formulir penyerahan artikel & pernyataan ijnp (indonesian journal of nursing practices) secretariat: school of nursing universitas muhammadiyah yogyakarta faculty of medicine and health sciences siti walidah building f3 4th floor campus terpadu umy jl. brawijaya/ lingkar selatan, kasihan, bantul, yogyakarta 55183 email: ijnp@umy.ac.id web: http://journal.umy.ac.id/index.php/ijnp author statement i, the undersigned below: 1. name of author correspondency : febriana sartika sari 2. paper title : anxiety and aggressive behavior in adolescents ............................................................................................................ 3. author affiliation : poltekkes kemenkes surakarta ............................................................................................................................................ . 4. mailing address : febriana.sartikasari@gmail.com ............................................................................................................ 5. phone number : +6285642244710 email : ............................................................................................................ i hereby declare that the below statements are true: 1. the manuscript is originally written by the author and contains no plagiarism. 2. it contains no material previously published or currently not in the process of other journal publications. 3. mentioning other author names along with the first author (if the research involves more than one author). 4. the manuscript has received all authors’ consent to be published (if the manuscript involves more than one author). 5. no conflict of interest. 6. the manuscript has received the consent of the research protocol ethics committees. if any statement specified above is found to be incorrect, i am disposed to be given legal sanctions in a later time. surakarta, october 2022 authorised signatory ( febriana sartika sari) mailto:ijnp@umy.ac.id http://journal.umy.ac.id/index.php/ formulir penyerahan artikel & pernyataan ijnp (indonesian journal of nursing practices) office: school of nursing faculty of medicine and health sciences universitas muhammadiyah yogyakarta siti walidah building f3 4th floor brawijaya street/ south ring road, kasihan, bantul, yogyakarta 55183 email: ijnp@umy.ac.id web: http://journal.umy.ac.id/index.php/ijnp author statement i, the undersigned below: 1. name of correspondence author : ……………………………………………………………………………………………………… 2. paper title : ……………………………………………………………………………………………………………. ……………………………………………………………………………………………………………. 3. author affiliation : ……………………………………………………………………………………………………………. ……………………………………………………………………………………………………………. 4. mailing address address : ……………………………………………………………................................................. ……………………………………………………………................................................. phone number : ……………………………………………………………................................................ email : ……………………………………………………………................................................ i hereby declare that the below statements are true: 1. the manuscript is originally written by the author and contains no plagiarism. 2. it contains no material previously published or currently not in the process of other journal publications. 3. mentioning other author names along with the first author (if the research involves more than one author). 4. the manuscript has received all authors’ consent to be published (if the manuscript involves more than one author). 5. no conflict of interest. 6. the manuscript has received the consent of the research protocol ethics committees. if any statement specified above is found to be incorrect, i am disposed to be given legal sanctions in a later time. ……………….., ……………………… authorised signatory, (………………………………………) ni gusti ayu eka perceived incivility and stress of final year nursing students universitas pelita harapan boulevard sudirman no 15 lippo karawaci tangerang indonesia 15811 08121902239 gusti.eka@uph.edu tangerang 29 juli 2022 ni gusti ayu eka mailto:ijnp@umy.ac.id http://journal.umy.ac.id/index.php/ijnp office: school of nursing faculty of medicine and health sciences universitas muhammadiyah yogyakarta siti walidah building f3 4th floor brawijaya street/ south ring road, kasihan, bantul, yogyakarta 55183 email: ijnp@umy.ac.id web: http://journal.umy.ac.id/index.php/ijnp author statement jurnal mjn vol. 3 no. 1 juni 2016.indd 69 muhammadiyah journal of nursing yudan harry sandika1, ema waliyanti2 program studi ilmu keperawatan fkik umy email : yudan.sandika@yahoo.co.id telepon : 085643357042 sikap mahasiswa terhadap kebijakan kampus bebas asap rokok di universitas muhammadiyah yogyakarta abstract smoking is one of the problems in society that is diffi cult to be resolved. in 2011, 6 million deaths each year are caused by smoking. the number of smokers in indonesia continues to grow which is dominated by the age of 15 years and above. to overcome these problems, the government issued a policy of banning smoking in the learning process places. umy is one of the places that have already implemented smoke-free campus since 2011, however there are people who still smoke in the campus. the purpose of this study was to determine how the students’ attitude of universitas muhammadiyah yogyakarta toward a smoke-free campus policy. this study was a qualitative research with phenomenological approach. the data was taken using the disccusion focus groups, depth interviews and observation. participants in this study were determined by purposive sampling which were 20 participants consisting of students and campus employees in umy. the validity of the data in this study was done by using triangulation, triangulation methods and peer debriefi ng. data analysis by using the soft ware open code version 4.2. the results indicated that the students who were active smokers agreed and disagreed on kbbr, nevertheless there are diff erences in attitudes related to compliance with these rules. students who were active smokers who agreed to kbbr supported and there were students who did not support the kbbr. but students who were active smokers that did not agree to kbbr did not support the implementation of kbbr on campus. unlike the students who were active smokers, passive smokers students all agreed and supported kbbr in umy. by that attitude, umy needs to increase their knowledge and socialization of kbbr to the students, therefore the students are able to increase the positive attitude towards kbbr in order to create a clean and smoke-free campus. keywords: attitude, kbbr, umy abstrak merokok merupakan salah satu masalah di masyarakat yang sampai saat ini sulit untuk diselesaikan. pada tahun 2011, 6 juta kematian tiap tahunnya disebabkan oleh kebiasaan merokok. jumlah perokok di indonesia terus bertambah yang didominasi oleh usia 15 tahun keatas. untuk mengatasi masalah tersebut pemerintah mengeluarkan kebijakan larangan merokok di tempat proses belajar mengajar. umy adalah salah satu tempat yang sudah menerapkan kebijakan kampus bebas asap rokok sejak tahun 2011, namun sampai saat ini masih ada yang merokok di dalam kampus. tujuan penelitian ini adalah untuk mengetahui bagaimana sikap mahasiswa universitas muhammadiyah yogyakarta terhadap kebijakan kampus bebas asap rokok.. penelitian ini merupakan penelitian kualitatif dengan pendekatan fenomenologi. data diambil menggunakan metode focus group disccusion, wawancara mendalam dan observasi. partisipan dalam penelitian ini ditentukan dengan purposive sampling sebanyak 20 orang partisipan yang terdiri dari mahasiswa dan karyawan kampus umy. keabsahan data dalam penelitian ini dilakukan dengan teknik triangulasi sumber, triangulasi metode dan peer debriefi ng. analisis data secara tematik dengan bantuan soft ware open code versi 4.2. hasil penelitian ini menunjukan bahwa mahasiswa perokok aktif memilki sikap setuju dan tidak setuju terhadap kbbr, namun ada perbedaan sikap terkait dengan kepatuhan terhadap aturan tersebut. mahasiswa perokok aktif yang setuju terhadap kbbr ada yang mendukung dan ada yang tidak mendukung adanya kbbr. sedangkan mahasiswa perokok aktif yang tidak setuju terhadap kbbr tidak mendukung penerapan kbbr di kampus. berbeda dengan mahasiswa perokok aktif, mahasiswa perokok pasif semuanya setuju dan mendukung adanya kbbr di umy. dengan adanya sikap tersebut umy perlu meningkatkan pengetahuan dan sosialisasi adanya kbbr terhadap mahasiswa sehingga dapat menumbuhkan sikap yang positif terhadap kbbr agar tercipta kampus yang bersih dan bebas asap rokok. kata kunci : sikap, kbbr, umy 70 muhammadiyah journal of nursing pendahuluan merokok merupakan salah satu masalah di masyarakat yang sampai saat ini sulit untuk diselesaikan. kebiasaan merokok merupakan salah satu perubahan gaya hidup yang disebabkan oleh efek globalisasi dan dapat mempengaruhi kesehatan manusia mengkonsumsi rokok dapat menimbulkan banyak kerugian dan menimbulkan berbagai masalah kesehatan, bahkan kematian1. 6 juta kematian terjadi setiap tahunnya yang disebabkan oleh kebiasaan merokok, termasuk di dalamnya yaitu perokok pasif2. pada tahun 2007 jumlah perokok usia 15-19 tahun mencapai 18,8%, angka ini menunjukan peningkatan dari tahun 2001 sebanyak 12,7%3. hal ini dikarenakan usia tersebut termasuk dalam kategori usia remaja dimana pada fase ini terjadi peralihan dari kanakkanak ke dewasa. fase ini merupakan masa pencarian jati diri melalui mencoba hal-hal baru dan perilaku beresiko4. n e g a r a i n d o n e s i a t e l a h m e l a k u k a n pengendalian asap rokok melalui undang – undang republik indonesia nomor 36 tahun 2009 dan peraturan gubernur daerah istimewa yogyakarta nomor 42 tahun 2009. peraturan ini mengamanatkan pentingnya pengembangan kawasan tanpa rokok. pada pasal 115 undang – undang republik indonesia menjelaskan kawasan tanpa rokok yaitu meliputi fasilitas pelayanan kesehatan, tempat proses belajar mengajar, tempat anak bermain, tempat ibadah, angkutan umum, tempat kerja, dan tempat umum dan tempat lain yang ditetapkan. universitas muhammadiyah yogyakarta termasuk tempat proses belajar mengajar yang telah menerbitkan surat keputusan rektor nomor: 164/ sk-umy/xii/2011 tentang implementasi program kampus universitas muhammadiyah yogyakarta bersih dan bebas asap rokok (kbbr). kebijakan kampus bebas asap rokok yang telah ada sejak tahun 2011 belum dapat menghilangkan perokok aktif di lingkungan kampus umy. berdasarkan hasil observasi masih terdapat mahasiswa universitas muhammadiyah yogyakarta yang merokok di dalam kampus. agar jumlah perokok dapat berkurang maka langkah awal yang perlu dilakukan adalah mengetahui sikap mahasiswa terhadap kebijakan kampus bebas asap rokok. sikap memberikan corak pada tingkah laku dan perbuatan manusia, dalam hal ini sikap mahasiswa terhadap kebijakan kampus bebas asap rokok menentukan tindakan dan perbuatan mahasiswa untuk mematuhi atau melanggar peraturan. metode penelitian ini merupakan penelitian kualitatif dengan pendekatan fenomenologi. partisipan dalam penelitian ini adalah civitas akademika umy yang terdiri dari mahasiswa dan karyawan sebanyak 20 partisipan. pengambilan sampel dalam penelitian ini menggunakan purposive samping dengan kriteria mahasiswa aktif yang dapat menunjukan kartu mahasiswa dan bersedia menjadi partisipan, kriteria inklusi untuk partisipan karyawan adalah karyawan yang telah bekerja di umy selama minimal 1 tahun dan bersedia menjadi partisipan. pengambilan data dilakukan dengan metode focus group disccusion (fgd,) wawancara mendalam dan observasi yang dilaksanakan pada bulani maret-juni 2016. instrumen yang digunakan dalam penelitian ini adalah panduan fgd, panduan wawancara mendalam dan ceklist observasi. dalam pelaksanaan pengambilan data dibantu menggunakan alat perekam, kamera, dan alat tulis untuk membuat catatan lapangan. keabsahan data dalam penelitian ini dilakukan dengan teknik triangulasi sumber, triangulasi metode dan peer debriefi ng. analisis data secara tematik dengan bantuan soft ware open code versi 4.2. 71 muhammadiyah journal of nursing hasil penelitian 1. karakteristik partisipan tabel. karakteristik partisipan karakteristik responden frekuensi (f) persentase (%) jenis kelamin laki-laki perempuan total 13 7 20 65 35 100,00 usia 20-30 31-40 40-50 total status akademik mahasiswa karyawan total 17 2 1 20 16 4 20 85 10 5 100,00 80 20 100,00 status merokok merokok tidak merokok 12 8 60 40 total 20 100,00 dari tabel diatas menunjukan bahwa partisipan paling banyak adalah laki-laki sebanyak 13 orang (65%) dengan usia paling banyak adalah sebayak 20-30 tahun (85%). status akademik terbanyak adalah mahasiswa sebanyak 16 orang (80%) dan status merokok partisipan terbanyak adalah merokok sebanyak 12 orang (60%). 2. sikap mahasiswa terhadap kbbr a. sikap mahasiswa perokok aktif gambar.1 sikap mahasiswa perokok aktif terhadap kbbr mahasiswa perokok aktif memiliki sikap setuju dan tidak setuju terhadap kbbr, namun ada perbedaan sikap terkait dengan kepatuhan terhadap aturan tersebut. hanya satu partisipan perokok aktif yang mendukung penerapan kbbr, yang ditunjukan dengan tidak merokok di dalam kampus. partisipan mengungkapkan bahwa dengan adanya kebijakan ini kampus jadi bisa bebas asap rokok dan tidak merugikan semua pihak. partisipan juga mendukung terlaksananya kebijakan ini dengan patuh terhadap kbbr. seperti yang diungkapkan partisipan berikut ini : “setuju sih, karena kan biar nggak ngerugiin semuanya …kalau di kampus enggak merokok (p9, wawancara mendalam) disisi lain sebagian besar mahasiswa perokok aktif yang setuju dengan kbbr tidak mendukung penerapan kbbr. mereka masih merokok di dalam kampus. partisipan mengungkapkan setuju dengan larangan merokok di dalam ruangan saja, namun untuk di luar ruangan partisipan masih belum setuju. partisipan mengaku masih merokok ketika berada di luar ruangan apabila tempat sepi, hal ini dilakukan karena tidak ada fasilitas yang disediakan untuk tempat merokok. berikut adalah ungkapan partisipan: “… mungkin kalau enggak boleh merokok ini misalkan di dalam ruangan ya, tapi setelah di luar ruangan boleh lah” (p3, diskusi kelompok 1) “…. kalau udah ngasih kebijakan gini setidaknya kasih lah satu area yang bebas asap rokok khusus buat perokok, jadi kan kaya perokok aktif kalau nggak ada tempat mesti nyuri-nyuri tempat…”. (p2, diskusi kelompok 1) selain sikap setuju terhadap kbbr ada partisipan yang benar-benar tidak setuju dan tidak mendukung penerapan kbbr. partisipan beranggapan bahwa orang itu semakin ditekan 72 muhammadiyah journal of nursing semakin melanggar dan peraturan semacam ini dapat mendiskriminasi perokok aktif. adapun ungkapan yang diutarakan partisipan, yakni: “….kalau tujuanya untuk mengurangi pongkonsumsi rokok kurang setuju juga. justru kebanyakan dikita orang itu semakin ditekan semakin melanggar. itu fakta..” (p7, wawancara mendalam) “enggak sih enggak setuju, soalnya itu apa yaa namanya rokok udah ada dijual berarti kan ya untuk dikonsumsi” (p8, wawancara mendalam) b. sikap mahasiswa perokok pasif terhadap kbbr gambar.2 sikap mahasiswa perokok pasif terhadap kbbr s e b a g i a n p a r t i s i p a n p e r o k o k p a s i f menyatakan bahwa mereka sangat setuju kbbr. partisipan beranggapan kebijakan ini dapat mengatur semua masyarakat kampus untuk tidak merokok. partisipan juga mengaku sangat setuju dengan kbbr dikarenakan alasan kesehatan, dimana rokok mengganggu kesehatanya, seperti yang diungkapkan: “sangat setuju, soalnya kan, soalnya kalau mereka berada di dalam kampus umy, ya mereka harus ngikutin apa yang peraturan umy itu. kecuali kalau udah di luar gerbang. di luar kampus gitu boleh keluar aturan, bukan tanggung jawab umy lagi. (p11, wawancara mendalam) “sangat setuju, karena sejatinya saya bukan perokok, jadi saya sangat terganggu sebetulnya kalau ada seorang perokok yang merokok di dekat saya, karena asap rokok sangat mengganggu buat saya. saya akan merasa pusing kalau terkena asap rokok dan itu sangat menyesakkan…..” (p10, wawancara mendalam) kemudian sebagian besar dari partisipan perokok pasif menyatakan setuju kbbr. mereka beranggapan bahwa kebijakan ini mampu mengurangi dampak akibat rokok. dengan berkurangnya dampak akibat rokok, angka kematian yang disebabkan oleh rokok juga dapat menurun. berikut adalah beberapa ungkapan partispan: “setuju, setidaknya itu bisa mengurangi dampak yang ditimbulkan, mengurangi angka kematian yang ditimbulkan oleh rokok” (p16, wawancara mendalam) pembahasan 1. sikap mahasiswa perokok aktif terhadap kbbr pada penelitian ini, sikap mahasiswa perokok aktif di umy adalah setuju dan tidak setuju terhadap kbbr. partisipan perokok aktif yang memiliki sikap setuju terhadap kbbr ada yang mendukung dan ada yang tidak mendukung penerapan kbbr. sikap memiliki berbagai macam karakteristik, salah satunya adalah keluasan sikap. keluasan sikap yang dimaksud adalah, kesetujuan dan ketidak setujuan orang terhadap objek sasaran terkadang tidak sama luasnya5. kesetujuaan dapat mengenai sedikit aspek saja, namun juga dapat mengenai semua aspek. partisipan mahasiswa perokok aktif dalam penelitian ini yang mendukung dan patuh terhadap kbbr memiliki sikap setuju pada semua isi sk rektor umy tentang implementasi kampus bebas asap rokok, sedangkan partisipan yang tidak mendukung penerapan kbbr hanya setuju pada sebagian isi saja. sikap setuju pada semua isi sk kbbr membuat mahasiswa patuh dan mendukung 73 muhammadiyah journal of nursing penerapan kbbr. mahasiswa yang memiliki sikap positif terhadap kawasan tanpa rokok di kampus unpad cenderung akan melakukan hal-hal yang diatur di dalam kawasan tanpa rokok di kampus unpad6. meski partisipan merupakan perokok aktif, namun ketika berada di lingkungan kampus partisipan memilih untuk tidak merokok. berbeda dengan mahasiswa perokok aktif yang setuju pada semua isi sk kbbr. mahasiswa yang setuju pada sebagian isi sk kbbr masih melakukan pelanggaran. hal ini dikarenakan partisipan hanya setuju pada larangan merokok di dalam ruangan. untuk larangan merokok di luar ruangan partisipan tidak setuju. responden yang memiliki sikap positif cenderung akan lebih patuh. sedangkan responden yang memiliki sikap negatif, lebih besar kemungkinanya untuk tidak patuh7. kemudian selain memiliki sikap setuju terhadap kbbr, partisipan perokok aktif di umy juga ada yang memiliki sikap tidak setuju dengan kbbr. mahasiswa tidak mendukung penerapan kbbr, mereka masih sering merokok di sembarang tempat di area kampus umy. siswa yang mempunyai sikap negatif cenderung ingin diberi kebebasan8. dalam hal ini mahasiswa menginginkan kampus memberikan kebebasan bagi mereka untuk merokok. beberapa partisipan menginginkan adanya ruangan khusus untuk merokok agar dirinya tetap bisa merokok ketika berada di kampus dan tidak merokok di sembarang tempat. hampir semua informan perokok baik dari fakultas kesehatan maupun non kesehatan setuju apabila diterapkan peraturan tentang adanya pembagian antara smoking area dan no smoking area9. mereka mengatakan perlu adanya tempat khusus untuk merokok sehingga mereka tidak merokok di sembarang tempat. namun hal ini tidak dapat dibenarkan, karena di dalam undang-undang republik indonesia nomor 36 tahun 2009 dan peraturan gubernur daerah istimewa yogyakarta nomor 42 tahun 2009 menjelaskan bahwa tempat proses belajar mengajar termasuk dalam kawasan tanpa rokok. 2. sikap mahasiswa perokok pasif terhadap kbbr semua partisipan perokok pasif memiliki sikap positif terhadap kbbr di umy yaitu sangat setuju dan setuju. mereka patuh dan tidak melakukan pelanggaran. responden yang mempunyai sikap cukup dan sikap baik cenderung patuh terhadap kawasan tanpa rokok10. selain patuh terhadap kbbr, mahasiswa perokok pasif juga mendukung penerapan kbbr dengan cara menegur pelanggar di area kampus umy. sejalan dengan sk rektor universitas muhammadiyah yogyakarta d i m a n a p r o g r a m k b b r i n i m e r u p a k a n tanggung jawab semua civitas akademika termasuk mahasiswa. simpulan 1. sikap mahasiswa perokok aktif terhadap kbbr di umy adalah setuju dan tidak setuju kbbr. sikap setuju pada semua isi sk kbbr membuat mahasiswa patuh dan mendukung penerapan kbbr, sikap setuju pada sebagian isi sk kbbr membuat mahasiswa terkadang melanggar kbbr, dan sikap tidak setuju terhadap kbbr membuat mahasiswa tidak mendukung penerapan kbbr.. 2. sikap mahasiswa perokok pasif terhadap kbbr di umy adalah sangat setuju dan setuju. sikap ini menjadikan mahasiswa patuh dan mendukung terhadap kbbr. saran universitas muhammadiyah yogyakarta d a p a t m e l a k u k a n s o s i a l i s a s i k b b r s e c a r a berkelanjuran kepada segenap warga kampus dan mendambah tanda larangan merokok di area 74 muhammadiyah journal of nursing kampus, baik di dalam gedung maupun di luar gedung agar mahasiswa memiliki pengetahuan yang baik tentang kbbr dan yang terpenting dapat memunculkan partisipasi segenap warga kampus dalam penegakan kbbr. sanksi tegas bagi pelanggar juga diperlukan untuk membuat efek jera pelanggar di area kampus. daftar pustaka firdiana, a. 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(2010). perilaku merokok di kalangan mahasiswa universitas muhammadiyah semarang. prosiding seminar nasional unimus. diakses pada 5 november 2015, dari htt p://jurnal.unimus. ac.id/index.php/psn12012010/article/ view/70. sax,g. (1980). principles of educational and psychological measurement and evaluation, 2nd edition, belmon:wadsworth publishing company. widiansyah, m. (2014). faktor-faktor penyebab perilkau remaja perokok di desa sidorejo kabupaten penajam paser utara. ejurnal sosiologi (4): 1-12. diakses tanggal 23 februari 2016, dari htt p://ejournal. sos.fisip-unmul.ac.id/site/wp-content/ uploads/2014/10/penting%20(10-02-14-1204-55).pdf. world health organization (who) tahun 2011. vol. 5 no. 2 december 2021 97 ijnp (indonesian journal of nursing practices) vol 5 no 2 december 2021: 97-103 muhammad fahri, lisa musharyanti* school of nursing, faculty of medicine and health sciences, universitas muhammadiyah yogyakarta, indonesia corresponding author: lisa musharyanti email: lisa.musharyanti@umy.ac.id nursing students’ perception on tutor performance and students’ critical thinking in pbl online article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v5i1.13349 : 29 may 2021 : 24 july 2021 : 10 dec 2021 abstract background: the covid-19 pandemic has influenced health education in many countries, including nursing education that moves to online learning. it has affected the tutor's performance and students' critical thinking skills, especially in online pbl tutorials. tutor and nursing students have to readapt to a new online meeting atmosphere that previously had face-to-face meetings. there was no previous investigation into the effect of online pbl on tutor performance and nursing students’ critical thinking skills in umy. purpose: this study aims to determine students’ perceptions of tutor performance in online problem-based learning tutorials and the critical thinking skills of nursing students in umy. methods: this research is a cross-sectional quantitative study. the sample included 91 second-year nursing students, using the total sampling technique. the researchers used two questionnaires with closed questions about the tutor's performance in pbl tutorials and the critical thinking skills. data were analyzed by univariate analysis. result: the majority of respondents were female (83.5%) and 19-20 years old (91.2%). the study results showed that the tutor's performance on the online pbl tutorial was good (95.6%), while the critical thinking ability was poor (54.9%). conclusion: this study showed that students still needed to adjust and adapt maximally to online problem-based learning tutorials and needed support and motivation to improve the quality of learning. keywords: critical thinking; nursing students; problem based learning; tutor performance introduction the covid-19 pandemic has had various impacts on countries worldwide, affecting the health care system and various sectors (dewart g et al., 2020). the schools or universities are closed, and learning is switching to an online system (li w et al., 2021). online and distance education using digital tools in higher education has increased over the last decade, particularly during the covid-19 pandemic (langegård et al., 2021). there are some differences between conventional and online learning or e-learning. this e-learning excels in the learning system in lectures because it is available anywhere and anytime. however, it has many drawbacks, including student feedback and http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/9558 vol. 5 no. 2 december 2021 98 self-motivation needs, limited internet networks, expensive digital tools, and the dangers of using gadgets for a long time (singh et al., 2021). several studies have compared traditional learning and virtual education, and there is no significant comparison. another advantage of this online learning is that students can learn directly through the internet, and knowledge can be transferred through various media (hakami, 2021). however, there are other challenges for international students who study far from their home country due to limited resources, technological readiness. readiness of institutions and infrastructure that are not always available (li et al., 2021) in tutorial groups, learning and its dynamics are the basis for problem-based learning. this dynamic is influenced by how a tutor interacts with his group. (edelbring et al., 2020). one of the big problems faced now in problem-based learning tutorials, especially during the covid-19 pandemic, requires teaching staff such as student lecturers to do learning from home. studying at home has now become more common nowadays. no specific reports are using pbl specialists to assess tutor performance, the quality and quantity produced by tutorial groups (addae et al., 2017) in learning, educators are adopting innovative steps in maintaining learning opportunities for students who are at home and unhurried during the pandemic with several methods of lectures, tutorials, demonstrations of skills, and even studying in bed (foo et al., 2021). pbl is supposed to provide students with relevant problem-solving skills applicable to medical settings. the results of pbl education are determined by the quality of the group interaction of students' learning motivation pbl cases and tutor qualifications (grasl et al., 2020). pbl is flexible and can add odd and odd parts in environments. some predominances employ traditional or pure pbl schemes; others wish to modify the traditional number adding system scheme. the results of this variation could enhance course efforts to increase the number of breeders and instructors or create failed businesses and missed opportunities (salari et al., 2018). therefore awareness and proper understanding of pbl is very important because these aspects can affect the academic achievement of nursing students (svensson et al., 2021). critical thinking in undergraduate students is one of the important factors in learning achievement in undergraduate study programs. elements of the national standards of higher education (directorate general of higher education, 2014) have four important elements: attitudes, knowledge, general skills and special skills. undergraduate students are expected to apply, study, design, and solve their problems using critical thinking skills because this ability dominates learning outcomes. critical thinking also trains the development of clinical judgment, or reasoning skills will be better, a student will be more professional in making a decision (jiménez-gómez et al., 2019) a preliminary study was conducted on six students from the 2019 nursing science study program class, faculty of medicine and health sciences, universitas muhammadiyah yogyakarta, by conducting interviews. some students were still less than optimal in learning pbl online tutorials, with less than optimal in learning this online tutorial they could have an impact on the poor ability to think critically or think critically in students, including the perceived obstacles are the difficulty of a stable signal, limited internet data, delivery of material from lecturers that is not optimal, material that is difficult to reach, limited learning resources, obstacles from cell phones, and less effective communication. hence, students become less active in conducting discussions during online learning and online tutorials. bad online learning can impact unfavorable events to affect the students’ achievement index. based on the above phenomenon, the researchers are interested in researching student perceptions of tutor performance in online problem-based learning tutorials and identifying the critical thinking skills in the second years nursing students of the school of nursing, universitas muhammadiyah yogyakarta (umy). methods this research method was a cross-sectional quantitative method using two questionnaires. the study sample was 91 second-year nursing students who underwent the pbl online tutorial in the pandemic era. two questionnaires were delivered indonesian journal of nursing practices 99 to the students by google form. data were analyzed using descriptive analysis. the sample was from a predetermined population, students from batch 2019 school of nursing, faculty of medicine and health sciences umy, selected using the total sampling method. this technique meets the inclusion and exclusion criteria set by the researcher in the study, where the number of samples is the same as the total population. the number of samples taken based on the total calculated from the class of 2019 was 91 students. the research was conducted at the faculty of medicine and health sciences, universitas muhammadiyah yogyakarta. the research was conducted from february 2021 to may 2021. the tutor's performance assessment instrument was made by degrave et al. (1991) and dolmans et al. (2003), with the validity and reliability results being tested. students' abilities have been measured using a questionnaire developed by o'hare (2005) in this critical thinking ability variable. students had been assessed individually for their critical thinking abilities. during online tutorial discussions, these questionnaires were tested for validity and reliability by 30 students from batch 2017 school of nursing, umy. the decision in the validity test concluded that both questionnaires were valid because the value of r counted all items > r table 0.361. the method of collecting data on tutor performance assessment variables and critical thinking ability variables using offline and online methods was carried out from february 15 to march 30, 2021. the analysis in this study only produced the frequency distribution and the percentage of each variable displayed in tables and curves in general. to obtain data with the research objectives, the researchers used computer-based analysis. before conducting the research, the researchers asked for permission regarding the ethics of the research ethics committee of the faculty of medicine and health sciences, universitas muhammadiyah yogyakarta. in collecting research data, respondents were first explained and asked to sign a consent form to become respondents in this study. result the characteristics of respondents in this study were classified based on gender and age. the following table shows the characteristics of the respondents. table 1 shows that most respondents are female (83.5%) and were 19-20 years old (91.2 %). table 2 shows that the level of tutor performance assessment is mostly in the good category (95.6%). while table 3 shows that most students are in the poor category of critical thinking (54.9%). discussion salari et al. (2018) found several positive impacts of pbl, such as improving students’ overall and higherorder performances and increasing instructional efficacy index in the specific subject. the pbl tutorial can be flexible depending on each institution. usually, several students follow the pbl tutorial in a small group with one tutor. the data obtained showed that most tutors' performance assessments in online pbl tutorials for school of nursing umy students batch 2019 were in a good category. this result is possible because when the learning process began, the tutor had directed and guided the course of this online tutorial following the adapted learning method. from the results, there was no significant difference between the performance of tutors and students in the class of 2019. similarly, (prayekti & nurdin, 2011) stated that as a tutor, they must act as a mentor and help students solve problems instead of becoming a lecturer who gives courses. the role and performance of the tutor need to be investigated further, especially the interaction of tutors and groups during pbl and coaching or training that the tutors follow. this suggestion is related to grasl et al. (2020). they stated that most tutors could achieve two-thirds to three-quarters of learning objectives despite having different academic backgrounds. on the other hand, students can have different perceptions about tutor performance if the student still follows online tutorials solely to complete the attendance schedule and get the best score. the nursing literature is full of studies showing that applying appropriate teaching strategies such as active learning improves students' ct scores (boso et al., 2020). vol. 5 no. 2 december 2021 100 (ahmad, 2017) revealed that one of the important tasks of managers or heads of departments towards lecturers is to assess the performance achieved whether it is good or still lacking, especially in assessing the performance of tutors in this pbl online tutorial process to evaluate the work performance of employees and lecturers and determine further policies. the ability of lecturers psychologically consists of potential abilities (iq) and reality abilities (knowledge + skills). a high educational background becomes one of the factors influencing the tutor's performance to achieve the expected performance. besides, the attitude of a tutor must always be ready to accept all conditions when dealing with work situations, and motivation is needed to move students to be more focused on achieving educational goals. tutor performance is important in a pbl tutorial, while on the other hand, other essential components can support and hinder students in achieving learning outcomes, including an understanding of the level of depth of knowledge, tutor involvement and interaction in groups (svensson et al., 2020) some of the causes of online learning are quite a concern because not everyone has internet data and a good network in online learning. this issue can decrease students’ learning achievement. the results showed that most students' critical thinking skills in online pbl tutorials fell poorly. students who participated in these online tutorials were judged on the knowledge and skills demonstrated during the tutorial. although online learning offers convenience and better accessibility of information regardless of the location or time of online learning, it also has limitations, including problems with internet access, poor internet connection quality and a high number of respondents (muflih et al., 2021). suparni (2020) explained in his research that in thinking, a person does not realize the importance of thinking critically in life. as a result, if students fail to think that involves reasoning activities, students will not realize the right standards in thinking, such as clarity, accuracy, logic, and thoroughness. in critical thinking, students must actively analyze their minds and have important knowledge of the problems they face. in pbl, critical thinking plays a major role in selecting the best idea for making changes if the idea is needed. in qualitative research conducted by boso et al. (2019), three factors could influence critical thinking: educators' behavior, students' characteristics, and administrative factors/support within the university environment. the ability and skills to solve these problems are emphasized in the pbl learning process. the problems or scenarios used in pbl function as a trigger for the students to be actively involved in asking questions and responses related to the content and context of the scenario. students are expected to show a critical, thorough, careful and responsible attitude, one of which is to continue to hone critical thinking skills through collaboration and actively participate and encourage cooperation among students because this is one of the factors to improve critical thinking skills. conclusion based on the results, the perception of second-year nursing students of the school of nursing, umy, on the tutors' performance in online tutorials was in a good category (95.6%). second-year students' critical thinking skills were poor (54.9%). many aspects can affect nursing students' critical thinking skill learning that has to be a concern in online learning in the pandemic era. acknowledgement the authors would like to thank all research subjects who have been willing to participate in this research. references addae, j. i., sahu, p., & sa, b. 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(2021). a survey of e-learning methods in nursing and medical education during covid-19 pandemic in india. nurse education today, 99(january), 104796. https://doi.org/10.1016/j.nedt.2021.104796 suparni, s. (2020). upaya meningkatkan kemampuan berpikir kritis mahasiswa menggunakan bahan ajar berbasis integrasi interkoneksi. jurnal derivat: jurnal matematika dan pendidikan matematika, 3(2), 40–58. https://doi.org/10.31316/j.derivat.v3i2.716 svensson, j., axén, a., andersson, e. k., & hjelm, m. (2021). nursing students’ experiences of what influences achievement of learning outcomes in a problem-based learning context: a qualitative descriptive study. nursing open, 8(4), 1863–1869. https://doi.org/10.1002/nop2.842 https://doi.org/10.1016/j.nedt.2021.104796 https://doi.org/10.31316/j.derivat.v3i2.716 https://doi.org/10.1002/nop2.842 indonesian journal of nursing practices 103 table 1. characteristics of respondents characteristics frequency (f) percentage (%) gender male 15 76 16,5% female 83,5% age >20 5 83 3 5,5% 19-20 91,2% <18 3,3% total 91 100% table 2. distribution of the frequency of tutor performance tutor performance assessment second-year nursing students frequency (f) percentage % good 87 95,6% poor 4 4,4% total 91 100% table 3. frequency distribution of critical thinking abilities critical thinking skill second-year nursing students frequency (f) percentage % good 41 45,1% poor 50 54,9% total 91 100% vol. 6 no. 1 june 2022 1 ijnp (indonesian journal of nursing practices) vol 6 no 1 june 2022: 1-7 rahmah1*, sri nabawiyati nurul makiyah2 1school of nursing, faculty of medicine and health sciences, universitas muhammadiyah yogyakarta, indonesia 2department of histology and immunology, faculty of medicine and health sciences, universitas muhammadiyah yogyakarta, indonesia corresponding author: rahmah email: rahmah@umy.ac.id quality of life of children with thalassemia in indonesia: review article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) :10.18196/ijnp.v6i1.10477 : 30 november 2020 : 06 march 2022 : 30 may 2022 abstract background: thalassemia is an inherited disorder of hemoglobin (hb) synthesis. treatment of thalassemia has not yet reached the level of cure. globally, the management of thalassemia is symptomatic in the form of lifelong blood transfusions. data on children with thalassemia major in indonesia has not been widely published. however, various studies clearly showed growth and development disorders and behavior that greatly affected the quality of life of children with thalassemia. blood transfusions and lifelong use of drugs often lead to feelings of boredom of treatment, not to mention physical changes and the feeling of being different from relatives or friends that will cause the feeling of inferiority. they often drop out of school and do not find work, which causes highly severe psychosocial effects. objective: this paper aims to provide an overview of the quality of life of children with thalassemia in indonesia so that it can be used as a reference in providing appropriate management regarding the quality of life of children with thalassemia. methods: this literature search used google scholar and pubmed for complete publications in 2010-2020 with the keywords "quality of life", "thalassemia children," and "indonesia”. result: there were six research articles related to this search. indonesia's average quality of life for children with thalassemia ranged from 50% to 67.2%. conclusion: of the four domains assessed, school function had the lowest average, followed by emotional, physical and social function. child health services need to optimize children's functional abilities and quality of life. keywords: children; indonesia; thalassemia; quality of life introduction thalassemia is an inherited hemoglobin disorder (hb) synthesis, particularly globin chains (bains, 2020; bakthavatchalam, 2019; batool et al., 2022). this genetic disease has various types and frequencies in the world. the clinical manifestations vary from asymptomatic to severe symptoms. data from the world bank shows that 7% of the world's population are carriers of thalassemia traits. every year about 300,000-500,000 newborns are mailto:rahmah@umy.ac.id http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/10477 indonesian journal of nursing practices 2 accompanied by severe hemoglobin abnormalities, and 50,000 to 100,000 children die from thalassemia β; 80% of this amount comes from developing countries (the act of health minister on thalassemia management, 2018; sharma et al., 2017; torcharus & pankaew, 2011) indonesia is one of the countries in the world's thalassemia belt, namely a country with a high frequency of thalassemia genes (number of carriers). it is evident from epidemiological studies in indonesia, which found that the frequency of the beta-thalassemia gene ranges from 3-10%. data from all teaching hospitals only registered around 7670 thalassemia major patients throughout indonesia. this figure is still much lower than the estimated actual number of data from the center for thalassemia, department of child health, fkuirscm; until may 2014, there were 1,723 thalassemia patients with the largest age range between 11-14 years. the number of new patients continues to increase to 75-100 people/year, while the oldest age of patients to date is 43 years (the act of health minister on thalassemia management, 2018). treatment of thalassemia has not yet reached the level of cure. worldwide, the management of thalassemia is symptomatic in the form of lifelong blood transfusions (shafie et al., 2020; torcharus & pankaew, 2011). the need for 1 child with thalassemia major with a body weight of 20 kg for blood transfusion and adequate iron chelation costs around rp. 300 million per year. this amount does not include the costs of laboratory examinations, monitoring, and management of complications that arise (the act of health minister on thalassemia management, 2018). data regarding the condition of children with thalassemia major in indonesia has not been widely published, but various studies clearly showed the growth and development of disorders and behavior which are later related to the high incidence of depression, anxiety and other psychosocial disorders which greatly affect the quality of life of children with thalassemia (ankush et al., 2018; kaheni et al., 2013). in indonesia, a study in 2009 on adolescents aged 13-18 with thalassemia major found that 50.5% of adolescents have a poor quality of life (the act of health minister on thalassemia management, 2018). children with thalassemia major are at risk of experiencing delays in cognitive development, impaired communication, motor, adaptive, or socialization than normal children. in addition, there may also be growth problems or disorders such as short stature, late puberty, and behavioral and emotional problems (thiyagarajan et al., 2019). developmental disorders can range from mild to severe, temporary to permanent, resulting from the incurable medical condition of thalassemia; repeated transfusions, which are tiring and traumatic, complications of the disease, and limitations to daily activities at school, play area, or workplace (yasmeen & hasnain, 2018). blood transfusions and lifelong use of drugs often lead to feelings of boredom of treatment, not to mention physical changes and the feeling of being different from relatives or friends that cause feelings of inferiority. they often drop out of school and do not find work, which causes highly severe psychosocial effects (hassan & azzab, 2016). child health services need to optimize children's functional abilities and quality of life so that children with thalassemia can grow into productive adults. pediatric quality of life inventorytm (pedsqltm) can be used to assess a child's quality of life over time (arian et al., 2020). based on the background above, this paper aims to provide an overview of the quality of life of children with thalassemia in indonesia so that it can be used as a reference in providing appropriate management regarding the quality of life of children with thalassemia. method this literature search used google scholar and pubmed for complete publications in 2010-2020 with the keywords "quality of life", "thalassemia children," and "indonesia". the inclusion criteria were the measurement of quality of life using the pediatric instrument quality of life inventory tm (pedsqltm) in children aged 2-18 years suffering from thalassemia in various regions in indonesia. vol. 6 no. 1 june 2022 3 there were 6 research articles related to this search. the articles were reviewed by looking for similarities and differences, providing views, comparing and summarizing, and drawing conclusions. the details can be visualized in the figure 1 below: (see figure 1) result (see table 1) discussion physical functions included in the quality of life assessment illustrate the child's ability to carry out daily activities independently. the emotional function assessment describes the child's ability to express anger, sadness, and fear. social function assessment describes a child's ability to interact with peers and get along with friends at school. assessment of school functions describes a child's ability to do the tasks given at school (kavitha & padmaja, 2019; mardhiyah et al., 2020; nikmah & mauliza, 2018). the result of the 6 studies above showed that the social function of children had the highest average of the other three functions while the school function had the lowest average of the other three functions. school function is the lowest domain in assessing the quality of life. it is due to obstruction of school activities and decreased academic achievement scores due to the treatment of thalassemia (isworo et al., 2012; mariani et al., 2014; nikmah & mauliza, 2018; wahyuni et al., 2011). this education problem needs to be solved with more concern for children with chronic medical conditions. children are expected to continue to attend regular school education according to their abilities. the school is also informed about the patient's medical condition, the need for regular school permission for transfusions, and the child's susceptibility to disease, and the school is expected to support the treatment of these patients. an emotional function is the second function after school function. disturbance of the emotional domain is probably caused by the thalassemia sufferer's physical condition, which causes its burden (a stress condition). it can affect immunological psychoneurotics. thus, if the physical condition is considered stress, a substance resembling beta-carboline, a gaba antagonist, causes a decrease in the number (down-regulate) of gaba receptors. it then causes reduced resistance to anxiety and eases reactions to stress (isworo et al., 2012; kavitha & padmaja, 2019; mardhiyah et al., 2020). emotional dysfunction is influenced by various things, such as feeling depressed during diagnosis, therapy that must be undertaken regularly every month and skipping school because of having to undergo therapy (nikmah & mauliza, 2018). sources of stress and fear for school-age children can come from the school environment, where experiences that cause stress include ranking competition with classmates, being recognized by teachers, labeling, being unable to learn, and worrying about not passing exams which can cause emotional discomfort. most of the fear of schoolage children is related to school and family (hastuti, 2014). psychosocial support from families is expected to reduce emotional problems in patients with beta-thalassemia major. further, it is explained that psychosocial support reduces emotional distress, increases the effectiveness of iron chelation and strengthens coping strategies to improve everyday life (armina & pebriyanti, 2021; halim-fikri et al., 2022; pranajaya & nurchairina, 2016; ramadhanti et al., 2020). physical function is the third function that is impaired after school function. the physical changes of the subject were very striking due to chronic anemia and iron deposition in the organs. physical changes occur in the form of facial bone deformity, splenomegaly, bone marrow expansion, short stature, and various symptoms caused by hemolysis. different appearance is an important factor that affects personality development, such as a lack of self-image, embarrassment, and refusal to socialize and go to school (kamil et al., 2020; nikmah & mauliza, 2018). the social function had the highest average score between 60 80% among physical, emotional and school functions. it illustrated that the social function of children suffering from thalassemia was still quite good compared to the other three functions. children could still socialize and adapt to peers or friends at school with all their limitations, such as the physical changes resulting from indonesian journal of nursing practices 4 treatment and the limitations of daily activities. limited physical activity makes the subject unable to do things that can be done by healthy normal peers (halim-fikri et al., 2022; nikmah & mauliza, 2018). conclusion based on the result of this study, it can be concluded that the mean quality of life of children with thalassemia in indonesia ranged from 50% to 67.2%. school function had the lowest mean of the four domains assessed, followed by emotional, physical, and social. health services that could improve the quality of life of thalassemia patients could be provided optimally with effective and efficient management strategies and involve all sectors, both formal and informal so that the quality of life for children with thalassemia would not be different from that of the normal children. acknowledgement the researchers would like to thank lp3m umy for funding this research. references ankush, a., dias, a., silveira, m. p., talwadker, y., & souza, j. p. 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(2016). faktor yang berhubungan dengan kualitas hidup anak thalasemia. jurnal ilmiah keperawatan sai betik, 12(1), 130–139. http://dx.doi.org/10.26630/jkep.v12i1.370 ramadhanti, i., patimah, i., & kusnadi, e. (2020). hubungan keteraturan pemakaian kelasi besi dengan kualitas hidup anak penyandang thalassemia. jurnal medika cendekia, 7(2), 118–126. https://doi.org/10.33482/medika.v7i02.148 shafie, a. a., chhabra, i. k., wong, j. h. y., mohammed, n. s., ibrahim, h. m., & alias, h. (2020). health-related quality of life among children with transfusion-dependent thalassemia: a cross-sectional study in malaysia. health and quality of life outcomes, 18(1), 141. https://doi.org/10.1186/s12955-020-01381-5 sharma, s., seth, b., jawade, p., ingale, m., & setia, m. s. (2017). quality of life in children with thalassemia and their caregivers in india. the indian journal of pediatrics, 84(3), 188–194. https://doi.org/10.1007/s12098-016-2267-z the act of health minister on thalassemia management, (2018). https://www.persi.or.id/images/regulasi/kep menkes/kmk12018.pdf thiyagarajan, a., bagavandas, m., & kosalram, k. (2019). assessing the role of family well-being on the quality of life of indian children with thalassemia. bmc pediatrics, 19(1), 100. https://doi.org/10.1186/s12887-019-1466-y torcharus, k., & pankaew, t. (2011). health-related quality of life in thai thalassemic children treated with iron chelation. the southeast asian journal of tropical medicine and public health, 42(4), 951–959. wahyuni, m. s., ali, m., rosdiana, n., & lubis, b. (2011). quality of life assessment of children with thalassemia. paediatrica indonesiana, 51(3), 163. https://doi.org/10.14238/pi51.3.2011.163-9 yasmeen, h., & hasnain, s. (2018). quality of life of pakistani children with β-thalassemia major. hemoglobin, 42(5–6), 320–325. https://doi.org/10.1080/03630269.2018.1553183 indonesian journal of nursing practices 6 s cr e e n in g e li g ib il it y in tr o d u ct io n in tr o d u ct io n records identified through database searching (n=166) google scholar (n=128) pubmed (n=38) duplicate article (n=1) screened by title and abstract (n= 165) records excluded with reason (n= 141) screened by fulltext (n=24 ) full-text articles excluded with reason (n=18 ) studies included in literature review (n= 6) figure 1. prisma flow diagram vol. 6 no. 1 june 2022 7 table 1. research in various regions in indonesia regarding the quality of life of children with thalassemia no title (years) method result conclusion 1 quality of life assessment of children with thalassemia (2011). wahyuni et al. children aged 518 years who suffer from thalassemia at adam malik hospital, medan the mean of physical function: 53.1% the mean of emotional function: 50.9% the mean of social function: 62.5% the mean of school function: 36.2% the mean quality of life: 50.9% the highest mean is a social function, and the lowest mean is a school function 2 hemoglobin levels, nutritional status, food consumption patterns and quality of life of thalassemia patients (2012). isworo et al 32 children with thalassemia aged 6-15 years in banyumas regional hospital the mean of physical function: 64.9% the mean of emotional function: 63.9% the mean of social function: 81.4% the mean of school function: 60% the mean of quality life: 67.2% the highest mean is a social function, and the lowest mean is a school function 3 the effect of the thalassemia education package on the quality of life of thalassemia children (2014). hastuti. 14 children aged 8-18 years at abdul moeloek hospital bandar lampung the mean of physical function: 66% the mean of emotional function: 61.4% the mean of social function: 79.29% the mean of school function: 53.9% the mean quality of life: 65.36% the highest mean is a social function, and the lowest mean is a school function 4 analysis of factors that affect the quality of life of children with betathalassemia major (2014). mariani et al 84 children aged 5-18 years at rsu kota tasikmalaya and ciamis the mean of physical function: 60.86% the mean of emotional function: 57.61% the mean of social function: 61.46% the mean of school function: 54.52% the mean quality of life: 50.9% the highest mean is a social function, and the lowest mean is a school function 5 factors related to the quality of life of thalassemia children (2016). pranajaya and nurchairina. 102 children aged 5-18 years at abdul moeloek hospital bandar lampung the mean of physical function: 65.72% the mean of emotional function: 61.72% the mean of social function: 70.34% the mean of school function: 56.01% the mean quality of life: 62.75% the highest mean is a social function, and the lowest mean is a school function 6 quality of life for thalassemia patients based on the pediatric quality of life inventory 4.0 generic core scales in the nursing room of cut meutia hospital, north aceh (2018) nikmah and mauliza. 