DELEGATION OF MEDICAL ACTION AUTHORITY OF DOCTORS TO NURSES IN HEALTH SERVICES IN EMERGENCY DEPARTMENTS: EMPIRICAL LEGAL

Purpose: This study aims to analyze the implementation of the delegation of authority of medical actions of doctors to nurses in the emergency department and explore the legal responsibility of the delegation of authority of medical actions of doctors to nurses in the emergency department in Indonesia. Theoretical Fremework: Theoretically, this research is expected to contribute intellectually and academically to the enhancement of understanding of healthcare laws for healthcare practitioners, institutional leaders, and to provide a sense of security and protection in carrying out healthcare services functions to the community, especially in the provision of medical procedures at healthcare facilities. Additionally, it is expected to provide practical insights for the goverment, hospital directors, and health departments in order to improve healthcare services to the public and ensure legal protection for healthcare workers in carrying out their professional duties. Method: The type of research method used is empirical legal research. Data primarily obtained from respondents using a list of questions (questionnaire) and direct interviews with the research object. In addition to that, it is also based on legal materials that are relevant to the discussion or problem being researched and other supplementary legal materials that can provide explanations. Results: The delegation of medical action authority from doctors to nurses in healthcare services at emergency rooms is regulated in Article 290 of Law Number 17 of 2023 concerning Health. Medical and healthcare services, consisting of both mandatory delegation. The scope of work delegated through partnership must be clearly and specifically defined in writing within the authority delegation letter and adjusted according to the level of competence of the nurse. The doctor as the delegator and the nurse as the recipient of medical authority there are also responsibilities of the hospital, as well as the central and local governments, especially in meeting the national needs for medical and healthcare personnel. In handling medical dispute cases, law enforcement agencies must prioritize the mechanism of restorative justice. If no agreement is reached, the dispute is then taken over by the professional disciplinary board under the Ministry of Health to determine whether there has been any violation of professional discipline by medical and healthcare personnel. Conclusions: 1) Delegation of authority for doctor’s medical actions to nurses in health services in emergency departments in Indonesia, regulated in Law No. 17 of 2023 concerning Health Article 290, Minister of Health Regulation No. 2052 of 2011 Article 23 and Minister of Health Decree No. HK.01.07-425 of 2020 concerning Nursing Professional Standards; 2) Responsibilities by doctors, nurses, and hospitals regarding the delegation of authority for doctors’ medical actions to nurses in health services in emergency departments must be carried out by laws.


INTRODUCTION
Health is recognized as a Constitutional Right in the 1945 Constitution of Republic of Indonesia, Article 28H paragraph (1) states that, "Every person has the right to live in physical and spiritual prosperity, to have a place to live, and to have a good and healthy environment, and to receive health services".The development in health sector is aimed at increasing awareness, willingness and ability to live healthy for everyone to achieve optimal health status.(Sofyan, 2015) Doctors in practicing medicine will not be able to carry it out alone, let alone provide quality health services without the help of other health personnel, especially nurses (Indar, 2017).The relationship established with the patient can be seen as an endeavor of care and healing or a therapeutic transaction, where this gives rise to rights and obligations between different parties namely doctors, nurses, and patients themselves (Komalawati, 2002).
The ratio of doctors to the total population in Indonesia is 6.95 per 10,000 population, which is the third lowest in Southeast Asia.This data means that one doctor has to serve almost The data above does not talk about the distribution of doctors in the regions in Indonesia.
Urban areas such as Jakarta and other big cities in Java have a good population doctor ratio due to the large number of doctors in Java.This is in contrast to East Nusa Tenggara which has the lowest population doctor ratio in Indonesia (Maharrani, 2020).
The limitations of medical personnel (doctors) lead to situations that require nurses to perform treatment or perform medical actions that are not their authority.In the research at Kardinah Regional General Hospital in Tegal City, it was found that there was no internal regulation (Hospital By Laws) governing the delegation of authority of doctors to nurses in performing medical actions (Sutarih, 2018).
In the perspective of the law, the delegation of authority for medical actions is permitted, but with certain requirements and under specified conditions.The same applies to the consequences of the delegation of authority.Conflicts to medical disputes can occur due to delegation of authority between doctors and nurses or with patients.This is a risk that has to be managed and mitigated to ensure that the conflict can be resolved and not further escalate into a dispute (Pramudito & Widjaja, 2022).

