Issues found in each of these stages must be met and the risk of bias or potential bias must be explored. Exploration of heterogeneity can help determine whether general conclusions are reliable or high-quality research observations are needed to make conclusions. Recommendations are generated based on the strength and weakness of the evidence or data found (Khan, K.S., Kunz, R., Kleijnen, J., Antes, 2003). The systematic review process as shown in Figure 1. Each article or abstract is read by the researcher with reference to the questions that have been mapped. Systematic reviews or reviews are more widely used than descriptive reviews because they use systematic, explicit methods and reduce the effects of bias. The quality of the studies conducted can also be assessed and concluded based on the methodology used and the most votes (B’Far, 2005). In this study, a systematic review methodology was used to identify, assess and compile evidence from research to develop caring measurement instruments; Indonesian perspective. The stages in conducting a systematic review consist of 5 stages, namely (Fling, 2009) : (1) question mapping, the problem to be analyzed must be specific, clear and the researcher prepares structured questions before the review. Why do we have to develop caring instruments according to the Indonesian perspective? What is the appropriate caring instrument to be applied in Indonesia? How can the development of caring instruments be accepted and applied directly to Indonesia? (2) Identification of relevant publications. A comprehensive literature search for literature published between 2009 and 2019 was carried out using several search engines including ScienceDirect, Scopus, Google Scholar, SpringerLink, EBSCOhost, ProQuest, Wiley Online. Other criteria in search are articles with English and Indonesian, accredited journals, theses, and dissertations. The search term is broadly determined with the aim of finding as much relevant literature as possible. The inclusion of one or more keywords or text terms is also determined with the aim of focusing the results on the desired topic. The keywords used are caring instruments, development of an instrument to measure care. Of the 2100 articles obtained in the search results, researchers determined 15 articles that met the inclusion criteria. (3) Assessing the quality of research. Preparation of research questions (stage 1) and study selection criteria (stage 2), the next step is to describe the minimum acceptable design level. Study designs received from observation to experiment. Another article is a book, domestic legislation that supports a systematic review of why we should develop caring measurement instruments with an Indonesian perspective. (4) Summarize the evidence. Data synthesis consists of a tabulation of study characteristics, quality and results and also statistical methods to explore differences between studies and combine results. In this study, the search results were categorized in themes related to the development of caring measurement instruments with Indonesian perspectives to be concluded based on the evidence found. (5) Interpretation of findings. Issues found in each of these stages must be met and the risk of bias or potential bias must be explored. Exploration of heterogeneity can help determine whether general conclusions are reliable or high- quality research observations are needed to make conclusions. Recommendations are generated based on the strength and weakness of the evidence or data found (Khan, K.S., Kunz, R., Kleijnen, J., Antes, 2003). The systematic review process as shown in Figure 1. Each article or abstract is read by the researcher with reference to the questions that have been mapped. RESULTS Search results are analyzed and categorized in large themes. In general, the theme is related to why we should develop caring measurement instruments JURNAL NERS http://e-journal.unair.ac.id/JNERS | 405 with the perspective of Indonesians grouped into caring instrument development, cultural factors that influence the development of caring instruments, benefits of developing caring instruments, validity and reliability of the development of caring instruments. The results of the literature study conducted by researchers found several studies that used the cultural influence of a country in developing caring instruments. The research conducted by Ayala, et al (2017) reports on the process of cultural adaptation from the Caring Behavior Assessment Tool for Spanish. The results of the development of the instrument are considered valid and reliable and will facilitate caring measurements in countries with Spanish (Ayala & Calvo, 2017). Fleming, R. developed a Japanese version of the Care Planning Assessment Tool (J-CPAT) whose original instrument was developed in Australia for people with dementia (Fleming et al., 2009). Instrument development was carried out because at that time around 2 million Japanese people experienced dementia. A comprehensive assessment is very important in providing appropriate services and for improving the quality of life for elderly people with dementia. J- CPAT is valid and reliable for planning care in Japan (Fleming et al., 2009). The study conducted by Piredda, et al developed and conducted psychometric testing of Caring Behavior Scale nurses who speak Italian. Patient's perception of nurse caring behavior is a predictor of quality from care. Caring behavior is culture-specific, but there is no instrument to measure the patient's performance regarding the caring behavior of nurses in Italy. Most measurements of caring behavior are very long, showing unclear psychometric performance, failing to assess actual behavior or not being widely used with different caring theories. The study aims to contribute to caring nurse investigations. The scale of caring behavior of nurses who speak Italian is a measure with good construct validity and strong reliability in assessing the perception of hospitalized patients in Italy on nurse behavior. This study contributes to the operationalization of caring and provides instruments that can be used regardless of the caring model in nursing practice. The Nursing Caring Behavior Scale (NCBS) shows excellent psychometric performance (Piredda, M., Ghezzi, V., Fenizia, E., Marchetti, A., Mannis, M.G.De., Sili, 2017). DISCUSSION Andres's research aims to evaluate the validity and reliability and measure the technical competence of nurses in Colombia with the Spanish version of Technological Competency as Caring in Nursing Instrument (TCCNI). TCCNI is translated into Spanish. The Spanish version of TCCNI shows consolidated validity, being a viable and reliable instrument for measuring nurse technology competencies in Colombia. Some dimensions of the Spanish version of TCCNI; knowing is caring, professional and disciplinary values of nursing, care, and ethics, technological competency, healing (Álvarez & Díaz, 2017). The Burbank study, et al shows that ageism has become an issue in the U.S. and also globally reflected in nurses' attitudes towards older patients. Most research in this field measures the attitudes of the elderly differently from the feelings of nurses about caring in the elderly. The purpose of the study was to determine the reliability and