41 children aged 2-18 years in the pediatric ward of cut meutia hospital, aceh utara the mean of physical function: 55.67% the mean of emotional function: 69.51% the mean of social function: 79.02% the mean of school function: 36.96% average average quality of life: 60.48% the highest mean is a social function, and the lowest mean is a school function indonesian journal of nursing practices 60 ijnp (indonesian journal of nursing practices) vol 5 no 1 june 2021: 60-66 ichsan rizany1, herry setiawan1, musafaah2 1nursing management department, nursing school, lambung mangkurat university, banjarbaru city, indonesia 2health policy administration and health promotion department, study of public health, lambung mangkurat university, banjarbaru city, indonesia corresponding author: ichsan rizany email: ichsan.r.psik@ulm.ac.id the relationship between waiting time and patient satisfaction in the outpatient of public hospital in banjarbaru article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v5i1.10275 : 14 november 2020 : 02 may 2021 : 05 may 2021 abstract background: outpatients often complain about hospital services, one of which is waiting time. high complaints have an impact on patient satisfaction. currently, in several outpatient rooms at the hospital, long queues and long waiting times frequently occur. objective: this study aims to determine the correlation between waiting time and patient satisfaction at public hospital. method: this study used a non-experimental approach with a cross-sectional design. samples were 93 patients selected by using random sampling technique at the public hospital in banjarbaru city. the instruments used were the patient satisfaction questionnaire and waiting time observation. data were analyzed using the chi-square test. results: the results showed that 35 (37.6%) patients felt the standard waiting time according to regulations from the ministry of health (60 minutes), while 55 (59.1%) patients were satisfied with the services provided. there was a significant relationship between waiting time and patient satisfaction (p-value = 0.021). conclusion: it can be concluded that there is a relationship between waiting time and patient satisfaction. hospitals can implement online registration and manage the arrival of doctors in outpatient care so that waiting times and patient satisfaction can be managed according to minimum service standards keywords: outpatient; patient satisfaction; waiting time introduction good service to patients is the primary goal of the hospital. the quality of good hospital services is seen from the superiority of infrastructure, the availability of qualified equipment, an excellent physical picture, and the commitment and ability of officers to take actions following the profession (supartiningsih, 2017). patients, as internal customers, have expectations of the services provided to them (suhonen et al., 2012). patients will judge the service based on their satisfaction rate. http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/10275 vol. 5 no. 1 june 2021 61 patient satisfaction is the clarity between what is desired and the reality felt by the patient (xesfingi & vozikis, 2016). patient satisfaction is also defined as the patient's emotional form after experiencing health services in the hospital (marquis et al., 2012). when the patient is not satisfied with the services provided, they do not want to return and look for other services (russell et al., 2015). the target of patient satisfaction at service is 90, following the ministry of health's minimum service standards (menteri kesehatan, 2008). patient satisfaction in different hospitals varies. 27.6% (117) patients felt dissatisfied with outpatient services in hospitals in kuwait (alhashem et al., 2011). based on data, patient satisfaction in west china was lower than patient satisfaction in central and east china (he et al., 2018). in martapura hospital, outpatient satisfaction was still below the spm (minimum service standards in health regulations) as 90 (jannah et al., 2020). at the same time, patient satisfaction at indramayu district hospital found that 76 patients (82.6%) expressed dissatisfaction (laeliyah & subekti, 2017). it shows that the indicator of satisfaction is still a hospital problem. there are several factors influencing patient satisfaction. it can be influenced by patient characteristics such as age, occupation, education, and marital status (abdilah & ramdan, 2014; kurniawan & intiasari, 2012; yoder-wise, 2014). other factors that can affect satisfaction are nursing schedule, nursing services, doctor services, and facilities (ammo et al., 2014). furthermore, patient satisfaction is also influenced by the patient's emotional and service quality and waiting times (sumaedi et al., 2016). waiting time for patients on an outpatient is the time used by patients to get outpatient services from the registration point to the doctor's examination room (torry et al., 2016). long queues and long waiting times are indicators of efficiency as dimensions of health service quality (purwiyanti et al., 2019). the long waiting time causes discomfort to the patient. moreover, long queues indicate that many patients are waiting for services (nursanti et al., 2018). the observations from the preliminary study found that many outpatients waited in front of the clinic. the outpatient unit also viewed that a high number of waiting patients caused discomfort among them. researchers asked one patient who had waited more than 60 minutes. patients also occasionally asked the officers whether they had been called or not. another study also mentioned that long queues occurred in outpatient care in the morning. patients also felt exhausted waiting for the doctor who did not arrive based on the schedule (jannah et al., 2020). based on the explanation above, this study aims to analyze the relationship between waiting time and patient satisfaction in the outpatient at the public hospital. method this study used a cross-sectional design and was conducted at a public hospital in banjarbaru city. this hospital is a regional general hospital in banjarbaru city. it was selected as its satisfaction rate was still low, and there were several complaints about outpatient services. the number of samples used was 93 patients treated in the outpatient. the inclusion criteria of this study included adult patients, below 60 years old, willing to be respondents, and able to read and write. none of the selected samples were excluded from the research data. the researcher made the instrument used in the study. the satisfaction questionnaire was based on the management book (hariyati, 2014; marquis & huston, 2012; nursalam, 2014), and the waiting time instrument referred to the minimum hospital service standard (menteri kesehatan, 2008). the satisfaction instrument consisted of 25 questions with a likert scale (1-5). the waiting time instrument used a check sheet observed directly by the researcher, calculated from the incoming patient to the patient meeting the doctor. the satisfaction instrument had been declared valid with the results as data r count> t table (0.407 0.868> 0.361) for all statements in the satisfaction questionnaire. the reliability test result using cronbach's alpha was 0.976, which indicates strong reliability. validity and reliability tests were carried out on 30 outpatients with the same inclusion criteria in this study. the research process was carried out by waiting for the patient in the registration room. the researchers carried out a shared perception of the data collection process. the team calculated the time, starting from the patient who took the registration indonesian journal of nursing practices 62 room ticket until the doctor examined the patient. when the patient awaited the examination in the waiting room, the researcher approached the patient to ask them to fill out a questionnaire. the satisfaction was categorized into two, including satisfied and dissatisfied, with the cut point mean of 106.12. the waiting time was also categorized into 2, including standard and non-standard, based on the minimum service standard of 60 minutes. this study was analyzed using the chi-square test. this study has passed the ethical test on the faculty of medicine's ethical committee, the university of lambung mangkurat, with the number ethical was 294 / kepk-fk unlam / ec / vii / 2019. researchers paid attention to aspects of autonomy by providing consent forms to respondents. researchers had also explained the purpose and benefits of this study. results respondent characteristics were seen based on age, gender, education level, and occupation. the patients' mean age was 39.34 years, with the youngest was 18 years old and the oldest was 60 years old. table 1 shows that most female patients were 54 (58.1%). the highest level of education was senior high school, with 64 people (68.8%). most occupations were housewives, with a total of 38 people (40.9%). table 2 shows that 55 people (59.1%) felt satisfied, and 58 patients (62.4%) felt that the patient's waiting time was non-standard. meanwhile, table 3 shows a significant relationship between waiting time and patient satisfaction in outpatient settings (p = 0.021). 31.2% (29) of dissatisfied patients mentioned that the waiting time was below standard. discussions the average age of the respondents was at a productive age. the age of 39 years was the peak age in carrying out the productivity of a job. at this age, health begins to decline due to high activity (taufikurrahman et al., 2020). the increasing age of a person shows thinking maturity so that they are more likely to judge the satisfaction wisely (kurniawan & intiasari, 2012). most respondents' education was high school. it aligns with other research that 53 (48.2%) patients were treated with high school education (chairunnisa & puspita, 2017). indonesia required its people to go to high school, but there was no obligation for the community to continue to a higher level after graduating. besides, the higher the patient's education is, the higher the level of understanding will be (alhashem et al., 2011). it also has an impact on the sensitivity of the services felt by patients. the number of respondents with undergraduate education was also fewer, as 17.2%. the results also showed that there was no significant relationship between age, education, and patient satisfaction. the result of this study showed that most patients were housewives. this result aligns with other studies where 54 patients (49.1%) who seek treatment were dominated by housewives (chairunnisa & puspita, 2017). furthermore, this result also showed that 59.1% of patients had worked. patients who worked and went to the hospital had high expectations for services (ernawati et al., 2018). however, the results of this study did not show a relationship between work and patient satisfaction. moreover, the result of this study showed that only 59.1% of the patients were satisfied. based on research, it was stated that the patient satisfaction rate must reach 90% to get the hospital’s optimal service (jannah et al., 2020; menteri kesehatan, 2008). another study stated that 62.9% of outpatients were satisfied (nofriadi et al., 2019). based on the findings, low patient satisfaction was caused by health care services, length of service, and waiting for chair facilities that did not fit the number of patients. another research also strengthened that infrastructure, waiting room, and cleanliness of facility's comfort can affect patient satisfaction (budijanto, 2007). in addition, outpatient satisfaction is influenced by professional skills, competencies, and attitudes of health workers (zhao et al., 2017). thus, the satisfaction in this study was also considered not optimal according to the hospital's expectations of service. besides, this study also showed that 62.4% of respondents felt that the waiting time was still not standardized. based on the results of previous research, it was stated that most of the waiting times for outpatients were in the long category with a mean of 70.18 minutes (laeliyah & subekti, 2017). vol. 5 no. 1 june 2021 63 other research also stated that the waiting time was in the non-standard category exceeding 60 minutes, with the total average waiting time for internal medicine outpatient services was 157.13 minutes. waiting times were not ideal due to doctors who arrived late at the clinic (torry et al., 2016). based on observations, patients stated they had received an initial examination from the nurse, but they still had to wait for doctors who had not come to the clinic. ernawati also confirmed that 25% of patients were satisfied due to the ideal waiting time (less than 60 minutes) (ernawati et al., 2018). the results of this study also showed that there was a significant relationship between waiting time and patient satisfaction in outpatient. this result was in line with other studies that outpatient satisfaction was influenced by long patient waiting times (he et al., 2018). another study also proved that outpatient satisfaction was influenced by the patient's waiting time (p = 0.003) (sun et al., 2017). this data showed that 29 patients (31.2%) who had waited a long time were dissatisfied. furthermore, these results also showed that 29 patients (31.2%) who waited a long time still felt satisfied. patient satisfaction was not only affected by the waiting time but also other factors such as infrastructure, the comfort of the waiting room (kashinath et al., 2010), and cleanliness (budijanto, 2007). in addition, patient satisfaction was influenced by professional skills, competencies, and health workers (zhao et al., 2017). therefore, patients who have waited a long time might still feel satisfied. conclusions this study concludes a significant relationship between waiting time and patient satisfaction in outpatient (p = 0.021). 31.2% of patients (29 people) who were unsatisfied felt the waiting time did not meet the standard. meanwhile, patients who were satisfied with the waiting time were 26 people (28%). recommendations were given to hospitals to improve the service procedures to lower waiting times by 60 minutes. commitment from health workers was also essential to ensure that outpatient services were run on time so that patients did not wait long. it was expected that patient satisfaction can be increased by 90% through proper service management. acknowledgments acknowledgment was given to the enumerator team, who helped in collecting data at the hospital. acknowledgment was also given to mrs. lesti for her information and support in the data collection process in the public hospital. author contribution ir carried out studies in the hospital, participated in the sequence alignment, and drafted the manuscript. hs participated in the design of the study and carried out studies in the hospital. m performed the statistical analysis. all authors read the manuscript and approved the final manuscript. conflict of interest there is no conflict of interest in this study. references abdilah, a. d., & ramdan, m. 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(2016). patient satisfaction with the healthcare system: assessing the impact of socio-economic and healthcare provision factors. bmc health services research, 16(1), 94. https://doi.org/10.1186/s12913-016-1327-4 yoder-wise, p. s. (2014). leading and managing in nursing (5th ed.). elsevier. zhao, p., yoo, i., lavoie, j., lavoie, b. j., & simoes, e. (2017). web-based medical appointment systems: a systematic review. journal of medical internet research, 19(4), 1–9. https://doi.org/10.2196/jmir.6747 https://doi.org/10.1186/s12889-017-4667-z https://doi.org/10.18196/jmmr.6122 https://doi.org/10.33859/dksm.v10i1.462 https://doi.org/10.21776/ub.jkb.2016.029.03.3 https://doi.org/10.21776/ub.jkb.2016.029.03.3 https://doi.org/10.1186/s12913-016-1327-4 https://doi.org/10.2196/jmir.6747 indonesian journal of nursing practices 66 table 1. characteristics of respondents (n=93) variable n % p gender • female • male 39 54 41.9 58.1 0,689 education level • none • elementary school • middle school • high school • bachelor 2 2 9 64 16 2.2 2.2 9.7 68.8 17.2 0,388 work • farmer • college student • labor • housewife • police • civil servants • general employee • teacher • trader 1 7 12 38 4 11 15 3 2 1.1 7.5 12.9 40.9 4.3 11.8 16.1 3.2 2.2 0,361 table 2. description of waiting time and patient satisfaction (n= 93) variable n % satisfaction • dissatisfaction • satisfaction 38 55 40.9 59.1 waiting time • standard • non-standard 35 58 37.6 62.4 table 3. correlation between waiting time and patient satisfaction (n= 93) satisfaction `waiting time p standard nonstandard total n(%) n(%) n(%) dissatisfaction 9 (9.7) 29 (31,2) 38 (40,9) 0.021* satisfaction 26 (28) 29 (31,2) 55 (59.1) total 35 (37.6) 58 (62,4) 93 (100) 7. 10275-ichsan rizany; bookmark_clean.pdf 7. 10275-ichsan rizany-lampiran_clean.pdf indonesian journal of nursing practices 70 ijnp (indonesian journal of nursing practices) vol 4 no 2 december 2020 : 70-76 resti yulianti sutrisno1, yanuar primanda1, fahni haris1 1program studi keperawatan, universitas muhammadiyah yogyakarta corresponding author: resti yulianti sutrisno email: restiyulianti@umy.ac.id student's satisfaction on online nursing osce (on-osce) assessment application article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v4i2.10142 abstract background: objective structured clinical examination (osce) is one of the final assessment components for nursing students. osce assessment uses the on-osce (online nursing osce) application to fulfill the need and overcome the manual osce assessment challenges using papers. the manual osce assessment with multiple checklists is very detailed and takes a long time in scoring. besides, the evaluation using papers tends to cause a miscalculation in scoring a total of ratings that can harm the student. method: this research was a non-experimental study with a descriptive design and cross-sectional approach. the samples were 480 nursing students. the instrument of assessment of satisfaction was analyzed based on the score accuracy, time to retrieve score, and examiner's attention. data analysis used descriptive frequency and percentage distributions. results: the majority of students were satisfisfied (n= 365, 76%) based on the time to retrieve score. more than half respondents (n= 285, 59,4 %) were also satisfied with on-osce related to the score accuracy. regarding the examiners' attention, 273 students (56,9 %) felt the examiners ignored the students' actions. they focused on the laptop to provide an assessment. it could be due to the new on-osce application for the examiners and their unfamiliarity with operating the application. conclusion: most students were satisfied with the assessment using the on-osce application to retrieve scores and the score accuracy. however, they were less satisfied with the examiners' attention. the examiners should be more familiar with the on-osce. keywords: assessment, application, online nursing osce, on-osce, osce, nursing introduction objective structured clinical examination (osce) evaluates nursing students' clinical skills learned in the skills lab. osce is a tool for assessing several clinical competence components such as assessment, physical examination, procedural, interpretation of lab results, patient problem management, communication, and attitudes (ananthakrishnan, 1993). the usage of osce can facilitate students' psychomotor skills and knowledge and attitudes (baid, 2011). osce is a valid and reliable method for assessing clinical competence objectively in various settings (kurz, mahoney, martin-plank, & lidicker, 2009). by using osce, the clinical skills can be evaluated to see the competencies achieved by students. http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://doi.org/10.18196/ijnp.v4i2.10142 vol. 4 no. 2 december 2020 71 osce provides many benefits, including developing student confidence and preparing students' skills and understanding for clinical practice (alinier, 2003; barry, noonan, bradshaw, & tighe, 2011). osce requires the students to actively demonstrate how they will apply the acquired knowledge to simulated "real world" situations (franklin, 2005). skills competency examination with osce provides examiners at each station with real-time direct observation and assessment of each nursing student's performance (quero munoz, o'byrne, pugsley, & austin, 2005). examiner assesses each student's performance using a checklist or rating scale (robbins & hoke, 2008). the examination at each station test specific competencies that are scored using a scoring sheet. the sheet can be in the form of a checklist or a combination of checklists and global scores. examiners then provide a total score based on the student's overall performance (ahuja, 2009). osce assessment is carried out using various instruments. some are assessed using papers; some are assessed online. based on a study conducted by natarajan & thomas, osce assessment using paper has several shortcomings as follows: (1) results are not immediately available; (2) delay in providing scores and feedback; (3) time pressure for academic staff; (4) low ability to moderate and audit examination results; (5) high production costs; (6) pressure on the appraisal administration staff (natarajan & thomas, 2014). the paper-based osce scoring system's weaknesses make academics think of innovating to make the osce scoring system better, more effective, efficient, and accurate. the existing osce scoring system is developed in a paperbased system and electronic or online system and technological developments. several studies mention the development of an electronic osce scoring system. as has been done by primanda, sutrisno, and haris, they developed an online osce assessment application for the school of nursing called on-osce (online nursing objective structured clinical examination) (primanda, et. al., 2019). another study also explores the electronic osce management system for nursing osces (meskell et al., 2015). the development of the online osce system or on-osce (online nursing objective structured clinical examination) has also been carried out by the school of nursing, faculty of medicine and health sciences, universitas muhammadiyah yogyakarta since 2018. this application in the osce’s scoring process has been carried out since semester two in the academic years of 2018. therefore, it is essential to evaluate students' satisfaction when examined using the on-osce system in the process of osce. methods research design the study designed as a quantitative and nonexperimental study with descriptive design to determine the satisfaction of students who take osce with online assessments in terms of the scoring accuracy, the time (speed) of the score release schedule, and the focus/attention of the examiners to the actions done by students during the exam. this study was conducted with a crosssectional approach, and data collection was done only once. population and samples this study's population were nursing students in the first, second, third, and fourth years who took part in the osce using online osce assessment or on-osce. the sampling technique used was total sampling. the number of samples is 480 respondents. there are respondents who have taken osce by using the on-osce assessment for one semester (two blocks), two semesters (5 blocks), or three semesters (8 blocks). each block has an osce scoring rubric component according to its respective block. the inclusion criteria in this study were nursing study program students of umy who had participated in the osce using onosce assessment. data collection data collection was carried out using a questionnaire that was distributed online. respondents filled out online questionnaires using google form. online questionnaires and informed consent were distributed through the class leader, to be filled in by all respondents in that batch. each respondent filled out a student satisfaction questionnaire on the osce assessment using onosce system. the satisfaction questionnaire indonesian journal of nursing practices 72 consisted of three components, namely the speed of the assessment, the accuracy of the assessment, and the attention of the examiners during the implementation of the osce using onosce. respondents were then requested to provide an evaluation with a likert scale with a score of 0-10. a score of 0 indicates that the respondent is very dissatisfied, and ten indicates that the respondent is very satisfied. the score is then categorized as satisfied for a score of 8-10 and dissatisfied for 0-7. respondents were also allowed to provide descriptive assessments to describe more clearly the respondent's satisfaction/dissatisfaction regarding the assessment with the on-osce application. researchers had provided time to fill out the questionnaire for seven days. every respondent who filled out the questionnaire had the opportunity to get a reward. the researcher observed the completeness of the data and the number of respondents who filled out the online questionnaire based on the responses on the google doc. after seven days of data collection, the data on google doc was downloaded and the data was analyzed. ethics this study has passed the ethics committee of the faculty of medicine and health sciences' ethical clearance, universitas muhammadiyah yogyakarta with ethics number 051 / ec-kepk fkik umy / ii / 2019. this study also pays attention to ethical principles, namely informed consent. participants who are willing to participate in this study are then given explanations related to the research. as for confidentiality, the respondents' identity was not mentioned in the questionnaire to maintain confidentiality. the principle of justice is also carried out. whether students choose to participate or choose not to participate in this study will not affect their study. for the beneficence principle, this study will benefit students since it is also an effort to improve student evaluation instrument’s quality. data analysis data were analyzed descriptively. age demographic data were analyzed using numeric analysis of mean, minimum, maximum, standard deviation. for gender, student's year, score release speed/ time, score accuracy, and examiner attention/focus were displayed in the form of frequency and percentage. an exploratory, descriptive analysis of the satisfaction/ dissatisfaction explanations/ description given by the participants. results table 1. characteristics of respondents by age variable mean minimum maximum sd age 21 17 26 1,6 the respondent’s' average age was 21 years old, while the youngest was 17 years and the oldest was 26 years old. table 2. characteristics of respondents based on gender and duration of exposure to on-osce variable frequency percentage gender male 84 17,5 female 396 82,5 total 480 100,0 duration of on-osce exposure 1 semester 91 19,0 2 semesters 113 23,5 3 semesters 276 57,5 total 480 100,0 based on table 2, respondents' characteristics based on gender were found that most of the respondents were female, with 82.5%, then male by 17.5%. the majority of respondents have been exposed to the on-osce scoring system for three semesters, namely 276 respondents (57.5%). then two semesters and one semester. table 3. description of respondents' satisfaction based on the time to retrieve the score (speed), score accuracy, examiner's attention variable frequency percentage the time to retrieve the score (speed) satisfied 365 76 dissatisfied 115 24 total 480 100,0 score accuracy satisfied 285 59,4 dissatisfied 195 40,6 total 480 100,0 examiner's attention satisfied 207 43,1 dissatisfied 273 56,9 total 480 100,0 based on table 3, it was found that respondent satisfaction was based on the time to retrieve score (speed). most of the respondents were vol. 4 no. 2 december 2020 73 satisfied, namely as many as 365 respondents (76%); most of the respondents are satisfied with the scoring accuracy using the on-osce system. this can be seen in the number of respondents satisfied with the assessment's accuracy with 285 respondents (59.4%). respondent satisfaction was based on "the examiner's attention to the actions taken by the respondent (osce exam participant) during the osce implementation" there were more respondents who were dissatisfied than the respondents who were satisfied, with a small margin. respondents who were dissatisfied were 273 respondents (56.9%), while respondents that were satisfied were 207 respondents (43.1%). table 4. description of respondents' satisfaction on the time to retrieve score based on gender and duration assessed by on-osce variable the time to retrieve the score score accuracy examiners attention satisfied dissatisfied satisfied dissatisfied satisfied dissatisfied gender male 56 28 47 37 47 37 % male 66,7 33,3 56,0 44,0 56,0 44,0 % gender 11,7 5,8 9,8 7,7 9,8 7,7 female 309 87 238 158 238 158 % female 78,0 22,0 60,1 39,9 60,1 39,9 % gender 64,4 18,1 49,6 32,9 49,6 32,9 duration assessed using on-osce 1 semester 64 27 61 30 39 52 % 1 semester 70,3 29,7 67,0 33,0 42,9 57,1 % total semester 13,3 5,6 12,7 6,3 8,1 10,8 2 semester 80 33 65 48 65 48 % 2 semester 70,8 29,2 57,5 42,5 57,5 42,5 % total semester 16,7 6,9 13,5 10,0 13,5 10,0 3 semester 221 55 159 117 103 173 % 3 semester 80,1 19,9 57,6 42,4 37,3 62,7 % total semester 