THEORETICAL FRAMEWORK
Generally, every research should always be accompanied by theoretical thoughts or concepts used by the author, and the variables studied will depict the relationships between one variable and another.this research is expected to contribute intellectually and academically to the enhancement of understanding of healthcare laws for healthcare practitioners, institutional leaders, and to provide a sense of security and protection in carrying out healthcare services functions to the community, especially in the provision of medical procedures at healthcare facilities.Additionally, it is expected to provide practical insights for the goverment, hospital directors, and health departments in order to improve healthcare services to the public and ensure legal protection for healthcare workers in carrying out their professional duties.

METHODS
The type of research used in this legal research is empirical legal research, the type of research referred to is empirical legal research or socio-legal research, which is another approach model in studying law as its subject matter.In this case, law is not only seen as a prescriptive and applied discipline alone, but also as empirical or the reality of law (Irwansyah, 2021).
Primary data is obtained from respondents using a list of questions (questionnaire) and direct interviews with the research object.Secondary data is legal materials relevant to the discussion or problem being researched.Tertiary data is legal material that can provide explanations or instructions for primary and secondary legal materials, such as dictionaries and encyclopedias.
The participants were purposefully selected from selected hospitals in urban areas of

RESULTS AND DISCUSSION
Authority is a legal power, which is given legislatively by laws and regulations or administrations.In the context of the health profession, this authority is related to the power given legally in seeking a person's health (Pramudito & Widjaja, 2022) According to Law of Republic of Indonesia No. 17 Nurses in school do their practicum at a teaching hospital or a hospital that collaborates with the school.They are taught how to practice putting in IVs and injecting safe drugs.They have SPO to do that.So it is indeed socialized in the nurse environment during general orientation.And it's standardized for both students and intern nurses".

Figure 1
Characteristics of the educational level of emergency room nurses  The author administered a questionnaire regarding 12 medical actions often performed in the Emergency Department (ED) and the pattern of medical action delegation to nurses in the emergency department of Padjonga Daeng Ngalle Regional General Hospital and Lanto Daeng Pasewang Regional General Hospital, with the following description: Table 1 Medical Actions by Nurses The delegation of authority, whether by mandate or delegation, is determined by the hospital director as a standard operating procedure.According to the conditions for delegation of authority in Regulation of the Minister of Health concerning Implementation Regulations of Law of Nursing Article 28, " the implementation of tasks based on delegation of authority can only be given in written form by doctors to nurses to carry out a medical action and evaluate it".The obtained depiction is as follows: Table 2 Delegation of authority for medical actions Furthermore, the author administered a questionnaire to emergency department doctors at Padjonga Daeng Ngalle Regional General Hospital and Lanto Daeng Pasewang Regional General Hospital regarding their knowledge of the delegation of authority regulations in-laws.

