Theoretical Perspectives Of Occupational Health Nurses (OHN) Career In Indonesia: A Critical Review And Future Exploration

Abstrak: In practice the Occupational Health Nurses (OHN) in Indonesia do not have suﬃcient career objectives regardless of the availability of 30.381 medium-large industries. These opportunities and challenges prove that from the OHN employment viewpoint, the prospects for the OHN professionals are very promising. In terms of education where OH nursing specialization in Indonesia is still very limited, the career of the OHN corporate nursing profession needs to be analyzed and explored. This review aims to enhance the understanding of OH nurses' careers based on theoretical perspectives in an increasingly dynamic educational environment, provides comprehensive understanding of the work for OHN nurses and oﬀers future research direction. The method used was Assessment Model of Meleis to review selected documents by implementing three types of career path, i.e. Career Framework, Change Model and Nursing Career Framework. There were 71 documents were reviewed include of the nursing education system by the Ministry of Health, the National Education System, Ministry of Higher Education (Ristekdikti), Development and Empowerment of Healthcare Human Resources (BPPSDM), AAOHN, OHN Career Guide Canada and several journals of the last ﬁve years, from 2016 to 2020. Meleis’ Model provides a deeper understanding of the OHN career. Meanwhile, reviewing career framework theories also contribute to the career path of OH Nurses, both in practice, research, education and administration in various dimensions of nursing care in the industrial se�ings.


INTRODUCTION
Theoretically and practically the Occupational Health Nurses (OHN) in Indonesia do not have clear career path regardless of the availability of 30.381 medium-large industries (BPS, 2020).The condition is followed by the growth in healthcare services, which is classified as the highest among 17 existing sectors (Databoks, 2020).These opportunities and challenges prove that from the OHN employment perspective, the career of OHN professionals is in fact very promising, from the nursing education of Diploma until Post Graduate levels.Polytechnics of Health (Poltekkes) of the Ministry of Health throughout Indonesia produced 8,709 nurses for the diploma III education level and 2,162 young nurses for the undergraduate level in 2019 (MoH, 2020).From other colleges or universities of non-MoH educational institutions, in the same year, 138,206 graduate nurses were produced (MoH, 2020).The total number of nursing education graduates occupies 43% of all non-medical health education graduates in Indonesia.This means that the nursing profession is much demanded, dominating the healthcare profession in Indonesia.Law No.38 of 2014 states that what is meant by professional nurses is at least a bachelor's degree and has a nursing license (MoH, 2019).Nurses working in industries need to pursue their career (AAOHN, 2012).Globally, the nursing workforce reaches 59% of all health professions in the world (WHO, 2020).This number will continue to increase and change according to the needs of the times (Tukayo et al., 2021).Changes in the environment, such as increasing globalization, rapid technological advances, increasing workforce diversity, and expanding the use of outsourcing and part-time and temporary employees, have changed traditional organizational structures (Sullivan and Baruch, 2020).The relationship between employers and employees, and the work context, also leads to changes in how individuals carry out their careers.
Traditionally, nursing career has been defined as the individual's relationship with organizational work.This linear career is described as taking place in the context of a stable, organizational structure (Super, 1957), with individuals advancing up the corporate hierarchy seeking greater extrinsic rewards (Rosenbaum, 1979).Historically, this model was popular during the 1950s and 1960s, supported by an economic and workplace environment characterized by the introduction and growth of new technologies as well as social norms and structures (Sullivan & Croci o, 2007).One decade later, health services in the industries are also experiencing developments.Tukayo (2020) mentioned that the number of OHN nurses in Indonesia is relatively rare.Based on data as of April 26, 2020, the Ministry of Industry (Kemenperin, 2020) noted that they had issued operational permits and mobility for industrial activities to 14,533 companies.The total workforce is 4,330,215 people (CNBC, 2020).
Yet, the problems of Occupational Health Nursing services in industries still exist.The graduate nursing program in Indonesia started in 1985 (Universitas Indonesia, 2020).Yet, OH Nurses are still very limited in numbers, apart from the unavailability of nursing education institutions that carry out OHN specialization programs, OHN teaching staff are not yet available, OHN training in universities in Indonesia also does not exist (Tukayo et al., 2021).According to WHO (2012), the role of OHN nurses includes clinician, nursing manager, adviser, educator, researcher and coordinator.The lack of quality and quantity of OHN services in the future will affect healthcare services in general in the industrial world in Indonesia.Due to these phenomena, this study analyzes the career development of OH nurses in Indonesia and their future prospects from theoretical perspectives, with the hope that it can be used as a reference for pursuing OHN's career path in the future.