46,0 11,5 33,1 24,4 21,5 36,0 based on table 4, it was found that male respondents were mostly satisfied with the time to retrieve the score within 24 hours after the osce. a percentage of 66.7% and female respondents were also mostly satisfied with a percentage of 78%. while the respondent's satisfaction with the time to retrieve score of the osce score based on the duration of exposure to on-osce explained that most of the respondents were satisfied for the respondents who had participated for three semesters, namely 221 respondents (46% from full semester), then followed by those who had participated for two semesters and then one semester. most male and female respondents were satisfied with the accuracy of the osce scoring using the on-osce application. namely, 56% of male respondents were satisfied, and 60.1% of female respondents were satisfied. as for satisfaction with the accuracy of the scoring based on the duration participating the osce using the onosce system, it was found that there were more of the respondents who are satisfied than those who are dissatisfied, both in the exposure of 1 semester, two semesters, and three semesters. meanwhile, the highest satisfaction was for students who participated for one semester, three semesters, and two semesters. female respondents were more dissatisfied with the examiners' attention during the osce exam compared to male respondents. based on the table, it can also be seen that students who took osce for two semesters were more satisfied (57.5%) with the examiner's attention than those who were not satisfied (42.5%). more respondents who had participated in osce with on-osce system for one semester and three semesters were not satisfied with the examiners' attention. in addition to the descriptive results using a questionnaire, this study also analysed the respondent's descriptive evaluation/explanation of the osce. several themes were obtained from the evaluation delivered by the respondents, namely: 1. the usage of the on-osce system is a good improvement: indonesian journal of nursing practices 74 a. the usage of on-osce is excellent at the present b. examiners are becoming more objective c. it is better to use on-osce so that the score can be accessed quickly, and when there are some errors in the score, it can be corrected together d. this scoring system is already good, and i prefer the current scoring system. hopefully, the credibility will be improved e. i prefer the online osce assessment because the results come out faster, so i won't have to wait for too long f. it is better for the examiner to not only just sitting down in osce 2. with on-osce system, the osce score can be accessed easier and faster a. "it's nice to have it online. the results come out right away." b. using the online osce, we can get our score faster 3. examiners focus on laptops instead of the student's actions a. it is better if examiners can pay more attention to students during the osce so that the scores given are correct b. several lecturers were glued to their tablets and paid no attention to the student's process c. sometimes examiner only focus on the laptop d. sometimes examiners did not pay attention to students who were practicing but were busy paying attention to the laptop list. sometimes, students had executed the action on the list, but often the examiners were not aware or missed it. discussions based on this study's results, it was found that osce scoring using the "online-nursing osce (onosce)" system was more effective and efficient because it was more satisfying for students. this can be seen from the student satisfaction level based on the score release/retrieval speed and the scoring accuracy. this is in line with luimes & labrecque's research, which stated that electronic-based scoring systems are more effective and efficient than paper-based assessments (luimes & labrecque, 2018; snodgrass, et. al., 2014; currie, et. al., 2017). osce scoring using an online system in the form of on-osce makes the scores quickly released because the data inputted by the examiner is immediately calculated and the results come out right away whether the student passes the exam or has to repeat it. besides that, the grades can be accessed by the admin and announced directly to students. on the other hand, when the assessment was still using the paper-based system, the examiner still needs time to sum up, the detailed item score, then the admin inputs the score into the system announces it to the osce participants; in this case, the osce score cannot come out real-time but need to be processed for several days. with the online osce scoring system, students feel very satisfied with the score release speed based on quantitative and qualitative results, stating that "scoring with on-osce is very good because the score comes out straight away." the existence of this innovation makes the work time shorter and faster. grades come out quickly, so students can find out if they passed the osce or if they need to retake the exam. with the quick release of the osce score, students can prepare themselves better when taking the retest. the osce online scoring system was very satisfying in terms of the score release speed since the assessor and admin's working time was shorter, which is also in line with what was conveyed by onwudiegwu, who stated that the usage electronic scoring system saves time (onwudiegwu, 2018). this is also in line with the statement of treadwell, who compared paperbased osce with electronic methods. these findings suggested that electronic methods are just as effective and more efficient (take less time) than traditional paper-based methods (treadwell, 2006). another thing that satisfies students using the on-osce scoring system is that they are more accurate than the paper-based system. the online calculation system can produce complete accuracy than the manually written system. the on-osce system automatically calculates each scoring item that has been listed by the examiner. vol. 4 no. 2 december 2020 75 the system automatically performs the calculation and concludes whether the student passed the exam or has to take the retest. manual calculations by examiners run the risk of causing errors because examiners add up each scoring item manually. also, in the on-osce system, respondents are satisfied that the osce scoring with the on-osce system is better in terms of the accessibility of the score detail, including the details of the examinee's mistake noted by the examiners. this can be done because the examiners are provided a place to write comments when scoring student errors or incompleteness in the osce process. the feedback from the examiners becomes more complete. this is in line with lumino's research, which stated that the electronics osce system improves the efficiency of assessment and examiners' objectivity and can provide faster feedback to students (luimes & labrecque, 2018). the assessment results of each action taken by students who take osce and are examined using on-osce are recorded in the system. they can be used to analyze further educational development and evaluation of the learning process implemented, including improving guidelines, checklists, teaching strategies, or even the curriculum. this is in line with what meskell et al. who stated that the electronic osce scoring system could further analyze student performance and develop strategies for improving student performance (meskell et al., 2015). in this study, an aspect that still did not satisfy students was the examiner's attention when the examiner begins using on-osce. for example, students' descriptions show that examiners are more focused on laptops or checklists on laptops, making the examiners not fully face the student or pay attention to student performance. this happened because examiners are not familiar with the system, considering that on-osce has only been used for three semesters. this is a challenge for examiners to adapt to the new system to keep paying attention to the assessment checklist while also paying attention to students' actions throughout the osce process. this is in line with the research submitted by snodgrass et al., which mentioned that lack of knowledge of the scoring system is one of the examiners' challenges in using an electronic-based scoring system (snodgrass et al., 2014). conclusions most of the students are satisfied with the release time of osce score and the accuracy of scoring results using the on-osce system. however, many students are still dissatisfied with the examiners' attention. the examiners focused more on the tablet or laptop they held during the osce than the student's performance. the examiners should be more familiar with the scoring system and objectively score student's performance based on the thorough observation acknowledgement this study was supported by a research grant from universitas muhammadiyah yogyakarta. the researchers thank the head of the school of nursing and all students for their support and efforts to perform this project. the authors also address the special thanks to the students for their cooperation. references ahuja, j. (2009). osce: a guide for students, part 1. practice nurse, 37(1), 37–39. alinier, g. (2003). nursing students' and lecturers' perspectives of objective structured clinical examination incorporating simulation. nurse education today, 23(6), 419–426. https://doi.org/10.1016/s02606917(03)00044-3 ananthakrishnan, n. (1993). objective structured clinical/practical examination (osce/ospe). journal of postgraduate medicine, 39(2), 82– 84. retrieved from http://www.jpgmonline.com/text.asp?1993 /39/2/82/628 baid, h. (2011). the objective structured clinical examination within intensive care nursing education. nursing in critical care, 16(2), 99– 105. https://doi.org/10.1111/j.14785153.2010.00396.x barry, m., noonan, m., bradshaw, c., & tighe, s. (2011). an exploration of student midwives' experiences of the objective structured clinical examination assessment process. nurse education today, 32, 690–694. https://doi.org/10.1016/j.nedt.2011.09.007 indonesian journal of nursing practices 76 currie, g. p., sinha, s., thomson, f., cleland, j., & denison, a. r. (2017). tablet computers in assessing performance in a high stakes exam: opinion matters. journal of the royal college of physicians of edinburgh, 47, 164–167. https://doi.org/10.4997/jrcpe.2017.215 franklin, p. (2005). osces as a means of assessment for the practice of nurse prescribing. nurse prescribing, 3, 14–23. https://doi.org/10.12968/npre.2005.3.1.175 09 kurz, j. m., mahoney, k., martin-plank, l., & lidicker, j. (2009). objective structured clinical examination and advanced practice nursing students. journal of professional nursing, 25(3), 186–191. https://doi.org/10.1016/j.profnurs.2009.01. 005 luimes, j., & labrecque, m. (2018). implementation of electronic objective structured clinical examination evaluation in a nurse practitioner program. journal of nursing education, 57, 502–505. https://doi.org/10.3928/0148483420180720-10 meskell, p., burke, e., kropmans, t. j. b., byrne, e., setyonugroho, w., & kennedy, k. m. (2015). back to the future: an online osce management information system for nursing osces. nurse education today, 35(11), 1091–1096. https://doi.org/10.1016/j.nedt.2015.06.010 natarajan, j., & thomas, d. s. (2014). integrative review literature on objective structured clinical examination and its implications in nursing education. iosr journal of nursing and health science, 3(4), 23–30. https://doi.org/10.9790/1959-03412330 onwudiegwu, u. (2018). osce: design, development, and deployment. journal of the west african college of surgeons, 8, 1– 22. primanda, y., sutrisno, r. y., & haris, f. (2019). the development of online osce prototype for osce in school of nursing : lesson learned. advances in health sciences research, 15(icosihsn), 215–220. https://doi.org/https://doi.org/10.2991/icos ihsn-19.2019.47 quero munoz, l., o'byrne, c., pugsley, j., & austin, z. (2005). reliability, validity, and generalizability of an objective structured clinical examination (osce) for assessment of entry-to-practice in pharmacy. pharmacy education, 5(1), 33–43. https://doi.org/10.1080/156022104000253 47 robbins, l. k., & hoke, m. m. (2008). using objective structured clinical examinations to meet clinical competence evaluation challenges with distance education students. perspectives in psychiatric care, 44(2), 81–88. https://doi.org/10.1111/j.17446163.2008.00157.x snodgrass, s. j., ashby, s. e., anyango, l., russell, t., & rivett, d. a. (2014). electronic practical skills assessments in the health professions: a review. the internet journal of allied health science and practice, 12(1), 1–10. retrieved from http://ijahsp.nova.edu/articles/vol12num1/ pdf/snodgrass.pdf treadwell, i. (2006). assessment the usability of personal digital assistants ( pdas ) for assessment of practical performance. medical education, 40(6), 855–861. https://doi.org/10.1111/j.13652929.2006.02543.x vol. 4 no. 2 december 2020 87 ijnp (indonesian journal of nursing practices) vol 4 no 2 december 2020 : 87-93 syahruramdhani syahruramdhani1, muhammad taupikurrahman1, altaf maulana pasha1 1program studi keperawatan, universitas muhammadiyah yogyakarta corresponding author: syahruramdhani email: syahruramdhani@umy.ac.id perception, attitude, and knowledge of nursing students towards wet cupping therapy (hijamah) article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v4i2.10269 abstract background: complementary and alternative medicine (cam) is a part of the health system that is well known and useful worldwide. one of the therapies used by many people is wet cupping therapy (hijamah). nowadays, wet cupping therapy (hijamah) is taught in nursing and medical school. objective: the study investigated the perception, attitude, and knowledge of nursing students toward wet cupping therapy (hijamah). method: this study was quantitative research that uses descriptive research design and cross-sectional approaches. the sampling technique used was purposive sampling with 85 respondents. the data were collected using questionnaires and analyzed with bivariate analysis. result: the result showed that the perceptions of the respondents were mostly in the average category, with the best perception of respondents is in the benefit component (76.5%). respondents have good view of cupping therapy as is useful as a form treatment, and is more practical and affordable. the respondents' attitudes and knowledge were in the average category, which was 58.8% and 68.2%. this study showed that most respondents already understand that cupping (hijamah) is a treatment with contraindications to specific health conditions. respondents also could show the basic scientific concepts of cupping and hadiths that explained cupping. however, some respondents still think that cupping (hijamah) can be applied for all ages. conclusion: in conclusion, respondents' perceptions, attitudes, and knowledge toward wet cupping therapy (hijamah) were still insufficient in some aspects. keywords: perception, attitude, knowledge, wet cupping therapy (hijamah) introduction national center for complementary and integrative health (nccih) defines complementary, and alternative medicine (cam) is a group of medications and treatment systems that are not part of conventional medicine (nccih, 2018). based on the world health organization (who), the use of cam worldwide increased in 2018. there are 98 who member countries that have developed national policies on cam, and 109 countries have national policies on cam (who, 2019). a study conducted in saudi arabia showed the high prevalence of the usage of cam by the community, especially herbs, prayer therapy, consumption of honey, and wet cupping (elolemy & albedah, 2012). http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://doi.org/10.18196/ijnp.v4i2.10269 indonesian journal of nursing practices 88 wet cupping is a widely used therapy in various countries and cultures. it is known in the islamic term as hijamah. wet cupping is beneficial for pain relief (al-bedah et al., 2019), lowering cholesterol (allafi & al-haifi, 2020), and increasing parasympathetic nerve activity (arslan, yeşilçam, aydin, yüksel, & dane, 2014). a study showed the perception of medical students towards studying cam is in average category because more students still need to accept cam for cam to be considered as an important part of the healthcare system (al mansour et al., 2015). another research showed that medical students have poor knowledge and attitudes toward complementary medicine. it is necessary to enhance students’ awareness through cam courses in the university (hooshangi et al., 2017). a recent study describing the attitude, perception, and knowledge of the public regarding cupping therapy, concluded that healthcare providers should be educated regarding cupping and create an open, respectful environment for communication with patients about cupping therapy (al-yousef, wajid, & sales, 2018). the use of wet cupping therapy is the responsibility of health workers, especially nurses. nurses should always improves their knowledge about wet cupping therapy as lack of understanding will harm the patients. one way to improve attitudes and knowledge is through the academic, educational, and university systems (khorasgani & moghtadaie, 2014). this study investigates nursing students' perceptions, attitudes, and knowledge towards wet cupping therapy (hijamah). this study's results are expected to impact policymakers in formulating curriculum or educational programs related to cam. methods this research was a quantitative study using a descriptive research design and a cross-sectional approach. this population was 108 students of the nursing study program at the muhammadiyah university of yogyakarta. the sampling technique used was purposive sampling and a sample size of 85 people based on the slovin formula. in this study, the inclusion criteria were all of the fourth-year nursing students who were willing to be respondents and were in the research location when the data were collected using a questionnaire. this study's exclusion criteria included students who were not present when distributing questionnaires and students who had not received teaching and practice related to cupping due to illness and other reasons and were unwilling to be respondents. this research was conducted in february 2019. the instrument used to obtain data in this study was a questionnaire. the authors have designed this questionnaire, and three expert researchers in cupping therapy confirmed the validity of the questionnaire. the questionnaire internal reliability was calculated using cronbach’s alpha and factor analysis. it was piloted by using 20 participants who were similar to the research participants in terms of demographics features. this pilot study helped the authors to remove the potential problem of the questionnaire. the questionnaire to measure perceptions and attitudes used likert scale with multiple choices answer, including strongly disagree, disagree, agree, and strongly agree. meanwhile, the questionnaire to measure the level of knowledge used the guttman scale with multiple choices. data collection began by filling out the informed consent sheet, followed by filling out the research questionnaire. furthermore, the questionnaire was collected back to the researcher. research assistants assisted the researchers in data collection process. this study used univariate analysis. the results of data analysis were presented in the form of frequency and percentage. this research has passed the ethical clearance of the ethics commission of fkik umy with ethics number 028/ep-fkik-umy/i/2019. results the respondent's characteristics in this study were classified based on the age and gender (table 1). vol. 4 no. 2 december 2020 89 table 1. respondents characteristic (n=85) characteristic frequency percentage (%) age 20-22 79 93 23-25 6 7 gender male 18 21.2 female 67 78.8 table 1 shows that most of respondent's characteristics, according to the age range, are 2022 years old, with a total of 79 people (93%) and based on gender he majority of respondents were female, with a total of 67 people (78.8%). table 2. the perception of respondents (n=85) perception components category frequency (n) percentage (%) benefit good 20 23.5 average 65 76.5 safety good 17 20 average 59 69.4 poor 9 10.6 indication good 6 7.1 average 66 77.6 poor 13 15.3 contraindication good 8 9.4 average 74 87.1 poor 3 3.5 based on table 2, the result shows that the perceptions of the respondents are mostly in the average category for each component of perception, namely 65 people for the benefit (76.5%), 59 people for the safety (69.4%), 66 people for the indication (77.6%) and 74 people for contraindication (87.1%). table 3. the attitude of respondents (n=85) category frequency percentage (%) good 35 41.2 average 50 58.8 table 4. the knowledge of respondents category frequency percentage (%) good 12 14.1 average 58 68.2 poor 15 17.6 based on table 3, the results show that the respondent's attitude is mostly included in the average category (58.8%). whereas, based on table 4, the result shows that the respondent's knowledge regarding cupping therapy is mostly in the average category (68.2%). discussions the number of respondents involved in this study based on age was dominated by the age range of 20-22 years old (93%) and female respondent(78.8%). according to the who, this age is categorized as young adults (17-25 years old) (who, 2020). this age's characteristics is that people of this age started to see themselves as adults and show attitudes, thoughts, and behavior that are getting older (paramitasari & alfian, 2012). they have been able to make wise decisions and learn to be a responsibleperson for themselves and others, even though it is not yet performed entirely. a. the perception of respondents the results of this study indicated that the best perception of respondents is in the benefit component. this result is in line with previous research, which stated that 59.6% of respondents had a positive perception that cupping was effectively used in treatment (razzaq, khan, & zehra, 2013). in comparison, the worst perception is in the indication component (15.3%). this result is not in line with finding of previous study explaining that most respondents agreed on the existence of a specific age recommended for cupping (al-balawi, almutairi, alawad, & merghani, 2016). based on the benefit component, respondents already understand the benefits of cupping (hijamah), which is indicated by the answers which result in the average statement agreeing that diseases such as gout, cholesterol, and heart disease can be overcome by cupping (hijamah) in addition to conventional medicine and they also agree that cupping (hijamah) is an affordable treatment. a study revealed that one of the reasons for undergoing and choosing cupping therapy was the efficacy or suitability of therapy for hypertension (kamaluddin, 2010). furthermore, one reason for choosing is also because “it is a cheap alternative medicine” which is frequently considered a genuine reason. the present study is also in line with a study which explains that there is a public opinion that getting or finding complementary medicine is not as indonesian journal of nursing practices 90 complicated as medical treatment (al mansour et al., 2015). based on the safety component, most of the respondents understand that cupping (hijamah) is an action that cannot be conducted every day as it will cause infection or irritation. the respondents understand that cupping (hijamah) can only be carried out in a closed room for safety and also to avoid exposure to outside pathogens. however, this study found that the respondent has a low category of perception since the respondents still think experts and people in general can still perform the cupping since it will make no difference (hijamah). a study explained that most hypertensive patients choose complementary alternative therapies due to their nature and the absence of side effects from the cupping therapy (syahruramdhani, chiu, & kartina, 2017). other studies explain that people use cupping (hijamah) as it is safe and has no side effects (razzaq et al., 2013). according to sridhar's study on client in the united arab emirates who used complementary and alternative medicine, which showed that 51.6% of the client had a positive perception of cupping therapy benefits, safety, and effectiveness (sridhar, shariff, al halabi, sarmini, & harb, 2017). based on the indication component, this study shows that respondents believe cupping (hijamah) can be a treatment option to reduce disorders and pain in the body. however, some respondents still think that cupping (hijamah) can be applied to all ages of people. this perception is not in line with previous theories and research. based on the hadith from ibn sina it was stated that it is not permissible to apply cupping (hijamah) for client less than two years old and over sixty years old (qureshi et al., 2017). this statement is also supported by a study stating that the age group that uses cupping therapy more widely are between 20-39 years old (70.63%) and 40-59 years old (17.5%) (damayanti, muharini, & gunawan, 2012). al-balawi explained that as many as 57.4% of respondents agreed that there was a specific age recommendation for cupping (albalawi et al., 2016). based on contraindication components, respondents understand that cupping (hijamah) is a treatment with contraindications for specific health conditions. cupping (hijamah) is not recommended when the patients are in excessive hunger or full condition. furthermore, pregnant women are also prohibited from getting cupping therapy (hijamah) as they are concerned about its impact or side effects. according to razzaq's research, it was stated that the majority of respondents had a positive perception where they (59.6%) agreed that cupping was significant and had no side effects (razzaq et al., 2013). however, some respondents still think that people with leukemia and hemophilia can be treated with cupping (hijamah). the present study is not in line with previous research, which explained that as many as 25.3% of respondents understood that cupping was contraindicated in patients suffering from certain diseases (al-balawi et al., 2016). b. the attitude of respondents the result of this study indicates that the majority of respondent’s attitude toward cupping therapy is in the average category (58.8). student's attitude toward hijamah in the average category indicates that most respondents in this study have not fully responded well to cupping therapy. the educational factor is the most dominant factor affecting the level of knowledge in students. when someone has good knowledge, it will automatically affect one's attitude. this statement is in line with a study that investigated the knowledge and attitude of nursing students regarding traditional medicine. it showed that the attitude/custom of using traditional medicine method had been created in academic and universities circles (khorasgani & moghtadaie, 2014). introduction of cam in the curricula is important because the lack of evidence supporting cam practices was considered to be the major barrier toward more students using cam and advising their patients to use cam in the future (al mansour et al., 2015). other research showed that one type of complementary and alternative therapy that was quite popularly used for medicine was cupping therapy (hijamah) (el sayed, mahmoud, & nabo, 2013). the present study is in line with previous research, which explained that respondents agreed that alternative medicine helped conventional medicine (khorasgani & moghtadaie, 2014). it also follows the research done in indonesia which vol. 4 no. 2 december 2020 91 explain that there has been an increase in the use of complementary and alternative therapies as treatment from year to year (supardi, 2010). this study showed that most respondents responded positively to cupping therapy, although it was in average attitude category. respondents have a good view for cupping therapy as it is useful as a form of treatment and is more practical and affordable. this result is in line with the current research which explained that cupping effectively enhanced blood supply and activated the