Doctor's knowledge about delegation of authority
To construct legal liability because of delegation of authority, it is necessary to have a prior understanding of the therapeutic contract.The doctor-patient relationship is established based on mutual trust.If there is no longer trust between both parties, the doctor-patient relationship might be terminated.Within this relationship exists an agreement between the doctor and the patient, which involves the doctor's efforts to promote the patient's health.This agreement is referred to as a therapeutic contract.The achievement doctors must fulfill is the maximum effort to heal patients (inspaningsverbintenis).In practice, therapeutic contracts are rarely in the form of definite contracts (resultastsverbintenis.Therefore, it is appropriate for doctors to be patient-oriented in their efforts to promote health and healing.Medical action and treatment can only be performed on a patient after they have received an explanation of the intended actions, given their consent, and carefully considered what is best for their body.(Astuti, 2019) According to (Amir & Purnama, 2021), the delegation of authority by doctors to nurses must meet the following terms: a. Doctors who decide in making diagnoses, determining therapy and determining indications.Decision making by doctors cannot be delegated.
b. Delegation of medical action can only be done if the doctor is sure that the nurse who receives the delegation is able to carry out the task properly.
c.The delegation of authority must be done in writing including clear instructions regarding its implementation, how to act if complications arise and so on.
d.In the implementation of the delegation by mandate, there must be medical guidance and supervision.13 e.Refusal of delegation may be made if the delegatee feels unable to perform the medical action.
Agreement is one of the legal requirements for a contract according to civil law.In this delegation of authority, the nurse agrees to accept the authority and perform medical actions that the doctor has previously agreed to grant to the nurse.Both legal subjects must possess competence in action and authority.As the recipient of delegated authority, a nurse must be of sufficient age and in good physical and mental health according to the law.Attribution of authority refers to the acceptance of authority due to legal coercion, while nurses in the delegation or mandate of authority obtain authority based on our will and agreement regarding the transfer of a task.This is by Article 1233 of the Civil Code, which states that an agreement arises from consent and the law.(Agustina, 2015) Violations of discipline by doctors, nurses, and other healthcare professionals can result in disciplinary sanctions as described in Article 306 of the Health Law, which states that: "Disciplinary sanctions may include written warnings, the obligation to undergo It can be drawn as a red thread that if there is an error in medical action, the responsibility is borne by the nurse independently in delegated actions, doctors in mandated actions or the hospital as the institution.This is stated in Article 468 of Law No. 17 of 2023 Regarding Health, which states that hospitals also bear the liability for the actions of health personnel if there are mistakes in carrying out their duties.It is necessary to trace how the medical error occurred and whether it was under the applicable operational standards or otherwise.