METHODS
The method used in this article is Assessment Theory Model by Meleis (2016) to review 71 documents to match with three types of career paths, i.e.Career Framework, Change Model by Ko er and the Nursing Career Framework that have been used by Bernard and Oster (2018).These three types of nursing career models were selected after being compared with two other models that have been used in career development, namely the Delphi Model (Rahimi et al., 2020) and the competency-based Quinn Model used by Fitria (2016).Meleis' model (Figure 1) consists of 5 phases: analysis, criticism, test, support and description of the theory.Meleis's Model was used for the study as it enables the analysis of scientific research in a systematic and broad manner, favoring the description and dissemination of knowledge produced.Besides, it is more applicable with the situations and conditions of the Indonesian nurses.

RESULTS
The analysis theories model proposed by Meleis consists of 5 phases: analysis, criticism, test, support and description.Analysis of the Theory is the process of identifying parts and components which includes concept analysis and theoretical analysis.Concept analysis is a useful process for theory development and evaluation, including semantic analysis, logic and contextual derivation, in addition to the description of antecedents and consequences of concepts (Neto et al., 2016).This study analysed 71 documents and their contents or theories were identified whether relevant with OHN career.The theory involves important factors that can influence the development of the theory and its current structure.Criticism of the Theory aims to build relationships between structure and function such as analyzing clarity, consistency, simplicity, complexity, theoretical diagrams, circles of transmission (geographic origin of theory, geographic expansion and influence of theory), utility (in practice, research, education / training and management) and external components such as personal values, conformity with other professional values, conformity with social values and social significance (Neto et al., 2016).In this phase the 35 documents (49.29%) were assessed for eligibility as per clarity, simplicity, geographic expansion, research, education and training.Other documents (36 or 50, 71%) were excluded).Test of the Theory deals with practice, submi ing for use, conducting reviews.This phase consists of inspection, a systematic process in which theoretical proposals are submi ed to research for accuracy in all their forms and approaches (Neto et al., 2016).The consequences of testing the theory of the study results may suggest changes and improvements.The test of the theory is a dynamic process and provides verification of theory development.In this stage 20 documents (57.14%) out of 35 were tested in which 1 model (Meleise's) and 3 theoretical (models) were selected, i.e.Career Framework, Change Model by Ko er and the Nursing Career Framework.Support of Theory is a phase in which the extent and acceptance of the proposed theory is evaluated, in order to identify the existence of a scientific community that applies this theory or in different situations (Neto et al., 2016).In this phase 3 scientific theories were applied out of 20 focused documents and 15 documents (42, 85%) were treated as supporting documents.The Description of Theory includes functional components (OHN focus, nursing problem, nurse-client interaction and environment) and structural (assumption, concept and proposition).There were 13 documents (31.14%) that focus on OHN, nursing problems and other related information in this stage.
The results of Meleis's model are then explored and divided into three stages after sorting out that the three types of nursing career are most appropriate in planning future career paths for the OHN nursing profession, i.e.Career Framework Model, Ko er's Change Model and the Nursing Career Framework.However, a clear description of OHN's career is presented by the OHN Canada nurse association (OOHNA, 2012) and Randolf's (2014) with the recommendation on how to become a certified OHN nurse.These models were not only recommended by many scholars who use the same models (Neto et al., 2016), but also because they focus on OHN issues and are relevant to the OH nurses' situations and conditions in Indonesia.Jurnal Berita Ilmu Keperawatan, Vol. 14 (2), Tahun, 2021;p-ISSN:1979p-ISSN: -2697;;e-ISSN: 2721e-ISSN: -1797 In nursing, Career development programs play an important role in advancing the professional practice of nurses, contributing to the organization, and generating job satisfaction through effective commitment (Vasquez & Crawford, 2016).The benefits of a career framework include standardization: job descriptions across the care system, required competencies and clinical practice skills, role requirements, education and certification, succession planning models, role expectations, targeted development and management careers (Becom & Kegerese, 2014;Kovick et al. al, 2015).This model matches with the policy of nursing education and registration systems implemented by the Ministry of Health (MoH, 2016).