autonomous nerves (sympathetic and parasympathetic nerves). cupping therapy could cause the release of nitric oxide (no) from endothelial cells, hence, can induce certain beneficial biological changes. no is a triggering gas molecule that mediates vasodilatation and regulates blood flow and volume (al-bedah et al., 2019). a study showed that cupping therapy restored sympathovagal imbalances (sympathetic and parasympathetic nerves) by stimulating the peripheral nervous system. these results indicate for the first time in humans that cupping might be cardioprotective (arslan, yeşilçam, aydin, yüksel, & dane, 2014). the present research is supported by research stating that a relationship between patient's attitudes and traditional medicine, where respondents have a positive attitude towards traditional medicine, in this case the treatment used was the cupping therapy (al-yousef, wajid, & sales, 2018). people with middle and lower-income groups widely use cupping therapy (hijamah) as it is very affordable compared to medical treatment. recent research revealed that one of the reasons for choosing cupping therapy was its effect (hijamah) on blood pressure, namely a decrease in blood pressure in hypertensive patients (altabakha et al., 2018). the present study is also in line with a research explaining that 62.5% of people used cupping therapy due to its medicinal benefits (damayanti et al., 2012). c. the knowledge of respondents this study indicates that the majority of respondents have an attitude in the average category (68.2). student’s knowledge data showed that the majority of respondents in this study did not fully understand about cupping therapy. the educational factor is also very influencing as the higher the person's education is, the more understanding they will have. this research showed that most respondents already understood that cupping, in general such as the types and indications of cupping. the present inquiry is in line with recent studies where respondents could answer cupping types consisting of dry, wet, fire, and synergy cupping. besides that, respondents could show the basic scientific concepts of cupping and hadiths that explained cupping. this study showed that most respondents already understand that cupping (hijamah) is a treatment with contraindications to specific health conditions. it is not recommended when patients feel hungry or full. a study showed respondents agreed that cupping therapy is contraindicated with patients suffering from certain diseases (alghadir, al-yousef, al-hussany, hasaneen, & iqbal, 2016). this study is also supported by the results of other research which explained that cupping (hijamah) is linked to certain conditions, thus, cupping (hijamah) is not recommended for patients with low skin elasticity, anemia, chronic skin diseases, hypotension, blood disorders (leukemia and hemophilia) and also patients with low platelets (hooshangi et al., 2017; syahruramdhani, agustiningsih, & sofro, 2016). conclusions in conclusion, respondent’s perceptions, attitudes, and 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(2020). adolescent health in the south-east asia region. retrieved from https://www.who.int/southeastasia/health -topics/adolescenthealth#:~:text=who%20defines%20'adole scents'%20as%20individuals,age%20range %2010%2d24%20years" vol. 6 no. 2 december 2022 109 ijnp (indonesian journal of nursing practices) vol 6 no 2 december 2022: 109-116 fahni haris1,2, wei-cheng shen3, jifeng wang4, yori pusparani3,6, ardha ardea prisilla3,7, min-wei lu8, ben-yi liau9, chi-wen lung5,10* 1school of nursing, faculty of medicine and health sciences, universitas muhammadiyah yogyakarta, indonesia 2department of healthcare administration, asia university, taiwan 3department of digital media design, asia university, taiwan 4department of mechanical engineering, national yang ming chiao tung university, taiwan 5department of creative product design, asia university, taiwan 6visual communication design study program, budi luhur university, indonesia 7fashion design, lasalle college jakarta, indonesia 8department of mechanical engineering, national united university, taiwan 9department of biomedical engineering, hungkuang university, taiwan; 10rehabilitation engineering lab, university of illinois at urbana-champaign, united states of america corresponding author: chi-wen lung email: cwlung@asia.edu.tw the effect of different inflated air insole in the foot plantar pressure article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) :10.18196/ijnp.v6i1.17023 : 02 december 2022 : 23 february 2023 : 02 march 2023 abstract background: exercise promotes health in people with diabetes. weight-bearing activities increase the risk of foot ulcers. airpressure shoes may relieve high plantar pressure. objective: nevertheless, no study has investigated whether airpressure shoes affect the plantar foot. methods: a repeated measures study design, with five healthy subjects tested with three inner air pressures (80, 160, and 240 mmhg) and 20 minutes of walking to examine their effects on peak plantar pressure (ppp). ppp after walking was measured from the forefoot in the big toe (t1), first metatarsal head (m1), and second metatarsal head (m2). we used a one-way anova to analyze the results. result: we found that after walking for 20 min, inner air pressure significantly affected plantar pressure in the m1 and m2 (p = 0.008 and 0.006, respectively). regarding the inner air pressure effect, there was a significant difference in the m1 head between 80 and 240 mmhg (274.2 ± 35.6 kpa vs. 689.4 ± 106.3 kpa, p = 0.002) at 20 minutes of walking duration. moreover, there was a significant difference in the m2 head between 80 mmhg and 240 mmhg (250.6 ± 30.1 kpa vs. 572.4 ± 87.3 kpa, p = 0.002) and 160 and 240 mmhg (396.6 ± 35.3.7 kpa vs. 572.4 ± 87.3 kpa, p = 0.050). this finding is significant http://journal.umy.ac.id/index.php/ijnp https://portal.issn.org/resource/issn/2548-4249 https://portal.issn.org/resource/issn/2548-592x https://journal.umy.ac.id/index.php/ijnp/article/view/17023 indonesian journal of nursing practices 110 because the higher inner air pressure shoes can increase plantar pressure compared to 80 mmhg inner air pressure. conclusion: based on the findings of this study, it is recommended that individuals at high risk of developing foot ulcers wear shoes with inner air insoles (80 mmhg). keywords: air insole; foot ulcer; mechanical properties; metatarsal head; walking introduction it has been demonstrated that physical activity benefits health and reduces the risk of chronic complications in individuals with diabetes mellitus (dm) as well as peripheral vascular disease (liao et al., 2019). according to the american diabetes association (ada), dm people should engage in vigorous aerobic exercise for 75 minutes each week or moderate-intensity aerobic exercise for 150 minutes each week (ada, 2020). a study has demonstrated that moderate and vigorous levels of exercise are effective in improving peripheral circulation, but light levels of exercise do not (liao et al., 2019; mak, zhang, & tam, 2010; weist, eils, & rosenbaum, 2004). both people with and without diabetes usually engage in walking as a common exercise (wu et al., 2021; wu et al., 2020). the risk of dfus among dm people is greatly increased by walking because increased peak plantar pressure (ppp) increases the incidence of dfus (haris, firman, irawati, & rahman, 2022; lung et al., 2021; wu et al., 2020). wearing proper insole material for stiffness optimization can reduce the ppp. plantar tissue injuries and stress fractures of the metatarsals may be more likely to occur when wearing a stiffer insole (haris et al., 2021; wu et al., 2020). in addition, several studies have demonstrated that continued physical stress over the skin significantly contributes to the development of plantar tissue injury (haris et al., 2021; lung et al., 2021). furthermore, several studies have demonstrated that proper insoles stiffness would reduce the ppp as well as decrease the risk of developing dfus (speed, harris, & keegel, 2018; van netten et al., 2018; zulkifli & loh, 2020). kim et al. analyzed the effects of air insole associated with the use of space fabric on the dynamic balance abilities of young adults (g.-c. kim, lee, kim, & nam, 2015). it has been demonstrated that the air insole reduces sway and promotes balance when subjects wear airinsole shoes. chang et al. prototyped a multi-airbag adaptive insole (chang & lee, 2003). additionally, the method can be used to design and manufacture athletic and personal insoles and medical therapeutic insoles. however, researchers did not propose a statistical analysis of its use for gaining different ppps. moreover, to prove the strength of the intended sensing pad, kim et al. examined nine inflated air insoles to achieve accuracy and precision (k. kim, shin, & kong, 2018). the results indicate that different inflated air insoles have some kilogramforce accuracy errors. still, the study did not discuss differential plantar pressure between inflated air insoles. however, no study has evaluated the effects of various inner air pressure on the mechanical properties of the plantar foot in healthy people. this research is the first study to compare inner air pressure shoes and plantar pressure patterns after 20 min walking durations. based on the findings of this research with healthy subjects, an understanding of the effects of walking can be provided. therefore, this study aims to explore the effects of various inner air pressure and walking duration on healthy plantar pressure subjects. we hypothesized that different inner air pressure insole shoes (80, 160, and 240 mmhg) cause different plantar pressure patterns. method research design a repeated measures study design, including three inner air pressure (80 mmhg, 160 mmhg, and 240 mmhg) and 20 min walking duration, was used in this study. there were three different walking procedures tested in this study. during the first week of the study, the participant received a procedure of 80 mmhg, then 160 mmhg in the vol. 6 no. 2 december 2022 111 second week, and then the final protocol of 240 mmhg in the third week. the walking speed setting is moderate to fast (3.6 mph). each procedure was divided by 7 ± 2 days. three walking procedures, namely: 1st walking procedure: wearing shoes (air pressure: 80 mmhg) for 20 min; 2nd walking procedure: wearing shoes (air pressure: 160 mmhg) for 20 min; 3rd walking procedure: wearing shoes (air pressure: 240 mmhg) for 20 min. subjects this study recruited healthy participants with shoe sizes 41-43 (males) and 37-39 (females) from asia university, taichung, taiwan, aged 18 to 40. their bmi was no more than 23 kg/m2 (pan & yeh, 2008). applicants were excluded if they had dm, active foot ulcers, hypertension, vascular diseases, or could not walk for 20 minutes independently or at a speed of 3.6 mph. participants signed an informed consent form approved by the institutional review board of china medical university (no: 111-017) before the screening and experimental procedures. the examinations were conducted to maintain a comfortable environment. furthermore, the temperature was set at 24 ± 2 ◦c to maintain a comfortable temperature in the room. experimental procedures in order to prevent the effects of prior weightbearing activity on the mechanical plantar tissue property, the participant removed their socks and shoes prior to taking part in the walking protocol. the participant lay in a supine position for 30 minutes before beginning the walking protocol. participants were instructed to walk continuously on a treadmill at a constant pace (3.6 mph) (haris et al., 2021; lung et al., 2021; wu et al., 2020) on the first visit with an appropriate size of standard shoes (hsin he hsin co., ltd., taichung, taiwan) at an inner air insole with 80 mmhg pressure. the inflated air insole was made by using thermoplastic polyurethane material properties. a prior study showed that thermoplastic polyurethane (tpu) was a good insole material for pressure reduction (haris et al., 2021). measurement of plantar pressures was conducted using the plantar pressure insole measurement system (tekscan, south boston, ma, usa). it is necessary for the participant to wear the insole sensors inside the shoe for three minutes before the calibration. insole sensors were calibrated in accordance with manufacturer's instructions (jan, lung, cuaderes, rong, & boyce, 2013; lung, hsiao-wecksler, bums, lin, & jan, 2016). data on plantar pressure were collected at a frequency of 300 hz. following the 20-minute walking session, participants returned to the laboratory to perform 160 mmhg on their second and 240 mmhg on their third visit. we evaluated three regions of interest (roi) in the big toe (t1), first metatarsal (m1), and second metatarsal (m2) after they finished walking for 20 minutes. (see figure 1) statistical analysis using a one-way analysis of variance (anova), we compared the ppp between three inner air pressures (80, 160, and 240 mmhg) in 20 min walking durations. the ppp measurement focused on the forefoot, especially in the big toe (t1), first metatarsal (m1) head, and second metatarsal (m2) head. a matlab r2020b program (mathworks, inc., natick, ma, usa) was used to analyze fscan data. (see figure 2) result five non-dm, healthy participants (two men and three women) were enrolled in this study. according to the demographic data (mean ± standard deviation): age, 25.2 ± 6.2 years; height, 169.2 ± 6.5 cm; weight, 59.4 ± 7.4 kg; and bmi, 20.8 ± 2.4 kg/m2. the one-way anova showed that the inner air pressure had a significant main effect on the first metatarsal head (m1) and second metatarsal head (m2) (p < 0.05) but not on the big toe (t1) (table 1). under 20 minutes of walking duration, there was a significant difference in m1 plantar pressure between 80 mmhg and 240 mmhg (274.2 ± 35.6 kpa vs. 689.4 ± 106.3 kpa, p = 0.002). in the m2, there was a significant difference between 80 mmhg and 240 mmhg (250.6 ± 30.1 kpa vs. 572.4 ± 87.3 kpa, p = 0.002) and between 160 mmhg and 240 mmhg (396.6 ± 35.3.7 kpa vs. 572.4 ± 87.3 kpa, p = 0.050). (see figure 3) there was a significant difference in the m1 plantar pressure between 80 mmhg and 240 mmhg (274.2 ± 35.6 kpa vs. 689.4 ± 106.3 kpa, p = 0.002). in the m2, there was a significant difference between 80 mmhg and 240 mmhg (250.6 ± 30.1 kpa vs. 572.4 ± 87.3 kpa, p = 0.002) and between 160 mmhg and 240 mmhg (396.6 ± 35.3.7 kpa vs. 572.4 ± 87.3 kpa, p = 0.050). the data were presented as mean ± indonesian journal of nursing practices 112 standard errors; *, a significant difference (p < 0.05); **, a significant difference (p < 0.01). (see table 1) discussion this study investigated different inner air pressure insole on ppp response in non-dm. by inserting the tpu insole under the foot, we were able to achieve a 'customized' inflated air insole that enhanced the redistribution of pressures. the use of these treatments should result in similar function rates for non-dm feet if the lower ppp is the key to reducing the risk of forefoot ulcers. prior study has determined the tpu as the "gold standard" of care for ppp reduction, ranging from 30-40%. according to the results of this study, the inner air pressure insole (80, 160, and 240 mmhg) is a significant factor in inducing plantar pressure after the 20 min walking duration. the findings showed that after 20 min walking, the ppp on 80 mmhg inner pressure was significantly lower in the m1 region as well as in the second metatarsal (m2) region. still, the t1 difference was insignificant. based on the inner air pressure effect, after 20 min walking duration, there was a significant difference in the m1 peak plantar pressure (ppp) between 80 mmhg and 240 mmhg (274.2 ± 35.6 kpa vs. 689.4 ± 106.3 kpa, p = 0.002) (table 1). the 80-mmhg air insole reached the lowest ppp, possibly because the 80mmhg air insole seemed like a total contact mechanical insole. in this condition, the subjects might meet their suitable walking pattern. additionally, the lowest ppp shown by the 80-mmhg air insole might cause a neutral subtalar joint position, neither a pronated nor supinated plantar position. the condition might affect 160 and 240 mmhg that inner air pressure pushed the forefoot region more pronated, inducing ppp on t1, m1, and m2 regions. moreover, elevated plantar pressures may lead to abnormal accumulations of tension over the plantar soft tissues (liau et al., 2019). during walking, an ankle joint inflated to high levels may display high pronation (escamilla-martínez, martínez-nova, gómez-martín, sánchez-rodríguez, & fernándezseguín, 2013). the transformation into a pronated position might be due to accumulating tension by the inner air insole that might cause increased pressure under the forefoot on 160 and 240 mmhg. after 20 min walking, the second m2, there was a significant difference between 80 mmhg and 240 mmhg (250.6 ± 30.1 kpa vs. 572.4 ± 87.3 kpa, p = 0.002) and between 160 mmhg and 240 mmhg (396.6 ± 35.3.7 kpa vs. 572.4 ± 87.3 kpa, p = 0.050) (table 1). during the push-off phase of walking, the tpu air insole, which provides high resilience, can effectively re-use mechanical energy at the forefoot (ahmed, barwick, butterworth, & nancarrow, 2020; jirapongpathai et al., 2022). polyethylene foam typically has a rebound resilience of 30% to 40% (wang, gong, & zheng, 2016). moreover, the tpu air insole material has extra resilience as a result of its cushioning function. kwon et al. stated that when the insole's resilience of the insole more than 40% was softer than 17%, that was stiffer (kwon, lim, choi, kwon, & ha, 2021). furthermore, to redistribute plantar pressure and to increase contact time between the foot and the insole, the australian diabetic association recommends that people with diabetes wear soft, but sufficiently resilient insoles (van netten et al., 2018). it indicated that air insole materials might be excellent in reducing the ppp as mechanical energy properties on walking. conclusion insole materials that reduce ppp in various air pressures are essential for a better understanding of the effects of ppp reduction in people with dm. we established that the appropriate inner air pressure was no more than 240 mmhg. the 80-mmhg inner air pressure was the appropriate air insole, with the lowest ppp in the m1 and m2 but not in the big toe. to minimize the risk of dfus and nurses, as healthcare member who spends the most time with patients, we recommend that dm patients wear appropriate air insole materials at appropriate walking speeds. references ada. 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(2020). a state-of-the-art review of foot pressure. foot and ankle surgery, 26(1), 25-32. https://doi.org/10.1016/j.fas.2018.12.005 https://doi.org/10.1016/j.apergo.2018.02.021 https://doi.org/10.1016/j.apergo.2018.02.021 https://doi.org/10.1186/s13047-017-0244-z https://doi.org/10.1002/vnl.21427 https://doi.org/10.1177/0363546504265191 https://doi.org/10.1177/1534734620915360 https://doi.org/10.1016/j.mvr.2019.103936 https://doi.org/10.1016/j.fas.2018.12.005 vol. 6 no. 2 december 2022 115 figure 1. walking test procedures figure 2. the plantar pressure in three regions of interest (roi): big toe (t1), first metatarsal (m1) and second metatarsal (m2) 80 mmhg 160 mmhg 240 mmhg20-min 3.6 mph 3.6 mph 3.6 mph 1st week 2nd week 3rd week indonesian journal of nursing practices 116 (a) (b) (c) figure 3. comparisons of the effect of inner air pressure (80, 160, and 240 mmhg) on the plantar pressure of the big toe (t1) (a), first metatarsal head (m1) (b), and second metatarsal head (m2) (c) at 20 min walking durations table 1. effect of inner air pressure on plantar pressure region duration inner air pressure oneway fisher lsd anova post hoc 80 mmhg (mean ± se) 160 mmhg (mean ± se) 240 mmhg (mean ± se) p value 80 mmhg vs. 80 mmhg vs. 160 mmhg vs. 160 mmhg 240 mmhg 240 mmhg t1 20 min 426.6 ± 107.8 635.8 ± 94.2 691.2 ± 145.4 0.283 0.233 0.138 0.745 m1 20 min 274.2 ± 35.6 454.8 ± 70.2 689.4 ± 106.3 0.008 ** 0.120 0.002 ** 0.051 m2 20 min 250.6 ± 30.1 396.6 ± 35.3 572.4 ± 87.3 0.006 ** 0.096 0.002 ** 0.050 * note: the plantar pressure under the first metatarsal head consisting of three regions, including the big toe (t1), first metatarsal (m1), and second metatarsal (m2) head; *, p < 0.05; **, p < 0.01. vol. 5 no. 2december 2021 123 ijnp (indonesian journalof nursing practices) vol 5 no2 december 2021:123-131 ferdinandus suban hoda1, serly sani mahoklory1*, yakoba ketzia pello2, irlin falde riti1 1 stikes maranatha kupang, indonesia 2 prof. dr. w. z johannes kupang hospital, indonesia corresponding author: serly sani mahoklory email:sani.mahoklory04@gmail.com association between family support and nurse motivation in managing patients with covid-19 article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v5i1.13352 : 10 aug 2021 : 28 nov 2021 : 21 dec 2021 abstract background: coronavirus (covid19) is a world public health emergency. the coronavirus transmission is highly fast that health workers are at high risk of contracting covid-19. it raises excessive anxiety for nurses when caring for covid19 patients, so one way to help reduce the fears and worries nurses face is by providing support and motivation from their families. purpose: this study aims to determine the relationship between family support and nurses’ motivation in caring for patients with covid19. methods: the method used was correlational quantitative, involving 84 nurses caring for patients with covid19. result: the results of the spearman rank test showed a p-value of 0,001 ≤ α 0,05, which indicated a relationship between family support and the motivation of nurses in caring for patients with covid19. furthermore,the coefficient correlation (r = 0,362) had a low level of relationship with a positive direction of the relationship. conclusion: it can be concluded that family support is very important in the psychological dimension by positively affecting nurses' work motivation. keywords: corona virus (covid19); nursing; nurse motivation; family support. introduction coronaviruses are a group of viruses that cause disease in humans and animals. it usually causes respiratory tract infections in humans, ranging from the common cold to serious illnesses such as middle east respiratory syndrome (mers) and severe acute respiratory syndrome (sars). since its outbreak in wuhan, china, the novel coronavirus was found in humans in the past december 2019, which was later known as severe acute respiratory syndrome coronavirus 2 (sars-cov2) and then led to coronavirus disease-2019 (covid-19) (xu et al., 2021). the world health organization (who) has declared a public health emergency of international concern (pheic) status. as of jan14st, 2022, the total confirmed cases were nearly five million, with around 350thousand deaths (cfr 6.1%) across 226infected countries (who and pheoc, 2022). meanwhile, there were 4.269.740 confirmed cases of covid-19 in indonesia, with nearly 144.163 deaths. in ntt, there were 64.333 confirmed cases with 1.352 death (rahayu & sugiarto, 2019; serly, 2019). http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/9558 vol. 5 no. 2 december2021 124 several studies have found that covid-19 is transmitted through close contact with an infected human and human droplets or by a medical procedure that produces aerosol formation (such as bronchoscopy, nebulization, etc.), leading to airborne transmission. due to the long contact time with covid-19 patients, the health workers have the highest risk of being infected by the virus. china’s national health commission reported at least 1.716 cases where the health workers in the country were infected with covid-19, with 80% experiencing mild symptoms. if efforts to prevent the spread of covid-19 are not addressed immediately, the trends will likely rise (nahidi et al., 2022). nurses are one of the front-line health workers at high risk of being infected with covid-19 due to direct contact with patients. in some health facilities, they can be 24-hour contact with the patients. the risk of being infected makes nurses stay in the hospital for fear of transmitting the disease to their families. therefore, nurses do not have the opportunity to meet and gather with their family members. it is one of the factors causing them to no longer want to work in the covid-19 patient care room (ali et al., 2020). nurses' nursing care to covid-19 patients generally has no difference from other infectious diseases. the only difference is in the use of personal protective equipment (ppe) (awano et al., 2020). it is in line with the study conducted by fadli et al. (2020), revealingthat the availability of personal protective equipment had a 51.7% influence on the anxiety of health workers in efforts to prevent covid-19. it will greatly affect the motivation of nurses in treating patients with covid-19. in 2020, petrin, r.l., conducted a study on health workers at the rscm, jakarta and found that respondents were highly concerned about the possibility of being infected by the coronavirus. excessive anxiety led to poor immunity, making it easy to get ill. similar statements were obtained from an interview conducted in rsud prof.dr. w.z. johannes, kupang, ntt involving five nurses from the hospital. generally, the nurses were saddened and uncomfortable with their taskdue to the fear of being infected or even spreading the infection to other family members. furthermore, the nurse’s family refused when assigned to the covid-19 team. moreover, the nurses experienced social isolation where the family members avoided getting in contact. for instance, when they were quarantined, the family would only deliver drinks, clothes, and other necessities if requested. they also thought that if covid-19 infected a family member, they were the ones who transmitted it due to their duties (galanis et al., 2021;galehdar et al., 2021). in this case, family support is essential to reduce the burden faced by the nurses to make them feel calm, recognized, loved, and increase self-confidence andcompetence. socially supportive relationships help a person improve stress management and overall health (kuo et al., 2020). in dealing with stressful situations, a person with family support performs better in handling stress than those who lack family support. in addition, family support effectively increases nurses' motivationto care for covid-19 patients (balay-odao et al., 2021). motivation triggers someone’s heart to do or achieve a goal (pai et al., 2020). the motivation makes nurses feel that they can achieve the desired goals and have higher responsibilities in carrying out the tasks. in other words, a nurse’s motivation is a process to achieve goals to provide the optimum nursing care in the management of covid-19 patients. a motivated nurse means that they have the strength to face all the challenges given, including fighting the covid-19 and having the courage to leave their family and loved ones to provide the best nursing care for patients. however, there is still no research on family support on the motivation of nurses in caring for patients with covid-19. therefore,this study aims to identify how strong the relationship between family support and the motivation of nurses in treating covid-19 patients is. methods this research is quantitative with a correlational analytic approach and a cross-sectional approach. the sample of this study was 86 respondents who were calculated based on the slovin formula from 106 populations. the sampling technique used was purposive sampling with the inclusion criteria of nurses in charge of treating covid-19 patients. the instrument used in this study was adopted from previous researchers, and each question item in the questionnaire had been tested for validity and reliability. the results of the validity test of the indonesian journal of nursing practices 125 family support questionnaire obtained 2 invalid question items, and the questions were removed from the questionnaire; thus, a total of 18 questions were asked. meanwhile, the nurse motivation questionnaire contained 4 invalid questions, and they were removed from the questionnaire; thus, the total questions were 27. furthermore, cronbach's alpha reliability test results were 0.919. it can be concluded that the family support questionnaire and the motivation of nurses were reliable. the instrument in data collection used a likert scale, including a statement of family support consisting of 4 points, namely assessment support, instrumental support, information support and emotional support. meanwhile, a motivational questionnaire consisted of physiological needs, security, social needs, self-esteem, and actualization. this research has been declared to have passed the ethical feasibility at the university of nusa cendanakupang with registration number un02210213. this research was conducted at prof. hospital. dr. w. z. johannes kupang. the data collection was carried out directly or face to face by the researcher using a questionnaire. the results of univariate data analysis in frequency distributions and presentations are presented in tables and then interpreted. the bivariate data analysis used spss 23 spearman rho computer to determine whether there was a relationship between family support and nurse motivation. result general data (see table 1) the table above shows that of the 84 respondents at prof w.z. johannes kupang, the highest number was in the age range of 26-35 years, namely 45 respondents (53.6%). the youngest respondent was 24 years, and the oldest respondent was 54 years. most of them were female,with a total of 63 respondents (75.0%). 