CONCLUSIONS
The results of this research are 1) Delegation of authority for doctors' medical actions to nurses in health services in emergency departments, regulated in Law No. 17 Delegation of Medical Action Authority of Doctors to Nurses in Health Services in Emergency Departments: Empirical Legal ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.2 | p.1-15 | e06155 | 2024.4 1500 people in Indonesia.For comparison, in Singapore, the ratio of doctors per 10,000 population is 24.3, meaning that one doctor "only" serves 411 people.The World Health Organization gives an ideal population doctor ratio of 1 to 1000 people.(WHO,2023) Data released by the Bureau of Communication and Public Services of the Ministry of Health in 2022 there are a total of 122,023 general practitioners and specialized doctors in hospitals across Indonesia.However, there is still a shortage of 8,182 doctors (Ministry of Health, 2022).
Indonesia.The research was conducted at the Emergency Department of Lanto Daeng Pasewang Regional General Hospital in Jeneponto Regency, South Sulawesi, and the Emergency Department of Haji Padjonga Daeng Ngalle Regional General Hospital in Takalar Regency, South Sulawesi.The population and sample include the Chairman of the Medical Committee, Chairman of the Ethics Committee, Chairman of the Nursing Committee, Head of the Emergency Room, Doctors, and Nurses from Lanto Daeng Pasewang Regional General Hospital (LDP RGH) and Haji Padjonga Daeng Ngalle Regional General Hospital (HPDN RGH).
of 2023 concerning Health Article 285, Medical and Healthcare Professionals must practice within their authority based on their competence.The definition of competence in Law concerning National Education System, as explained in Article 35 (1), refers to the qualifications and abilities of graduates that encompass attitudes, knowledge, and skills in accordance with consented national standards.Article 291 of the Health Law states that every doctor and health personnel must adhere to professional standards, service standards, and operational procedure standards in providing Delegation of Medical Action Authority of Doctors to Nurses in Health Services in Emergency Departments: Empirical Legal ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.2 | p.1-15 | e06155 | 2024.6 healthcare services.The professional standards for each type of medical and health Personnel are formulated by the Council and College and established by the Minister.The standard of service is regulated by the Ministerial Regulation.The standard operating procedures are established by the management of the Healthcare Facility".Basically, medical action performed by doctors always lead to two possibilities, namely successful and unsuccessful (failed).Doctors' failure in medical action can occur because it is caused by, among others: a.Because of Intention (Dolus); b.Because of Negligence (Culva); c.Because of Coercion (Force Majeure); d.Because of Emergency (Noodweer); e. because it does not conform with the standards of the medical profession (unprocedural).(Sallipadanget al., 2015) The medical action standards are the main foundation in improving the quality of medical actions in Indonesia.(Ilyas,2014) The problem of limited doctors in hospitals in rural areas also occurs in Lanto Daeng Pasewang Hospital and Padjonga Daeng Ngalle Hospital.Based on a preliminary survey by interviewing several nurses and doctors in charge of the Emergency Room at RSUD Lanto Daeng Pasewang Jeneponto, it was found that the average number of patients handled in the Emergency Room varies between 50-100 people every day.About 25% of all patients or as many as 20 patients who enter the emergency room with serious and emergency conditions.The Emergency Department of RSUD Lanto Daeng Pasewang Jeneponto has more nurses than doctors, namely, 9 nurses and 3 doctors per work shift.Therefore, the more numerous nurses in the emergency room often get a delegation of authority to perform medical actions.Likewise, in the emergency room of Padjonga Daeng Ngalle Hospital, it was found that only 2 doctors accompanied by 7 nurses were on every shift.The number of incoming patients is around 60-90 people every day.Article 275 of the Health Law states that doctors, nurses, and healthcare personnel practicing in healthcare facilities must first aid patients in emergencies.Therefore, they can be exempted from future liability claims if they are in accordance with the procedure.Furthermore, Article 286 states that under certain circumstances, doctors, nurses, and healthcare personnel are permitted to provide services beyond their authority, particularly in managing medical emergencies.The legality of delegation of authority for medical actions is regulated in the Health Law Article 290 that doctors and health personnel can receive delegation of authority to perform health services.The delegation of authority consists of mandate delegation and delegative delegation.Authority is delegated from doctor to health personnel, between doctors, and between health personnel.The juridical status of nurses has changed from the extension of the Delegation of Medical Action Authority of Doctors to Nurses in Health Services in Emergency Departments: Empirical Legal ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.2 | p.1-15 | e06155 | 2024.7 doctor's hands to the partner of the doctor, which is very complex.(Vitrianingsihand Budiarsih, 2019) The interview with the Chairman of the Medical Committee of Haji Padjonga Daeng Ngalle Regional General Hospital, Irmastuti, MD, MHA, states that "regulations are crucial to ensure that healthcare personnel understand the limitations of their responsibilities.Padjonga Hospital has a delegation of authority letter and a list of delegated actions.The cause of the delegation of medical actions is primarily due to time constraints and medical emergencies, necessitating prompt action, especially in the emergency department (ED).The delegation of medical actions at Padjonga Hospital must be carried out due to the need for expediency.The capacity of patient beds in the Emergency Department is up to 30 patients, and there are about 20 patients per shift.There are 2 doctors and 7 nurses on duty per shift.All nurses who work at Padjonga Hospital must have a BTCLS certificate before orientation, especially those in the emergency room who are more carefully selected.Essentially, it has become a tradition that some medical actions are the responsibility of nurses, especially in the emergency department, when speed is crucial.

Figure 2
Figure 2Characteristics of nurse's work experience in hospital

Figure 3
Figure 3Career path of Nurses education or training at educational institutions in the field of Health or the nearest educational hospital with the competence to provide such training, temporary deactivation of professional licenses, and/or recommendations for revoking professional certifications."Medical personnel or healthcare personnel who have undergone disciplinary sanctions and are suspected of committing a criminal offense will prioritize the resolution of disputes through the mechanism of restorative justice by the provisions of the laws.
of 2023 Article 290, Minister of Health Regulation No. 2052 of 2011 Article 23, Minister of Health Regulation 26 of 2019 Article 18 and Minister of Health Decree No. HK.01.07-25 of 2020 concerning Nursing Professional Standards; 2) Responsibilities by doctors, nurses, and hospitals regarding Delegation of Medical Action Authority of Doctors to Nurses in Health Services in Emergency Departments: Empirical Legal ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.2 | p.1-15 | e06155 | 2024.14 the delegation of authority for doctors' medical actions to nurses in health services in emergency departments must be carried out by legislation.