Change Model
The model in Figure 3 below describes the steps of change that can be applied in planning a career framework.The first step is determining the urgency, the second step is building a coalition, the third one is formulating a vision for change, the fourth is communicating the vision, the fifth is removing barriers and empowering staff, the sixth is creating short-term goals, the seventh is making revisions and the last is implementing changes.In essence, this model describes the applied steps of how to plan career from the start, in the form of identifying the background of what the real urgency of planning career is, to the end result that is global in nature, namely the existence of an integrated system change between the composition, the process with development and the achievement of the role of nursing leadership (Bernard & Oster, 2018).The final results of the review show the relationship between the nursing education system in Indonesia with the flow and structure recommended by the three models in general, without specifically mentioning OHN career framework, both in terms of requirements and the career development path of nurses from entry level to doctoral level.

Description of the Theory
Nursing education in Indonesia does not yet have OHN specialization (Hardy, 2012;Tukayo, 2020).OHN nurses play a key role in the industrialized health care system (WHO, 2012;Rogers et al. 2009).To improve professional conditions and the quality of care, OHN nurses need to have a clear career path.In order to achieve this goal, it requires a theoretical basis that can be accepted  (Tukayo et al., 2021).

Criticism of the Theory
What was not included in the study was the role of nursing leadership, who lived in the leadership work family (Bernard & Oster, 2018).Key stakeholders from all levels of clinical nurse, various nursing roles, advanced practitioner, educator, nurse leader, human resources, and management talents collaboratively design and competitive career frameworks for RN in organizations are the focus of her research (Barnard & Oster, 2018).Although this model is acceptable, the nursing education career framework in Indonesia refers to this Nursing Career Framework Model (Efendi, et al., 2019).The difference is that Indonesia does not have a framework related to career development for non-certified and certified nurses, from the entry level (Diploma or BSN) to the Master degree.The Nursing Career Framework is clearer and more detailed regarding the progress mapping of its profession.The development of a nursing career framework is significant because through career development one will be able to advance nursing professional practice in the context of quality and safety while shifting the paradigm for organizational advancement and aligning compensation away from seniority and towards advanced expertise (Bernard & Oster, 2018).Indonesia requires a system in which non-certified nursing diploma/degree holders can be recognised under their umbrella with less professional responsibility, without professional nursing license, but as nurse assistants or healthcare assistants.So that the roles and responsibilities of nurses are more focused on the nursing procedures.

Analysis of the Theory
The careers of OHN nurses described by the OHN nurses association in Canada are very clear regarding the educational prospects, future and welfare of OHN nurses (Oakley, 2003;OOHNA, 2012;OSHA, 2012) according to the role of OHN nurses (WHO, 2012).Therefore, in Indonesia there is a need for deeper studies and research related to OHN careers.

Figure 2
Figure 2 below is the Career Framework Model in which nurses see employers as stepping stones for future roles and successful professionals (Siscovick et al. 2015).This model explains that an organization needs to have a commitment to employee engagement, growth, development, and longevity.Understanding the importance of providing an internal career path model as a strong retention strategy (Becom & Kegerese, 2014; Kovick et al, 2015; Vasquez & Crawford CL, 2016) is one of the focuses.A career framework is a model that provides a structure and process for the alignment of career paths, jobs and growth and development opportunities, education, and relevant skills to visualize their careers on the development map in the organization (Bernard & Oster, 2018).
Figure 4 below describes the nursing career framework through formal education which is tiered from the initial stage (Entry Level N1) to specialization and master level (Master, N5).It also

Figure 6 :
Nursing Education in Indonesia academically, in accordance with existing laws and regulations.The Nursing Career Framework Jurnal Berita IlmuKeperawatan, Vol. 14 (2), Tahun, 2021; p-ISSN:1979 p-ISSN: -2697;; e-ISSN: 2721 e-ISSN:  -1797model which was applied byBernard and Oster (2018), in which nursing organizations include clinical nurses, advanced nursing practice, and roles that require nursing licenses in 17 acute care, home care, outpatient care, senior care, and and comprehensive hospice and palliative care services can be used as a reference.The description of OHN' main roles and responsibilities include general OH Nurse to the OH Nurse Specialist level, from Diploma until Doctorate level of education.These levels of education are not yet available in Indonesia, but training on K3 only