49 respondents (58.3%) had completed their diploma iii of nursing education,and most of them had more than 10 years of service,with a total of 48 respondents (57.1%). specific data family support (see table 2) table 2 shows that out of 84 respondents at rsud, prof w.z. johannes kupangmostly had good family support,with a total of 64 respondents (76.2%). nurse motivation (see table 3) table 3 shows that out of 84 respondents at rsud, prof w.z. johannes kupang mostly had an average motivation, with a total of 43 respondents (51.2%). correlation analysis between family support and nurse motivation in managing covid-19 patients in rsud. prof.dr. w. z. johannes, kupang (see table 4) table 4 shows that the results of hypothesis testing using spearman-rank-test derived a significance of 0.001, lower than the set limit of 0.05. thus, h1 was accepted (0.001 < 0.05). it indicated an association between family support and nurse motivation in caring for patients with covid19 in rsud. prof.dr. w. z. johannes, kupang. based on the significance of the spearman rank test, the above result showed a correlation score of 0.362, indicating a low association between family support and nurse motivation. discussion family support based on a study conducted on 84 nurse participants caring for patients with covid-19, 76.2% or 64 participants had good family support. in contrast to research by rahayu et al. (2019), there is no relationship between family support and nurses' motivation to work and continue nursing education. however, in terms of the high motivation of nurses, if it is not balanced with adequate support from the family, the process of nursing professionalism also cannot run well. vol. 5 no. 2 december2021 126 according to (thai et al., 2021), family support is defined as attitude and behavior of acceptance fromthe family, including informational evaluation, instrumental and emotional support. thus, it can be concluded that family support is a type of interpersonal relationshipthat includes attitude, behavior, and acceptance of a family member. social support from family refers to social supports accessible or expressed by their family, who will always help and support if needed (erdiana, 2015). the author assumed family is a source of good, correct, and calming information. in this case, the family supports nurses in all situations, either by giving support in information, emotional support, instrumental support, and appreciation. the objective of this support for nurses caring for patients with covid-19 is to counter the negative effect of stress on their health (santos, 2020). family support has a strong external motivational influence for nurses to continue providing comprehensive care for covid-19 patients. furthermore, optimum family support is an asset for nurses to survive this pandemic situation. nurse motivation according to a study conducted on 84 nurse participants who managed for patients with covid19, 51.2% or 43 participants have adequatenurse motivation. in other words, the higher the motivation of nurses is, the better the performance of nurses will be. it is in line with the research results by miladiyah, mustikasari, and gayatri (2015), revealing a relationship between motivation and nurse performance. nurses who have good work motivation during the covid-19 pandemic are frequently associated with the use of appropriate personal protective equipment (ppe) to avoid transmission of covid-19. the majority of nurses who have good motivation show compliance in ppe use (kustriyani et al., 2018). in nursing services, covid-19 patients have a high risk of transmission. the availability of personal protective equipment when performing nursing services highly motivatesthe nurses. moreover, support from family and coworkers is considered a guarantee of assistance provided by the organization when carrying out a job effectively and overcoming stressful situations (brewer & miller, 1996 in almasitoh, 2011). a report conducted by yanti, et al (2019) derived a correlation between nurse motivation and compliance to wash hands. the higher their motivation is, the more they are willing to comply with hand washing. itis beneficial, especially during the covid-19 pandemic, which focuses on hand washing practice to prevent coronavirus transmission (demirtaş-madran, 2020). furthermore, motivation is a strength that pushes someone to do or not do any behavior,either internally or externally, positive or negative. to guide it, people need strong guidance. motivation is the level of desire of an individual to do or support the organization's goal. motivation to work is an internal process in someone’s acceptance of a clear stimulus from their environment combined with internal condition (dagne et al., 2015). motivation to work is affected by several factors, either negatively or positively. those factors are a combination of energy that comes from within and outside oneself. this energy is used to behave in the working environment and determine the form, direction, intensity, and duration (yanti et al., 2020). the association between family support and nurse motivation in managing covid-19 patients based on the hypothetic test with the spearmanranktest, the author derived a significance of 0.001, lower than the set limit of 0.05. thus, h1 was accepted (0.001 < 0.05). it showedan association between family support and nurse motivation in caring for patients with covid-19 in rsud. prof.dr. w. z. johannes, kupang. the above result showed a correlation score of 0.362, indicating that the relationship was low. besides, support is an effort made by other external parties, both morally and materially. support can be given from family or colleagues. however, family support is considered the most effective support as family is the core people among others (pai et al., 2020). this coronavirus pandemic brings about the most appropriate times to support each other. family support is essential in each important step and crisis in life. many people withdraw as they do not know how to support other people. family support during this crisis is critical inincreasing nurse indonesian journal of nursing practices 127 motivation in caring for patients with covid-19 (ali et al., 2020). forms of family support during a pandemic can be appraisal support to solve a problem and ease stress. for instance, the family can listen to the nurse who cares for patients with covid-19, give tangible support, help in solving problems or difficulties, including providing food, mask, or medical necessities needed by the nurse, give selfesteem support in terms of thinking positively, and give belonging support such as in the form of acceptance in a social or group. in terms of the social aspect, it can be in theform of not isolating the nurse or the patient when they are ill (xu et al., 2021) social support from family in this pandemic era is essential psychologically. the positive effect of family support is giving confidence, comfort, life goals and safety (vanchapo et al.,2019). social support can lower various kinds of stress, increase coping mechanisms, and increase the quality of life and motivation (thai et al., 2021). furthermore, in terms of the research limitations, this research was conducted in the midst of the covid-19 pandemic. therefore, the process of observing and filling out questionnaires cannot be carried outoptimallydue to hospital policies and social distancing implementation. conclusion based on the result of this study, it can be concluded that there was a significant association between family support and nurse motivation in the management of patients with covid-19 in rsud. prof.dr. w. z. johannes,kupang. therefore, the role of the family becomes an inseparable part of the work motivation for nurses, especially in caring for patients with covid-19 to achieve comprehensive nursing care. this research is expected to become aninput in the nursing field in making policies related to nurses caring for covid-19 patientsin fulfilling support from families. thus, it can increase the nurses’ motivation in caring for covid-19 patients. in addition to family support,management of nursing work is also expected to provide compensation in accordance with the nurses' workload so that their work motivation can be increased. references ali, h., cole, a., ahmed, a., hamasha, s., &panos, 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(2021). psychosocial experiences of frontline nurses working in hospital-based settings during the covid-19 pandemic a qualitative systematic review. international journal of nursing studies advances, 3. https://doi.org/10.1016/j.ijnsa.2021.100037 https://doi.org/10.21927/jnki.2019.7(1).28-35 https://doi.org/10.21927/jnki.2019.7(1).28-35 https://doi.org/10.1016/j.ijnsa.2021.100037 vol. 5 no. 2 december2021 130 table 1.frequency distribution of respondents based on age, gender, education, and work period characteristics frequency percentage (%) age (years) 24-25 9 10,7 26-35 45 53,6 36-45 27 32,1 > 46 3 3,6 total 84 100,0 gender male 21 25,0 female 63 75,0 total 84 100,0 education diploma iii 49 58,3 ners 33 39,3 master of nursing 2 2,4 total 84 100,0 work period 0-2 10 11,9 3-6 16 19,0 7-9 10 11,9 > 10 48 57,1 total 84 100,0 table 2. respondents distribution based on family support at rsud prof w.z. johannes kupang family support frequency percentage (%) deficient 9 10,7 average 11 13,1 good 64 76,2 total 84 100,0 table 3 respondents distribution based on nurse motivation at rsud prof w.z. johannes kupang nurse motivation frequency percentage (%) deficient 3 3,6 average 43 51,2 good 38 45,2 total 84 100,0 indonesian journal of nursing practices 131 table 4. correlation analysis between family support and nurse motivation in management of covid-19 patients in rsud prof w.z. johannes kupang family support nurse motivation spearman's rho family support correlation coefficient 1.000 .362** sig. (2-tailed) . .001 n 84 84 nurse motivation correlation coefficient .362** 1.000 sig. (2-tailed) .001 . n 84 84 vol. 7 no. 1 june 2023 ©2023 ijnp (indonesian journal of nursing practices). this is an open-access article distributed under the terms ofthe creative commonsattribution 4.0 international license https://creativecommons.org/licenses/by/4.0/ 1 open access volume 7, issue 1, june 2023, p. 1-8 effect of family-based education on improving family health tasks in preventing the transmission of covid-19 lia meilianingsih1, citra windani mambang sari2* 1poltekkes kemenkes bandung, indonesia 2department of community health nursing, faculty of nursing, universitas padjadjaran, indonesia corresponding author: citra windani mambang sari email: citra.windani@unpad.ac.id article info online issn doi article history received revised accepted :http://journal.umy.ac.id/index.php/ijnp :2548 4249 (print) :2548 592x (online) :10.18196/ijnp.v7i1.17130 :13 december 2022 :09 march 2023 :10 march 2023 abstract background: during the 2020 pandemic, the accumulation cases was dominated by family clusters. the indonesian government established policies to protect family members from covid-19 transmission, namely modifying behaviours relating to carrying out activities by implementing health protocols. consistency in implementing health protocols is one way to prevent the transmission of covid-19. family-based education also has an important role to socialize and teach family members about health protocols that must be adhered to during the covid-19 pandemic. family-based education has been found to improve the implementation of health tasks in the family. however limited studies on family-based education during covid-19 have been conducted. objective: this study aims to determine the effect of family-based education on improving family health tasks in preventing the transmission of covid-19. methods: the research design used a quasi-experimental preand post-test control group design. the research respondents were 31 families for the intervention group and 31 families for the control group. the sampling technique was proportional random sampling. the educational intervention was provided in 3 meetings. data analysis used wilcoxon and mann-whitney. results: the results showed that there family-based education had an effect on increasing family health tasks relation to the prevention of the transmission of covid-19 (p-value =0.000). conclusions: therefore, it was recommended that the head of the public health and disease control program implement family-based education in order to prevent the transmission of covid 19 within the family and community. keywords: covid-19; education; family-based; family health tasks; prevention introduction coronavirus or severe acute respiratory syndrome coronavirus 2 (sarscov2) is a virus that attacks the respiratory system. since 2019 covid-19 has caused the death of 318,789 people worldwide (who, 2020). this disease has spread across 166 countries, including indonesia. on march 11th, 2020, the world health organisation (who) declared covid-19 as a pandemic. indonesia declared covid-19 a national disaster in march 2020. based on data from the information center and coordination of covid-19 west java province on september 18th, 2020, the number of positive confirmed cases of covid-19 was 232,628 in indonesia and 15,584 in west java with a deaths amounting to 9222 in indonesia and 309 in west java. in september 2020, the governor of west java declared that there were 4 red zones (where the transmission of covid-19 was considered high) in regencies or cities in west java, namely bekasi regency, bogor city, depok city, and cimahi city. the number of positive confirmed cases of covid-19 in cimahi city on september 14th, in 2020 was 262. based on data from the cimahi city health office, the accumulation of cases was dominated by family clusters (perdana, 2020). based on data from badan pusat statistik (bps), central cimahi district was one of the sub-districts of west java province with the densest population, so the risk of covid-19 transmission is high. https://creativecommons.org/licenses/by/4.0/ mailto:citra.windani@unpad.ac.id http://journal.umy.ac.id/index.php/ijnp https://portal.issn.org/resource/issn/2548-4249 https://portal.issn.org/resource/issn/2548-592x https://journal.umy.ac.id/index.php/ijnp/article/view/17130 https://orcid.org/0000-0002-1002-8328 https://crossmark.crossref.org/dialog/?doi=10.18196/ijnp.v7i1.17130&domain=pdf indonesian journal of nursing practices 2 consistency regarding the implementation of health protocols is one way to prevent the transmission of covid-19. to break the chain of the spread of covid19, public awareness is needed relating to carrying out health protocols. however, there are still many people who ignore this recommendation. the family as the smallest social institution in society and has a very important role in providing education. the family is the first and foremost institution in educating and protecting family members (achjar, 2010). the results of this study are in line with the previous study, which has a significant effect (pvalue 0.000) after being provided with family-based education on the behaviour of caring for families with diabetes (sari et al, 2016) and also the intention of pregnant women to optimize nutrition in the first 1000 days of life (naim et al, 2017). another study showed that family-based education had a significant effect (khatiban et al., 2014; srisuk et al, 2015) on the hypertension diet pattern. based on this, family-based education is important to socialize and teach family members about health protocols that must be followed during the covid-19 pandemic. family-based education is likely to improve the implementation of health tasks in the family. families who can carry out these duties will be able to recognize the problem of covid-19, make the right decisions in dealing with covid-19, implement efforts to prevent and overcome covid19, utilize health facilities appropriately, and create a home environment that can prevent the spread of covid-19. due to this, the role of the family becomes essential to remind family members to follow the rules that have been set by the government. this study aimed to determine the effect of family-based education on improving family health tasks in preventing the transmission of covid-19. method the research design used in this study was a quasiexperimental study, using a pretest-posttest control group. this research was conducted in the district of central cimahi. this research was conducted from january to december 2021. the population in this study were families in the cimahi tengah subdistrict, cimahi city. the number of samples was taken using the sample size formula to test the hypothesis difference 2 on average based on previous research by sari et al. (2016) with a standard deviation of alpha = 1.64; beta standard deviation = 1.28; σ = 4.49. after completing the calculation using the above formula, the sample size for this study was 28 families, plus the anticipated dropout of 10%, which was 3 families (naim et al, 2017). a random draw was conducted based on the population to determine the intervention and control groups. the draw was completed after the sample was selected based on the inclusion criteria. the sampling technique in this study was carried out by proportional random sampling, with inclusion criteria as follows: families residing in the cimahi district, central cimahi city, and families must participate in all intervention activities. while the exclusion criteria in this study were families who had participated in similar research activities or education/training on covid-19. the instrument used in this study is an instrument that measures family health tasks that was compiled by this study’s researchers based on friedman (2002), setiawan (2016) and riasmini (2017) which was subsequently modified. measurement of family health tasks in preventing transmission of covid-19 is based on the parameters: knowledge about covid-19 and how to prevent transmission based on health protocols in the covid-19 pandemic. the instrument is a questionnaire with 35 questions in the form of a true-false/yes-no dichotomy. the correct answer is given a score of 1 and the wrong answer is given a score of 0. the assessment ranges from 0-to 100. the results of the assessment can be categorized as high health task implementation, moderate health task implementation 60-79, low health task implementation <60. research instruments related to family health tasks were tested for validity with a correlation coefficient value of r = 0.50 and a reliability test with a cronbach alpha value of 0.892 (meilianingsih, 2017). however, in this study, the instrument was modified by the researcher adapted to the conditions of the covid19 pandemic and a content test was carried out by the head of the covid-19 task force, nursing department, poltekkes, ministry of health, bandung. in carrying out data collection, researchers were assisted by nurses from the cimahi tengah health center who were previously briefed on research and the process of providing family-based education vol. 7 no. 1 june 2023 3 about covid-19. family-based education in this research was provided 5 times, but during the covid-19 pandemic, family-based education was provided 3 times with the implementation of health protocols. each meeting is held for 60-90 minutes. research protocol development based on theory (glanz, 2004; green, 2005; herawati, 2020; azanella, 2020). univariate analysis was carried out to determine the family's health task in preventing the transmission of covid-19 before and after the intervention using a central tendency, namely the average value and standard deviation. the analysis used was the wilcoxon signed-rank test and the mann-whitney u test (dahlan, 2016). the hypothesis was accepted if the p-value < 0. 00 (α = 0.05). data was processed using the spss program. this research passed the ethical test with the number 49/kepk/vi/2021 from the health polytechnic of the ministry of health bandung. result table 1. distribution of respondents frequency based on family member characteristics (n=62) characteristic intervention control p-value n % n % gender 0.541 male 6 19.4 7 22.6 female 25 80.6 24 77.4 age 0.499 20 – 35 2 6.5 4 12.9 36 – 49 50 >60 18 11 58.0 35.5 17 10 54.8 32.3 education 0.842 junior 13 41.9 13 41.9 senior 14 45.2 13 41.9 academy 2 6.5 3 9.67 university 2 65 2 6.5 role in family 0.561 husband 7 22.6 8 25.8 wife 24 77.4 23 74.2 the table above shows that the majority of the respondents were female both in the intervention group (80.6%) and 77.4% in the control group. some of the respondents, namely 56.5% in the intervention group and 54.8% of respondents in the control group were in the age range of 36-49 years. almost half of them, namely 41.9% of respondents in the intervention group and the control group had completed junior high school. most (77.4%) of respondents were housewives. based on the homogeneity test of the characteristics of the respondents, it was found that the p-value > 0.05 indicated that the respondents in the intervention group and the control group were homogeneous. table 2. distribution of family health tasks in preventing the transmission of covid 19 before and after treatment in the intervention group and control group family health task intervention group control group mean min max mean min max pre 57.54 51.61 67.74 57.64 51.61 67.74 post 72.95 64.52 83.87 58.06 54.84 67.74 difference 15.41 0.42 indonesian journal of nursing practices 4 the table above shows family health tasks in preventing transmission of covid 19 in the intervention group, namely before treatment 57.74 were included in the category of low health task implementation and after treatment 72.95 was in the medium health task implementation category. in the intervention group, there was an increase of 15.41. family health tasks in the control group before treatment or at the initial measurement 57.64 and the final measurement 58.06. this shows that there is a slight increase of 0.42, remaining in the category of low health task implementation. picture 1. family health tasks in preventing the transmission of covid-19 before and after being given family-based education in the intervention and control groups table 3. family health tasks in preventing covid 19 transmission before and after treatment in the intervention group and control group n z p-value intervention pre – post 31 4.892 0.00 controlpre post 31 1.890 0.60 the table above explains the wilcoxon test results show that in the intervention group a p-value of 0.000 means that there is a significant effect of family health tasks in preventing the transmission of covid-19 after being given family-based education. the results of statistical analysis in the control group showed a p-value of 0.60. this means that there is no significant difference in family health tasks in preventing the transmission of covid-19 in the initial and final measurements in the control group. table 4. family health tasks in preventing covid 19 transmission before and after treatment in the intervention group and the control group group n mean rank sum of ranks p-value intervention group 31 47.00 1457.00 0.00 control group 31 16.00 490.00 total 62 57,54 72,95 57,65 58,06 0,00 10,00 20,00 30,00 40,00 50,00 60,00 70,00 80,00 pre tes pos tes intervensi kontrol vol. 7 no. 1 june 2023 5 the table above incicates that there are differences in the amount family health tasks in preventing the transmission of covid-19 in the intervention group and the control group. discussion based on the results of the initial measurement of the implementation of family health tasks in preventing the transmission of covid-19, the intervention group showed an average of 57.54 and 57.64 in the control group. this value was in the category of low family health tasks. in this study, the families already knew the meaning and causes of covid-19 but did not know in detail of the symptoms when exposed to covid-19. the process of recognizing health problems, including covid-19, was related to the perceptions, views and knowledge of the family. the higher the knowledge of the family, the faster the process of recognizing health problems that will be carried out by the family. the results showed that the family as respondents had not been able to optimally implement health protocols. from the results of the family observations, the result were not suitable with existing behaviour such as washing hands, using and removing masks, and applying cough/sneeze etiquette. the results of interviews with primary health officers, cadres and families may be because during the covid-19 pandemic, socialization was been carried out in local district about covid 19 and health protocols, but most of the material was given through lectures which not an optimal method for families to internalize the material. observations also showed that there were no leaflets or posters related to health protocols in meeting halls or public places, and there were no public handwashing facilities. the ability to apply health protocols can be hampered if there is a lack of knowledge and skills and the lack of facilities needed to carry out health protocol procedures. the results of the univariate analysis on the final measurement of family health tasks in preventing covid-19 transmission in the intervention group showed an average of 72.95 and was included in the category of medium family health tasks. in the intervention group, there was an increase of 15.41. this shows an increase in the family in recognizing the covid-19 concerns, making the right decisions in managing covid, carrying out efforts to prevent the transmission of covid-19 through the application of health protocols, utilizing health facilities appropriately, and creating a home environment that can prevent the transmission of covid-19. this increase was due to the intervention group being given family-based educational treatment. familybased education is a health education application with a family nursing approach. health education encompasses activities that provide and improve knowledge, attitudes and practices for individuals, families and communities (notoatmodjo, 2010). the implementation of family-based education does not only provide information and knowledge through lectures and discussions but through activities to influence people’s behaviour to reflect health values (friedman, 2010). the learning process through family-based education is more engaging and interactive so that families can better understand and apply the material being acquired. the family is the only social institution that starts out with the responsibility to instruct their members on desired behaviours, instruct on adjustment to the social environment and adapt to environmental changes that occur. the family is one of the most important agents of socialization by teaching its members about the rules expected by society. the ability of the family to control the individual continuously is a social force that cannot be found in other institutions. family-based education will be a determining factor in the application