validity of 24 Perspective on Caring for Older Patients (PCOP) items and develop a scale using a tool that is useful for measuring nurses' perspectives on caring for the elderly at the U.S. and internationally (Burbank, Burkholder, & Dugas, 2018). Joseph S. et al reported the results of his research that many children, adolescents, and young people were involved in parents, siblings or other relatives who had an illness, disability, mental health problems or other needs for care or supervision. This study aims to develop two new instruments to be used in research with young carers to examine caring activities and psychological effects on them. The Multidimensional Assessment of Caring Activities Checklist (MACA-YC18) is a self-report measurement with 18 items used to provide a total index of caring activities by young people. The Positive and Negative Outcomes of Caring Scales (PANOC-YC20) is a self-report measurement with 20 items used to provide positive and negative results from caring (Joseph, Becker, Becker, & Regel, 2009). Suhonen examines about adapting the scale of individual care for cross-cultural comparisons. Cross-cultural comparison studies use instruments of reliability and validity that can increase awareness of differences and similarities between the ability of health workers to respond to individual patient needs in different health systems. The purpose of this study was to explain the process of translation and adaptation of the Individualized Care Scale (ICS) and test the reliability and validity of the study of cultural litas. Given that ICS has been proven to be a useful measure for assessing patients' perceptions of individualized nursing care in Finland, Greece, Sweden and the United Kingdom, additional populations are needed to establish the normative characteristics of the instrument (Rn, R.S., Adjunct, D.M., Rnt, 2010). The results of the study by C. P. ASMORO, ET AL. 406 | pISSN: 1858-3598  eISSN: 2502-5791 Salimi show that nurses' caring behavior may be influenced by many variables. The purpose of this study was to develop an initial form of the instrument for evaluating the determinants of nurse caring behavior. The instrument uses a simple scale with good reliability and validity that provides comprehensive information about the determinants of caring behavior in a short time (Salimi, S., Azimpour, 2013). Steele-Moses examined the Caring Assessment for Care Givers (CACG). CACG revisions are reliable and valid and are useful for use in organizations. Specially designed to measure the Re- Igniting the Spirit of Caring program (Steele-Moses, Koloroutis, & Ydarraga, 2011). Karhe, L., et al studied about The Caring Loneliness Scale (CARLOS). This article assesses the constraints and constructs validity of the scale designed to measure patient experiences of loneliness in the relationship of professional care. This finding supports the reliability and validity of CARLOS for assessment of breast cancer and heart surgery but because of all the instruments, further validation is needed (Karhe, L., Kaunonen, M., Koivisto, 2016). Chen, et al conducted research on caring which aims to examine the validity and reliability of the Chinese version of the Caring Assessment Report Evaluation Q-sort (CARE-Q). The results indicate high reliability and good content validity. The original instrument was translated into Chinese and tested in Taiwan. The scoring was modified using a Likert scale between 1 and 7. Several modifications were made to the Chinese version of CARE-Q. The instrument is made with 50 items on six factors. Some of the factors modified, among others, comfort becomes anticipates and comfort, anticipates being respects, trusting relationship becomes a helping and trust relationship (Chen, S.Y., 2018). Research Galvin’s describes the qualitative development of tools that are sensitive to the dimension of human care informed by a life-world philosophical orientation. This tool can be applied to align staff with the human care dimension and offer items pointing to examples of humanizing and inhuman practice features in ways that have not been fully captured in caring literature (Galvin et al., 2018). ‘Caring for Country 'by Burges' is defined as indigenous participation in activities that are interrelated with the aim of promoting ecological and human health. Ecological services on land owned by indigenous peoples attract several institutional investments. However, health outcomes related to the participation of indigenous people in 'caring for the country' activities have never been investigated. This study shows initial support for the validity of caring for the country concept and a questionnaire designed to measure it. The study also highlights the importance of investigating customary health promotion activities. Further research in the same population is feasible to test generalizations from this questionnaire and to explore the relationship with other important indigenous health outcomes (Burgess, C.P., Berry, H.L., Guntorpe W., Baili, 2008). He T., et al investigated Perceptions of caring in China. This research was conducted in mainland compare the perception of nurses and patients about nurses caring behavior. The concept of caring is important for patients and caregivers. If patients and caregivers feel differently caring behavior, patients may not have their needs met or will not be satisfied with nursing. The gap between the two groups showed that nurses need to improve their understanding of and response to the needs and expectations of the patient's actual and perceived. In China, patients need more support from nurses about their psychological needs (He, T., Ms, Y Du, Wang, L., Zhong, Z.F., Y, XC., Ms, 2013). Della- Monica's study on the nurse caring patient development scale has two purposes. First, meta- synthesis of qualitative studies on the perception of nurses, students and patients on nursing care to produce new definitions of care and the development and psychometric analysis of the new instrument the Nurse Caring Patient Scale (NCPs). The second objective of this research is the development and testing of new instruments that measure the patient's perception of feeling cared for by a nurse. Item for NCPs is derived from descriptors meeting nurse-patient by the patient. NCPs, an instrument valid reliable, can provide a means to measure aspects of nursing care that is not visible in addition to the current measures for quality and satisfaction, and it can provide a cross-cultural comparison to the differences so as to provide a response to the call for evidence-based practice and patient-centric care. NCPs are also able to provide a more comprehensive evaluation of patient satisfaction with nursing care by assessing the patient's perception of nurses who currently hidden, and not measured (Della-Monica, 2008). CONCLUSION The basis for providing nursing care for patients by nurses is caring behavior. Nurse caring behavior can have an effect on quality services to patients. Caring is the essence of nursing. In Indonesia, there is a caring assessment for nurses based on nurse career paths that still need to be developed because it is still JURNAL NERS http://e-journal.unair.ac.id/JNERS | 407 not appropriate. 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