FACTORS ASSOCIATED TO BASIC EMERGENCY OBSTETRIC NEONATAL CARE ( BEONC ) NURSES ’ DECISION MAKING SKILL

Neonatal mortality rate (NMR) is one of indicator to measure population health. The three delays model explains three underlying causes of noenatal mortality, including delay in recognizing emergency condition, reaching health facilities, and receiving treatment. The main cause of delay in recognizing emergency condition is decision making skill of the nurse to determine emergency condition in neonatal. This research aims to analyze influence of age, gender, education level, advance training, working experience, and employment status of nurse to decision-making skill in basic emergency of obstetric and neonatal care (BEONC) at community health care center. This research is analytic correlational study with cross sectional approach. One hundred fifty three BEONC nurses in Malang district were involved in this research. ‘Critical Thinking Diagnostic Tool Nursing Executive Center’ was used to measure decision making skill. Result showed that age, training, working experience and employment status were not related to decision making skill (p>0.05). While, gender and education background are significantly associated to decision making skill of nurses. It is concluded that gender and educational background of nurse contribute to decision making skill in basic emergency of obstetric and neonatal care. This study gives insight about the importance of improving critical thinking skill through continuing education and gender consideration for nursing staff placement. Keyword : Characteristic, emergency, decision making, neonatal, nurse

Neonatal mortality rate in Malang district keeps increasing in the last few years.In 2014, the rate reached 6% from 1047 total case of asphyxia neonatal.In the same year, 7% from 1496 low birth weight infant died on first 28 days of life.In 2015, mortality rate of asphyxia neonatal cases increase to 7% (from total 698 cases) (Report of Public Health Office of Malang Distric, 2016).
About 5-10% new born babies need help in the process of adaptation from intra-uteri to outside environment (Soraisham, 2013).About 1% of them need resuscitation to avoid respiratory or heart failure (Biban, 2009).The high number of asphyxia-related death in neonatus is associated to delay in recognizing the signs of emergency, reaching health facilities, and receiving treatment (Manton, 2004).
In 1995, government launched Basic Emergency Obstetric Neonatal Care (BEONC) program.Through this program, it was expected that primary health care facility could increase the quality on maternal and neonatal emergency care (Okoli, 2012).One of standardized basic emergency service is the availability of competent emergency team.Nurses as part of the team should possess decision making skills in emergency condition (Lawn, 2010).Increasing neonatal mortality rate in primary care is associated to delay on decision making in regards to emergency conditions, particularly asphyxia neonatal (Wyllie, 2010).Decision to start initial treatment and integrate referral for neonatal emergency condition should be made in a timely manner (Manton, 2004

RESULT
One hundred fifty three nurses were involved in the study to determine factors associated to BEONC nurses' decision making skill.Their characteristics is shown in table 1. Multivariate analysis showed that educational background was the major factor contributing to decision making skill of BEONC nurse (Table 5).

DISCUSSION
This study aims at identifying characteristics that contribute to decision making skill of BEONC nurses.Result showed that there were no significant relationship between age, training and tertiary eduction, working experience and employment status and decision-making skill of nurses in basic emergency of obstetric and neonatal care.The results of this study are in line with Dehghani (2016) who found that there was no significant relationship between age, marital status, work unit, education, and length of work of nurses with the ability to think critically for problem solving.Critical thinking is known to be an important part for developing efficient communication, improving problems-solving, and understanding the concept of theoretical science in nursing (Akca, 2015).The ability to think critically in decision making is not influenced by age.Older ages do not guarantee that individual has maturity in thinking.Young people who have a lot of knowledge and experience can have better decisionmaking skill than their counterpart.
This study found that gender become one of factors influencing decision-making skill.Male nurses showed better skill than female nurses.However, the strength of the relationship between two variables is weak.This is in line with Rodzalan (2015) that found that ability to survive a job with a time limit and introduction of something new in men is better than women.In another study it was also found that problem solving skill of male nurses is better than female nurses (Aboshaiqah, 2014).In handling emergency and critical situation and working with specific time and target pressure, male nurses showed better resilience than female nurses.Skill to determine priority problems and effective interventions should be owned by an emergency and critical nurse.
Another factor that contributes to decision making skill is education background.Level of education of nurses is factor that influences their critical thinking skill.Nurses with bachelor's degree showed better skill to think critically than those with diploma degree.Research by Alghifari (2014) showed that level of competence and curriculum affect motivation of bachelor nursing to think nursing problem critically.After completing basic education, nurses are more often exposed to neonatal emergency conditions and various types of neonatal emergency cases.Those can improve their critical thinking skill (Huchon, 2014).Critical thinking skill should be set as learning outcome in nursing curriculum.Right learning method should be chosen to achieve the outcome, so that nursing graduate would possess the skill (Dehghani, 2016).To create health workers with special neonatal care competencies, it requires access to formal education and special training with comprehensive qualifications and competencies.If it can be achieved, neonatal mortality and morbidity rate can be lowered (Turrill, 2014) In this study, it was also identified that advance training and tertiary education of nurses did not have a relationship with decision-making skill.Emergency nurses are declared 'competent' in providing treatment for neonatal emergencies if they have attended training related to handling neonatal emergency cases and having minimum of 3 years work experience in emergency unit.Similarly, Pilevarzadeh (2015) noticed that there was no significant relationship between levels of education and the ability of nurse to think critically.Critical thinking in handling neonatal emergencies can be improved by exposing nurses to various neonatal emergency cases.To develop critical thinking skills in handling neonatal emergencies, role play learning methods based on case study can be employed.
Another factor that also did not show a relationship with decision-making ability in this study is the length of work experience.Most of respondents in this research had worked at the community health center of obstetric neonatal basic emergency service more than three years.Considering the length of work, they can be called as an advanced clinical nurse.However, most of nurses with educational background of nursing diploma had only followed general basic emergency training, which do not cover competence to handle neonatal emergency cases.Nurses who hold bachelor's degree of nurses showed better critical thinking skill.BEONC nurses is not only expected able to provide basic emergency care in neonatal, but also detect causal factors of neonatal emergencies (Brosseau, 2006).Case study-based research from several different cases of neonatal emergencies can be used to improve the critical thinking of nurses (Huchon, 2014).
Employment status in this study was not related to decision making skill of the nurses.Lack of association between two variabels because members of the emergency team own similar legality.Critical thinking skill is taught in basic education of nursing.Similar result was shown in Dehghani (2016).Length of work of nurses was not associated to ability to think critically in problem solving.Critical thinking in problem solving is a dynamic and ongoing process.The process does not stop at basic nursing education, training and advanced education.Individual's action to improve critical thinking and problem solving skill is driven by internal factors such as personal motivation and external factors such as management support and work environment (Akca, 2015).Regarding work environment, facilities and equalization system of workload will improve employee's comfort and productivity.Critical thinking skills can also be developed by exposing nurses to emergency handling team, not only by training.

CONCLUSION
Gender and education background contribute to decision making skills.This study gives new insight about the importance of improving critical thinking skill through continuing education and gender consideration in staff placement.