of health protocols that form new habits among family members (satrio, 2020). the task of family health in preventing transmission of covid-19 in the control group at the final measurement was 58.06. this shows that there is a slight increase of 0.42 but it is still in the category of low-health tasks. this is because this group was not given family-based education so there was no additional information on family health tasks in preventing the transmission of covid-19. the wilcoxon test results from pre and post measurements gave family-based education in the intervention group showed a p-value of 0.000 < (0.05) the null hypothesis was rejected meaning that there was a significant effect of family-based education on family health tasks in preventing the transmission of covid-19. family-based education is education given to family members who have a strong relationship and influence in the family so it indonesian journal of nursing practices 6 can have influence on changing family behaviour to be healthier (naim et al, 2017). family-based education provides an opportunity for individuals to acquire the information and skills needed to make quality health decisions (naim, 2017). health education in the family aims to empower and change families so that they can grow healthy lives and develop health efforts that come from families and communities (sari et al, 2016). this is confirmed by the research results that there is a significant effect between family-based education on the implementation of imd (p-value 0.004). likewise, the research conducted by heni showed that family-based education had a significant effect (p-value 0.044) on the hypertension diet pattern. in the pre-treatment/initial measurement, there were no differences in family health tasks in preventing covid-19 transmission in the intervention group and the control group, both were in the low health task category with values of 57.54 and 57.64. this illustrates that the two groups have the same start in the study. however, the measurement after treatment/end of the analysis showed that there was a significant difference in the family health task in preventing the transmission of covid-19 in the intervention group and the control group (p-value 0.000). through these results it can be interpreted that family-based education is meaningful and has an effect on family health tasks in preventing the transmission of covid-19 (sari et al, (2016). research shows that family-based education is effective in increasing self-care knowledge and skills. through family-based education, families can carry out their health duties properly. according to setiawan (2016) and riasmini (2017), families who carry out their health duties well will be the most important socialization agents in teaching their family members about implementing health protocols during the covid-19 pandemic. compliance with family members in carrying out health protocols will protect against covid-19 transmission. if every family is well entrenched in the habit of wearing a mask when leaving the house, the habit of keeping a distance, and the habit of washing hands, then controlling the spread of covid-19 will be more effective. the family is the smallest unit of society that greatly influences the degree of public health (friedman et al, 2010). besides that, family support is very important in the psychological dimension by positively affecting nurses' work motivation and family member motivation too (rumiati et al, 2021). this can be caused by the factors that can affect family-based education programs to changes in the stage of family development, namely the theory of family nursing used, the method used, the media implementation of the educational program and motivation from the family. the implementation of programs based on this theory emphasizes more on the provision of health education to improve disease understanding and monitoring, skills in maintaining healthy life and strategies to improve emotional welfare (bandura, 2004). this is reinforced by research conducted by leung et al (2005) about health education programs in intervention groups with covid-19 conducted by family nurses and the results are obtained from the respondents indicate they need more health education than support from members of the group. the method of the implementation of this research uses family visits because family involvement is in accordance with the theory of bailon and maglaya, in friedman (2010), however powerless the family still has the right and obligation to make decisions. the family's feelings and opinions on their problems and how they solve them need to be considered. educational programs can be successful if supported by good media. in this study, the media used was a module that could be used as a reference in the implementation of family visits. in this study, the intervention group received health education about the management of covid-19 during several visits using these modules. the results of this study indicate that the implementation of health education programs using media booklets can improve family development tasks. based on research, community nurses should employ health education in adapting to the covid-19 pandemic situation (akbar et al, 2022). conclusion this study found there is an effect relating to providing family-based education on family health tasks in preventing covid-19 transmission in the vol. 7 no. 1 june 2023 7 intervention group (p-value of 0.000). this intervention can be used to increase family independence in carrying out family health tasks. acknowledgement the authors would like to express our sincere gratitude to all respondents and all healthcare staff who were willing to join this project. thank you for the valuable information, time and support youprovided to this study. our gratitude also extend to the head of the community health centre for the permission and valuable support throughout this project. lastly, we’d like to extend our thanks to the health polytechnic of the ministry of health bandung who provided valuable support and grants to run this pilot project. references achjar, k. a. h. 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(2020). coronavirus disease (covid-19) situation report. http//www.who.int/docs/default.source/cor onaviruse/situation.reports/2 0200520. retrieved september 14, 2020. https://doi.org/10.18196/ijnp.v5i2.11437 https://doi.org/10.24198/jkp.v4i3.293 https://nasional.okezone.com/read/2020/06 https://nasional.okezone.com/read/2020/06 https://doi.org/10.1016/j.hlc.2015.06.709 http://www.who.int/docs/default.source/coronaviruse/situation.reports/2 http://www.who.int/docs/default.source/coronaviruse/situation.reports/2 vol. 5 no. 2 december 2021 67 ijnp (indonesian journal of nursing practices) vol 5 no 2 december 2021: 67-75 rumiati, i made kariasa, agung waluyo universitas indonesia, indonesia corresponding author: rumiati email: rumicute83@gmail.com the effectiveness of post-stroke patient care education intervention in stroke caregivers: a literature review article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v5i1.11437 : 05 april 2021 : 20 august 2021 : 31 august 2021 abstract background: educational interventions about stroke have been carried out by the health workers, one of which is by the nurse. however, the majority of the interventions focus more on the stroke patients than the stroke caregivers. meanwhile, poststroke patient care education interventions are urgently needed by the caregivers. therefore, the author intends to review current literature about post-stroke patient care education interventions on stroke caregivers. objective: this literature review aims to identify the effectiveness, methods, and impacts of daily care educational interventions for post-stroke patients on stroke caregivers. methods: the method utilized was by analyzing online databases about the related topics from reputable sources. seven articles that met the inclusions criteria considering randomized controlled trial (rct) and quasi-experimental design, time of publication, and english full text were obtained, and the results were presented. result: educational intervention could be carried out by several methods, including direct education at the patient's bedside, lectures followed by questions and answers, and booklets, home visits or telephone follow-up. educational interventions could improve caregiver knowledge and skills in providing daily care for post-stroke patients, reduce burdens, reduce anxiety and improve the caregiver's quality of life. educational interventions also positively impacted post-stroke patients, including improving the quality of life, functional abilities and the ability to do daily activities (adl), reducing cognitive impairment, anxiety, and depression. conclusion: daily care education interventions for post-stroke patients can reduce the burden on the caregiver, either physical, psychological or social burdens. keywords: education effect; intervention education; post stroke patients; stroke caregiver; stroke caregiver education introduction stroke is a clinical manifestation from focal and global cerebral dysfunction that lasts very quickly, more than 24 hours (kuncoro, 2017). according to junaidi (2011), a stroke is an acute focal or global brain functional problem caused by a stoppage of blood flow to the brain caused by bleeding or blockage. it has varying symptoms and signs depending on the portion of the brain affected, which can recover entirely, be disabled, or die. in general, stroke is divided into two, namely obstruction stroke (ischemic) with an incidence of http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/9558 indonesian journal of nursing practices 68 83% and bleeding stroke (hemorrhagic) by 17% (black & hawks, 2014). due to the increasing prevalence of stroke, the number of patients with disabilities is rising. as a result of low brain function, stroke frequently produces disability in the form of limb paralysis, problems in speaking, thinking processes, memory, and other forms of disability (rahmawati et al., 2019). stroke is the leading cause of mortality and the leading cause of disability and dependence in daily life activities around the world (deyhoul et al., 2020). stroke is one of the leading causes of chronic disability worldwide. approximately 5.5 million people die each year from strokes, and 44 million lose their life years adjusted for disabilities (ali et al., 2020). in the united states, it is estimated that a person has a stroke every 40 seconds on average and that someone dies from a stroke every 4 minutes (yu et al., 2019). the prevalence of stroke in indonesia based on the diagnosis of health workers is 7.0 per mile (riskesdas, 2013). according to the basic health research (riskesdas) (2018), the prevalence of stroke in indonesia based on a health diagnosis is 10.9 per mile. thus, there is an increase of 3.9 per mile in the prevalence of stroke in indonesia. the impact of ischemic and hemorrhagic strokes is the emergence of disabilities requiring long-term care. in carrying out post-stroke care, stroke patients are very dependent on their families. the family (informal caregiver) has a very important role in providing daily care for post-stroke patients. according to zainul (2018), one function of the caregiver is to provide care to ill family members and keep and maintain health for the family members who suffer from a disease. according to deyhoul et al. (2020), 25-54% of caregivers reported a burden in providing care for post-stroke patients in the first six months. poststroke patient care is a burden on the caregiver. the caregiver is not a load-free zone. the burden increases as they have to take full responsibility for the care of the post-stroke patients while they do not have sufficient knowledge and skills to care for the post-stroke patients at home (dharma et al., 2018; pesantes et al., 2017). the caregiver's burden can be in the form of physical or psychological burdens. physical burdens may include the emergence of fatigue (carrying the patient, moving the patient) due to excessive pressure and demands, while psychological burdens may cover anxiety, stress, emotions, and depression that will have an impact on the post-stroke patient care and decrease the quality of life of the caregiver (hekmatpou et al., 2019; pesantes et al., 2017). education is very important for the caregivers in providing care for post-stroke patients. the education can provide support to caregivers by providing appropriate and correct understanding, knowledge and skills about the daily care of poststroke patients (dharma et al., 2018). with good knowledge and skills, stroke caregivers can play an active role in the recovery process for post-stroke patients with functional disorders related to meeting daily needs (eating, drinking, activities, etc.) (nurramadany, 2014). educational interventions can also reduce the burden of stroke caregivers physically, psychologically and socially in caring for post-stroke patients (pesantes et al., 2017). caregivers who lack information or knowledge, and skills in providing care to post-stroke patients may not be successful in providing support in the treatment and may even endanger both the patient and the caregiver. it will subsequently affect their quality of life (dalvandi, 2018). health workers have carried out educational interventions about stroke, one of which is the nurse. one of the nurse's roles is as an educator. however, the majority of education focuses more on stroke patients than stroke caregivers. caregiver stroke is not a safe zone but full of burdens, physically, psychologically and socially. based on the problems above, the author intends to identify poststroke patient care education interventions' effectiveness on stroke caregivers. methods the method in this literature review used a prisma (preferred reporting items for systematic reviews and meta-analysis). the search was conducted by searching for research results published in the online database, namely proquest, sciencedirect, springer link, wiley, and google scholar, using education effect, intervention education, stroke caregiver, stroke family, and stroke caregiver education, post-stroke patients. "and" and "or" were used to combine the keyword searches. the vol. 5 no. 2 december 2021 69 inclusion criteria included articles published between 2015-2020, full text, open access, while the research design included quasi-experimental and (randomized controlled trial) rct. the topics included post-stroke care education interventions for stroke caregivers (family), while the exclusion criteria included: article was only an abstract, did not have a complete article structure, crosssectional design, the article was a literature review and systematic review. prisma flow diagram of the literature review process is shown in figure 1. (see figure 1) the analysis of the seven articles selected by the researcher according to table 1. (see table 1) abbreviation: cep-bam: caregiver empowerment program based on adaptation model, chn: community health nursing, fmep: family member education program, share: the home-based educational intervention called nursing home care intervention post stroke, fcep: family-centered empowerment program, adl: activities of daily living. note: the participants were the stroke caregivers and post-stroke patients, but the educational intervention was only given to the stroke caregivers. result a total of seven articles discussed post-stroke care education interventions for stroke caregivers. research conducted by hekmatpou et al. (2019) stated that their research focused on the effect of post-stroke patient care education on reducing the burden of care and improving the quality of life of stroke caregivers. educational interventions could significantly reduce the burden of care and improve the quality of life of stroke patient caregivers. the care burden of stroke patients was significantly related to economic health, marital status, number of children, hours of care, days of care, and the relationship between the caregiver and patients, while the quality of life had a significant relationship with health status. another study conducted by azizi et al. (2020) focused more on the effectiveness of informational support on the level of anxiety in caregiver stroke patients. the intervention found that the caregiver anxiety level of stroke patients significantly decreased. two other studies, namely yu et al. (2019) and dayhoul et al. (2020), about post-stroke patient care educational interventions for stroke caregivers, have the same focus, namely family (caregiver) empowerment. however, the effects investigated were different. yu et al. (2019) looked at the family member education program (fmep) intervention on cognitive impairment, anxiety, and depression in post-stroke patients, while dayhoulet al. (2020) identified the family-centered empowerment program (fcep) intervention on the increasing ability of post-stroke patients to carry out activities of daily life (adl) and reducing the burden of the caregivers in providing care for the post-stroke patients. fmep effectively reduced cognitive impairment, levels of anxiety and depression in post-stroke patients. fcep was shown to significantly increase the ability of post-stroke patients to carry out daily life activities (adl) and reduce the burden on caregivers in providing care for post-stroke patients. three other studies, namely ali et al. (2020), evaluated the effectiveness of planned education on caregiver knowledge and skills in caring for poststroke patients at home and improving the functional ability of post-stroke patients. implementation was carried out both individually and in groups. the educational interventions significantly increased the knowledge and skills of the caregivers in providing care for the post-stroke patients and improving the functional abilities of the post-stroke patients. dharma et al. (2018) studied the effect of the cep-bam program on the functional capacity and quality of life of post-stroke patients. the cep-bem intervention effectively improved post-stroke patients' functional capacity and quality of life at the sixth month after the intervention. it occurred since caregivers who received educational interventions would gain more knowledge and abilities, allowing them to care for post-stroke patients. furthermore, the caregivers could take an active role in the recovery process in functional issues due to this educational intervention, which would improve the quality of life of the post-stroke patients. this study looked at the effect of educational interventions on reducing the burden on caregivers in providing care for poststroke patients. the educational interventions given to the stroke caregivers are called nursing home care intervention post stroke (share) interventions. share has been shown to significantly reduce the indonesian journal of nursing practices 70 burden on caregivers in providing care for poststroke patients. discussion stroke is the most common cause of permanent disability worldwide and has various serious negative effects for the patients and caregivers who care for the post-stroke patients. there are four important points from the summary of the results of the literature review, namely: education interventions increase the knowledge and skills of the stroke caregiver (the family) in providing care for the post-stroke patients, especially daily care at home sufficient knowledge and skills can reduce the burden on caregivers in caring for stroke patients. according to azizi et al. (2020), one of the effects of stroke for the caregivers is anxiety in providing care for post-stroke patients. post-stroke patient care frequently causes anxiety to the stroke caregiver as the incident occurs suddenly and unexpectedly. the caregiver lacks knowledge and skills in providing care for post-stroke patients. apart from anxiety, another impact in providing care for post-stroke patients is that it is quite a burden for the stroke caregiver. caring for stroke patients at home is a complex and strenuous activity (deyhoul et al., 2020; hekmatpou et al., 2019). according to dharma et al. (2018), the caregiver burden increases as the caregiver does not have sufficient knowledge and skills to provide for post-stroke patients. therefore, with the education for the caregiver about the care of the stroke patients, the caregiver's knowledge and skills will increase; thus, they can provide proper care. the education can reduce anxiety and, in the end, will be able to reduce the burden on stroke caregivers. structured education can improve the caregiver's ability to care for the stroke patients educational interventions are also the primary caregiver's need in providing care for post-stroke patients (zawawi et al., 2020). when a family member experiences a stroke, the caregiver has a big role, namely providing care for the ill family member. the role of the caregiver as part of the patient support system is highly important in improving the quality of life of post-stroke patients. caregivers must be empowered to care for and guide patients to adapt to life after stroke. therefore, the caregiver's knowledge and skills in helping patients adapt to life after stroke must be improved. an increase in the caregiver's knowledge and skills in providing care for post-stroke patients will significantly impact the patient's functional ability and quality of life (dharma et al., 2018). education and training for the caregivers can reduce physical, psychological and social burdens in caring for the stroke patients the burden on the caregivers is not only physically but also psychologically and socially (hekmatpou et al., 2019). these burdens can be prevented, reduced, or even limited if the stroke caregivers receive education intervention and training about the post-stroke patients' care (pesantes et al., 2017). one of the interventions that can be used to overcome this impact is educational intervention on the post-stroke patient care for the stroke caregivers. this education intervention does affect not only the stroke patient caregivers but also the stroke patients. according to ali et al. (2020), education increases the knowledge and skills of stroke caregivers in providing care for post-stroke patients. besides that, it can also improve the patient's functional abilities. it is in line with research conducted by bakri et al. (2020), which stated that health education on stroke patient care at home incerased the family knowledge level. in addition, educational interventions also have an effect on reducing the burden on the caregivers in providing care for the post-stroke patients; hence it also has an impact on the quality of life of the caregiver (hekmatpuou et al., 2019). in line with this research, masriani (2014) denoted that health education directly provided to families increases the family knowledge in caring for stroke sufferers at home to improve the quality of life of the stroke patients and reduce the burden on the family itself. all in all, caregiver plays an active role in the recovery process of the post-stroke patients the caregiver plays an active role in the recovery process of the post-stroke patients neurological recovery occurs after the onset of the stroke, whereas functional recovery continues to some extent in the first three months to 6 months vol. 5 no. 2 december 2021 71 after the stroke (yenni, 2011). one of the caregiver's active roles is to assist in functional recovery, especially post-stroke functional disorders. functional impairment is a decrease in physical capacity to meet basic daily needs such as self-care, eating, drinking and decreased ability to interact with the environment in which the patient lives (nurramadany, 2014). it will be done correctly and appropriately by the caregiver if the caregiver is provided with education. education will increase the caregiver's knowledge and skills in providing care; thus, it will also impact the patient. these impacts include increasing the ability to carry out daily activities (adl), functional capacity, and stroke patients' quality of life. in this case, the caregiver plays an active role in the recovery process of poststroke patients (deyhoul et al., 2020; dharma et al., 2018). furthermore, according to yu et al. (2019), educational interventions will reduce cognitive impairment, anxiety, and depression in post-stroke patients. in terms of limitation of this review, the effectiveness of the educational intervention has not been carried out in in-depth analysis on caregivers who care for post-stroke patients with complex stroke conditions and severe disabilities. conclusion post-stroke patient care is a complex problem that requires collaboration with other health teams such as doctors, nurses, nutritionists, and the rehabilitation team. care education interventions for stroke patient caregivers positively impacted the caregivers and the post-stroke patients. these impacts, among others, were that the caregiver could increase the caregiver's knowledge and skills in providing care for the post-stroke patients, reduce the burden, reduce anxiety and improve the quality of life of the stroke caregivers. for the poststroke patients, the impacts included, among others, increasing the ability or functional capacity, increasing the ability to perform daily activities (adl), reducing cognitive impairment, anxiety and depression and improving the quality of life of the post-stroke patients. further research is recommended to provide this educational intervention to stroke caregivers who treat post-stroke patients with complex stroke conditions and severe disabilities. this educational intervention can be used as a permanent standard operating procedure (sop) for all hospitals in indonesia. references ali, e., el, a., sheha, m., abouda, a., soultan, a., malk, r. n., mohammed, e., & elsherbeny, m. (2020). effect of a planned health teaching on improving knowledge and competence of home care practice of post stroke patient among caregivers ’ achievement. 5(2), 51–69. https://doi.org/10.20849/ijsn.v5i2.761 azizi, a., khatiban, m., mollai, z., & mohammadi, y. (2020). effect of informational support on anxiety in family caregivers of patients with hemiplegic stroke. journal of stroke and cerebrovascular diseases, 29(9), 105020. https://doi.org/10.1016/j.jstrokecerebrovasd is.2020.105020 bakri, a., irwandy, f., & linggi, e. b. (2020). pengaruh pendidikan kesehatan tentang perawatan pasien stroke di rumah terhadap tingkat pengetahuan keluarga. jurnal ilmiah kesehatan sandi husada, 11(1), 372–378. https://doi.org/10.35816/jiskh.v11i1.299 black, j., & hawks, h. j. (2014). keperawatan medikal bedah : manajemen klinis untuk hasil yang diharapkan. (joko mulyanto dkk, penerjemah) (ed 8 vol.3). jakarta : salemba medika. dalvandi, a. (2018). effect of telenursing on levels of depression and anxiety in caregivers of patients with stroke : a randomized clinical trial. https://doi.org/10.4103/ijnmr.ijnmr deyhoul, n., vasli, p., rohani, c., shakeri, n., & hosseini, m. (2020). the effect of familycentered empowerment program on the family caregiver burden and the activities of daily living of iranian patients with stroke: a randomized controlled trial study. aging clinical and experimental research, 32(7), 1343–1352. https://doi.org/10.1007/s40520-019-013214 dharma, k. k., damhudi, d., yardes, n., & haeriyanto, s. (2018). increase in the functional capacity and quality of life among stroke patients by family caregiver empowerment program based on adaptation http://dx.doi.org/10.5530/jyp.2018.2s.30 http://dx.doi.org/10.5530/jyp.2018.2s.30 http://dx.doi.org/10.5530/jyp.2018.2s.30 http://dx.doi.org/10.5530/jyp.2018.2s.30 https://doi.org/10.4103/ijnmr.ijnmr https://doi.org/10.1007/s40520-019-01321-4 https://doi.org/10.1007/s40520-019-01321-4 indonesian journal of nursing practices 72 model. international journal of nursing sciences, 5(4), 357–364. https://doi.org/10.1016/j.ijnss.2018.09.002 hekmatpou, d., baghban, e. m., & dehkordi, l. m. (2019). the effect of patient care education on burden of care and the quality of life of caregivers of stroke patients. journal of multidisciplinary healthcare, 12, 211–217. https://doi.org/10.2147/jmdh.s196903 junaidi. (2011). stroke waspadai ancamannya.yogyakarta: andi offset. kuncoro. (2017). hubungan kadar mean platelet volume dengan derajat keparahanpasien stroke iskemik fae akut di rsud.dr.moewardi surakarta. masriani. (2014). pengalaman keluarga sebagai caregiver dalam merawat pasien strok di rumah. jurnal keperawatan padjadjaran, v2(n3), 161–170. https://doi.org/10.24198/jkp.v2n3.4 nurramadany. (2014). model kombinasi latihan kemampuan fungsional pada penderita osteoarthritis lutut. pesantes, m. a., brandt, l. r., ipince, a., miranda, j. j., & diez-canseco, f. (2017). an exploration into caring for a stroke-survivor in lima, peru: emotional impact, stress factors, coping mechanisms and unmet needs of informal caregivers. eneurologicalsci, 6, 33–50. https://doi.org/10.1016/j.ensci.2016.11.004 rahmawati et al. (2019). gambaran selfmanagement pada pasien stroke yang menjalani rawat jalan. 6(6). riskesdas. (2013). riset kesehatan dasar. https://www.litbang.kemkes.go.id/laporanriset-kesehatan-dasar-riskesdas/2013 riskesdas. (2018). laporan riskesdas 2018. in journal of chemical information and modeling 53(9). http://www.yankes.kemkes.go.id/assets/do wnloads/pmk no. 57 tahun 2013 tentang ptrm.pdf yenni. (2011). hubungan dukungan keluarga dan karakteristik lansia dengan kejadian stroke pada lansia hipertensi di wilayah kerja puskesmas perkotaan bukittinggi. 111. yu, f., li, h., tai, c., guo, t., & pang, d. (2019). effect of family education program on cognitive impairment, anxiety, and depression in persons who have had a stroke: a randomized, controlled study. nursing and health sciences, 21(1), 44–53. https://doi.org/10.1111/nhs.12548 zainul. u. a. (2018). peran keluarga terhadap kesehatan jiwa lansia di wilayah kerja puskesmas samata dan puskesmas bontoramba. zawawi, n. s. m., aziz, n. a., fisher, r., ahmad, k., & walker, m. f. (2020). the unmet needs of stroke survivors and stroke caregivers : a systematic narrative review. 29(00). https://doi.org/10.1016/j.jstrokecerebrovasd is.2020.104875 https://doi.org/10.1016/j.ijnss.2018.09.002 https://doi.org/10.2147/jmdh.s196903 https://doi.org/10.24198/jkp.v2n3.4 https://doi.org/10.1016/j.ensci.2016.11.004 https://www.litbang.kemkes.go.id/laporan-riset-kesehatan-dasar-riskesdas/2013 https://www.litbang.kemkes.go.id/laporan-riset-kesehatan-dasar-riskesdas/2013 http://www.yankes.kemkes.go.id/assets/downloads/pmk http://www.yankes.kemkes.go.id/assets/downloads/pmk https://doi.org/10.1111/nhs.12548 https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104875 https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104875 vol. 5 no. 2 december 2021 73 figure 1. prisma flow diagram (http://www.prisma-statement.org) records identified through database online searching (n=22.341) 1. proquest (n = 22.230) 2. sciencedirect (n = 60) 3. spinger link (n = 15) 4. wiley (n = 5) 5. google scholar (n = 31) records after duplicates are removed (n=576) records screened in title and abstract (n= 576) records excluded (n=532) full text articles assessed for eligibility (=44) studies included in review (n=7) id e n ti fi c a ti o n full text articles excluded (n=37) 1. english version was not available (n=5) 2. the intervention focused on the nurses, not on the stroke caregivers (n=10) 3. incomplete text, only abstract or summary of the report (n=22) s c r e e n in g e li g ib il it y in c lu d e d indonesian journal of nursing practices 74 table 1. article review no author year participant treatment setting individu al/grou p study design outcome 1. dharma et al 2018 cep-bam: 42 (stroke caregivers: 21 and post-stroke patients: 21) chn: 42 (stroke caregivers: 21 and post-stroke patients: 21) cep-bam group quasy eksperimental significantly improves the functional capacity and quality of life of the poststroke patients 2. yu et al 2019 fmep+ conventional treatment:72 (stroke caregivers: 36 and post-stroke patients: 36) conventional treatment: 72 (stroke caregivers: 36 and post-stroke patients: 36) fmep+ convention al treatment group randomized controlled trial (rct) significantly reduces the cognitive impairment, anxiety and depression of the poststroke patients 3. day et al 2020 share+convention al care: 24 (stroke caregivers: 12 and post-stroke patients: 12) conventional care: 24 (stroke caregivers: 12 and post stroke patients: 12) share+con ventional care group randomized controled trial (rct) significantly reduces stroke caregiver burden: physical, psychological and social burden 4. ali et al 2020 planned educational program: 32 (stroke caregivers: 16 and post-stroke patients: 16) routine treatment: 32 (stroke caregivers: 16 and planned educational program group quasiexperimental significantly increases the knowledge and skills of post-stroke patient care on stroke caregivers and improving the functional ability of the vol. 5 no. 2 december 2021 75 post-stroke patients: 16) post-stroke patients in performing daily activities significantly 5. azizi et al 2020 information support intervention: 40 (stroke caregivers: 20 and post-stroke patients: 20) routine treatment: 38 (stroke caregivers: 19 and post-stroke patients: 19) informatio n support interventio n group quasiexperimental significantly decreases the anxiety levels of stroke caregivers 6. deyhoul et al 2020 fcep: 58 (stroke caregivers: 29 and post-stroke patients: 29) routine treatment: 60 (stroke caregivers: 30 and post-stroke patients: 30) fcep group randomized controled trial (rct) significantly reduces the burden of stroke caregivers and improves the adl ability of the poststroke patients 7. hekmat pou et al 2019 face to face training: 50 (stroke caregivers: 25 and post-stroke patients: 25) routine treatment: 50 (stroke caregivers: 25 and post-stroke patients: 25) face to face training group randomized controlled trial (rct) significantly reduces the burden and improves the quality of life of the stroke caregivers vol. 5 no. 2 december 2021 104 ijnp (indonesian journal of nursing practices) vol 5 no 2 december 2021: 104-111 shinta antin kumalasari¹, sri suparti¹*, kala raani² ¹ faculty of health sciences, universitas muhammadiyah purwokerto, indonesia ² faculty of health and life sciences, management and science university, malaysia corresponding author: suparti email: srisuparti@ump.ac.id self-efficacy and readiness towards early clinical exposure among nursing students article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v5i1.13460 : 21 aug 2021 : 10 oct 2021 : 18 december 2021 abstract background: early clinical exposure is a learning approach that integrates classroom learning with the clinical practice at the students' academic stage. based on an interview with 3rdsemester nursing students, the results showed that they had low self-efficacy and readiness towards early clinical exposure. objective: this study aims to evaluate self-efficacy and readiness towards early clinical exposure among nursing students of universitas muhammadiyah purwokerto (ump). the study design was a cross-sectional study involving 218 undergraduate students at a private islamic university in their third semester. methods: data were collected using an online questionnaire of google form developed by the researcher, and the questions were valid and reliable based on a reliability test. the sampling method in this study was the total sampling technique. there were 50 questions of the item in the questionnaire and 6 items for demographic data. result: the majority of pupils showed strong self-efficacy (98.2%) according to the findings of this study and moderate self-efficacy (1.8%). the majority of students presented high readiness (97.7%) and moderate readiness (2.3%). according to the correlation test results, a correlation (r = 0.545, p0.05) was found between self-efficacy and readiness for early clinical exposure. conclusion: the higher the student's self-efficacy is, the more the readiness will be to face the practice of early clinical exposure. keywords: early clinical exposure; nursing students; selfefficacy; readiness introduction early clinical exposure (ece) is a learning approach that integrates classroom learning and clinical learning at the students' academic stage. early clinical exposure is a program that prepares firstyear nursing students to meet and learn about patients in a real-world context. it is the early initiation of professional socialization and the basics in learning in their relevance to medical practice. the purpose was to show students the real experience of taking care of patients in a real environment. early clinical exposure will be a medium for students to apply their knowledge from university into real clinical settings. effective implementation of early clinical exposure can increase learning motivation and depth of learning, impacting better understanding and retention of knowledge. early clinical exposure also facilitates http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/9558 indonesian journal of nursing practices 105 students' ineffective learning of clinical skills (govindarajan et al., 2018). effective clinical education can build self-confidence and help students achieve competency. it is an important part of the nursing education process as it provides much experience for students in cognitive, psychomotor, and affective aspects (löfmark et al., 2012). nursing students need clinical education to apply classroom information to real-world patient care, practice therapeutic communication, apply technical skills, have caring behaviors, and know or experience nursing duties (benner et al., 2010). ece makes students understand the illness and the concept of health and sickness (yuliana et al., 2012). according to meshram, shaikh, & khobragade (2016), the total state of a person that makes them ready to respond in a specific way to a situation is known as readiness. factors that influence selfefficacy include experience in taking charge of something, social modeling, social persuasion, physical and emotional conditions. the first-year nursing undergraduate students often encounter difficulty in contextualizing their learning and integrating knowledge and skills into clinical settings (siah et al., 2019). factors that influence readiness are internal factors such as health, physical condition, mental condition, emotional condition, free-time availability, hobbies, self-maturity, intelligence, skills, and personality. meanwhile, the external factors are family, friends' support, faculty facilities, problems encountered, relationships with friends, parents, and environmental influence. emotional conditions also affect readiness to face early clinical exposure, such as tension, anxiety, insecurity (nyambe et al., 2016). students can adapt their role as nurses in a clinical environment to carry out nursing care properly, using the nursing process approach, professional attitudes, behavior, and applying skills professionally. the construct of self-efficacy supports professional education and practice as it is an assessment of someone's ability to manage and carry out their actions and accomplishments. more importantly, increased self-efficacy has been linked to improving professional practice behaviors. it has potentially significant implications for nursing education and early clinical exposure or any other clinical practices (cox & simpson, 2016). based on the study of nyambe et al. (2016), the average score of first-year students' readiness to face clinical practice is lower than second and thirdyear students. it occurs since the first-year students have no experience in clinical practice. the first year of nursing education (especially the first two years) or 2nd semester are crucial to nursing students' success. the success not only depends on knowledge gained but also practices in the real environment, attitude, therapeutic communication, relationship with patients, and family. besides, the senior nurses' perceptions of nursing students on professional nurses and patients' status based on nursing knowledge also affected their success. however, students' self-efficacy and readiness are important for completing their clinical practice, not only their skills, knowledge, and attitude. students who have confidence in their abilities are ready to carry out early clinical exposure, face challenges, and not be afraid of obstacles. in other words, if the students' self-efficacy is low, they might not be ready to carry the clinical posting and not get high results. if the students have low self-efficacy and readiness, they cannot adjust the condition of the problems. furthermore, the students feel helpless when encountering the real situation undergoing clinical exposure. in august 2019, the researcher interviewed ten 3rd semester nursing students and revealed that they had low self-esteem to face the early clinical exposure and learn the real clinical settings for the first time. the students mentioned they were afraid and not ready to carry out nursing services to real patients. their low self-efficacy leads to a lack of readiness to conduct early clinical exposure. students have to feel confident about their ability to do clinical practice and that they will be ready, prepare themselves to deal with clinical practice, challenges and tasks well. clinical practice can be challenging for students, and some of them require additional supervision. as clinical experience is a major source of clinical self-efficacy, nurse educators must enhance learning in the clinical context (plemmons et al., 2017). according to bandura and watts (1996), self-efficacy is individual beliefs about their ability to carry the tasks or actions to achieve an outcome. vol. 5 no. 2 december 2021 106 more importantly, increasing self-efficacy will also increase professional practice, readiness to face any situation, and problem-solving skill (fitri et al., 2016). the graduates meet the specified quality standard and prepare students to become professional health workers. nursing students of universitas muhammadiyah purwokerto have begun to deploy for clinical practice in the 3rd semester with early clinical exposure. the early clinical exposure is only allowed for the 3rdsemester nursing students to make observations and not make independent interventions without senior nurses' assistance. students are expected to apply what has been taught in preclinical learning during class, with the assistance of senior professional nurses, and expected to pay attention, gain new knowledge that has not been taught in preclinical learning during class and laboratory skills. based on the explanation above, this study aims to assess ump nursing students' self-efficacy and preparation for early clinical exposure. methods this study is an observational analytic descriptive study with a cross-sectional approach (sugiyono, 2017). primary data were obtained using a questionnaire of google form with 50 questions developed by the researcher. the instrument's content was demographic data such as age, gender, previous course, and motivation to take nursing; there were 50 likert questions items in the questionnaire. cronbach's alpha reliability was used to evaluate the measurement scale's precision. the results for readiness (0.831) indicated a high level of reliability. self-efficacy of 0.669 indicated a good level of reliability. the questionnaire was administered and distributed in bahasa indonesia to the respondent as it is their first language. furthermore, it was administered in english in this thesis to ease the reader from other countries. the target for this study was 3rd-semester bachelor nursing students at universitas muhammadiyah purwokerto. the 3rd semester bns students were selected as they did not experience any early clinical exposure yet; thus, they still had no idea how it felt to carry out early clinical exposure. the population of the 3rd-semester bns students was 292 active students. however, only 218 students responded to the questionnaire because 74 students were doing the osce exam and could not fill the questionnaire. as a total sampling method, the number of samples was equal to the total number of students. the ethical clearance of the research was obtained from the ethics department of universitas muhammadiyah purwokerto number kepk/ump/19/xi/2019. this study discovered the association between self-efficacy and readiness for early clinical exposure using correlation analysis and pearson product-moment. result descriptive analysis has been used in this study to define respondents' demographic profile, including age, gender, the course in high school before taking nursing, and motivation to take nursing. the results are based on the population's demographic data in table 1. (see table 1) based on the demographic data of the population, the finding in table 1 clearly shows that the majority of the respondent was 19 years old. 83.5% were females, 121 of the respondents previously took science courses, and 55.5% were their selfmotivation to take the nursing department. table 3 shows that third semester bns students at ump had high self-efficacy (98.2%) and moderate self-efficacy (1.8%), with no students falling into the low selfefficacy category. meanwhile, the majority of the students obtained a high level of readiness (97.7%) and moderate readiness (2.3%). this study also discovered a link between self-efficacy and readiness for early clinical exposure (r= 0.545, p0.05). it suggested that self-efficacy can influence readiness for early clinical exposure among students; if self-efficacy is strong, so is readiness (table 2). discussion readiness for the students is crucial as unreadiness will affect their belief of inability to carry out the early clinical exposure. as the students will be in professional healthcare, they must have selfefficacy, self-confidence, self-belief, readiness besides knowledge, skills, and others. it is in line with a study by akhmad et al. (2019), which showed that the majority of the students obtained high selfefficacy (56.8%), and the majority of students showed high readiness (89.6%). therefore, it can be assumed that high self-efficacy will raise selfconfidence. in other words, self-efficacy is selfconfidence in individuals to achieve some goals or results in their activities. readiness is affected by indonesian journal of nursing practices 107 confidence, self-ability or self-efficacy. self-efficacy is correlated with social cognitive knowledge or selfknowledge (arifin et al., 2014). self-efficacy is well correlated with readiness. they are both important. if one’s self-efficacy is high, so is their readiness, and vice versa. it also implies that students' self-efficacy has an impact on their preparation for early clinical exposure. self-confidence in their abilities affects the students’ early clinical exposure journey. low self-efficacy will close their attention to early clinical exposure even though they are interested in it. nevertheless, if their readiness is low, they are afraid and worried that they could not do the early clinical exposure well and get satisfying results. the impact of selfdirected learning readiness on critical thinking and self-efficacy among pupils in the class of physical education and sports discovered a significant link between self-directed learning readiness and general self-efficacy (r=.623 p=.000). the findings implied that self-directed learning preparedness impacts critical thinking, general self-efficacy, and other areas of education (turan et al., 2018). it is in line with the researcher's results that self-efficacy and readiness have a considerable positive link towards early clinical exposure. self-efficacy affects readiness and might influence other aspects of education such as knowledge, attitude, and others. a result by meshram, shaikh, & khobragade (2016) showed that ece piqued their interest in the subject, according to most students. they believed that ece helped them visualize concepts and remember details from their medical classes better than individuals who had not been exposed to clinical settings. it indicated that ece has a big impact on students and helps them understand the clinical practice, making them more familiar with various fields. most students regarded the ece experience as an inspiring, motivating, engaging, wonderful, useful, good form of learning that elicited selfinterest. they revealed that it helped them appreciate the importance of basic science in clinical practice. practically, interested students contacted doctors in their chosen specialty and pursued their interest in the issue (govindarajan et al., 2018). first-year medical students were introduced to the ece program to supplement standard clinical teaching sessions. the efficacy of this study was demonstrated by the students' ability to use their ece abilities in their usual clinical placements (rawekar et al., 2016). ece is helpful for the students in their routine clinical postings, and that they need to gain their self-efficacy to get them ready for clinical postings to achieve high results. according to research, there is a link between preparation for substance abuse treatment and selfefficacy based on life skills (moeini et al., 2020). the results of this study found that there was a significant relationship between self-efficacy and the substance users' readiness for treatment improvement. the present study was showed that the self-efficacy model predicts 20% to 25% of the readiness for treatment variance. significantly predictors of readiness for the treatment variables are communication and assertiveness, but ambivalence is highly correlated with problemsolving abilities. this result is in line with the researcher's findings that there was a significant relationship between self-efficacy and readiness, indicating that self-efficacy is affecting the students' readiness to carry out the early clinical exposure in order for them to get satisfied and high results. clinical practice experiences allow nursing students to apply what they have learned in lab practice skills and interact with patients, families, and nurses in a real environment. the higher the self-efficacy is, the higher the readiness will be. the higher the selfefficacy is, the more motivated and ready the person can be to achieve high results (rowbotham & owen, 2015). according to baiti, abdullah, & rochwidowati, (2017), higher self-efficacy is followed by higher readiness, while lower self-efficacy is followed by lower readiness. this study also showed a significant positive correlation between self-efficacy and readiness towards early clinical exposure. it is presented in table 4 that the results for pearson correlation are r=0.545, p<0.05 for both selfefficacy and readiness. it can be assumed that selfefficacy affects readiness, as the readiness is also high. the self-efficacy variable contributes readiness of the students (baiti et al., 2017). results from another study about the relationship between selfefficacy and readiness for change: the mediator roles of employee empowerment demonstrated a significant effect on self-efficacy towards readiness vol. 5 no. 2 december 2021 108 (emsza et al., 2016). as a result of the findings of the study on self-efficacy with vocational high school students work readiness, there is a positive and significant correlation between self-efficacy and work readiness, with coefficients of r=.676 and p=.000; p0.05 indicating that the higher the selfefficacy is, the higher the readiness will be, and vice versa, (utami & hudaniyah, 2013). the research results by reed et al. (2019) revealed a connection between self-efficacy and change preparedness. it indicated that self-efficacy and readiness to control heavy drinking could be important factors. it aligns with this research revealing that self-efficacy and readiness are important factors for students to obtain high results on early clinical exposure as they are the internal factors. in other words, they have to believe in themselves and be ready to carry out the early clinical exposure. furthermore, they also could encounter all of the obstacles without any doubt as they believe in themselves. in another study (alfaiz et al., 2017), self-efficacy as a students' readiness prediction factor greatly influences self-capability and affects every activity. self-confidence produces self-readiness, and that the results showed that the students' self-efficacy affects self-capability and individual student activity. when the students have high self-efficacy, their readiness will also be high. moreover, a study by mitchell & mcmillan (2018) revealed that self-efficacy improved where assignments of increasing complexity were used to stimulate critical thinking, analysis, and reflexivity. it is also affected when course subject instructors, not writing instructors, were the primary assignmentspecific writing supports. furthermore, another study by fitriati & dewi (2018) denoted that the higher the students' selfefficacy is, the higher the evaluation results will be. thus, all of the results supported the researcher's results that the higher students' self-efficacy is, the higher their readiness towards early clinical exposure will be. students who have high selfefficacy and readiness are expected to improve quality. the self-efficacy in students is related to readiness. it can help them ensure their abilities to do the tasks or actions needed to achieve certain satisfying and high results. to have high selfefficacy, the students need to develop through exercises carried out continuously according to students' capabilities. in this case, the exercises include preclinical (class theory) and laboratory exercises. these aspects can be a reference for the students to be more confident of their ability to solve the problems, more confident and motivated to achieve their goals, and students can well undergo early clinical exposure tasks and obstacles (omer, 2016). nursing students' confidence levels in the clinical setting may vary due to changes in the nursing curriculum that encourage more studentcentered learning activities (panduragan et al., 2011). the self-efficacy and readiness concept is important to undergo the clinical practice. thus, in preparing early clinical exposure, efforts are needed to improve self-efficacy and develop self-confidence optimally to get satisfying results. readiness shows a condition where someone can respond to early clinical exposure using mind, body strength, skills, and knowledge. moreover, students need a positive self-concept from self-confidence and selfacceptance to support their readiness. other aspects of supporting the readiness include selfefficacy through decision making, confidence in their abilities, and belief in themselves on how far they can identify their abilities to carry out early clinical exposure with satisfying results (yuwanto et al., 2016). conclusion based on the result of this study, it can be drawn that self-efficacy and readiness had a considerable positive correlation towards early clinical exposure among 3rd semester nursing students in ump. the higher the student's self-efficacy is, the higher their readiness will be to undergo the practice of early clinic exposure. the suggestion for the further research project is to add more variables and investigate pre-post early clinical exposure. acknowledgement i would like to thank universitas muhammadiyah purwokerto for all of the support, management & science from the university as a collaborated university and the support and directorate of higher education for credit program. references akhmad, v. s., yusuf, s., safitri, a., juwita, h., risnah, r., & arbianingsih, a. 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(2012). persepsi mahasiswa dan dosen terhadap early clinical experience pada program si keperawatan stik immanuel bandung. persepsi mahasiswa dan dosen terhadap early clinical experience pada program si keperawatan stik immanuel bandung, 1(2), 18–35. https://doi.org/10.22146/jpki.25082 yuwanto, d., mayangsari, m. d., & anward, h. h. (2016). hubungan efikasi diri dengan kesiapan kerja pada mahasiswa yang sedang mempersiapkan skripsi. jurnal ecopsy, 1(4). https://doi.org/10.20527/ecopsy.v1i4.506 https://doi.org/10.1016/j.nedt.2017.12.029 https://doi.org/10.7860/jcdr/2016/17101.7022 https://doi.org/10.1080/08995605.2019.1579607 https://doi.org/10.1016/j.nepr.2015.09.008 https://doi.org/10.1016/j.colegn.2019.05.003 https://doi.org/10.5430/ijhe.v7n6p98 https://doi.org/2301-8267 https://doi.org/10.22146/jpki.25082 https://doi.org/10.20527/ecopsy.v1i4.506 indonesian journal of nursing practices 111 table 1. demographic data of the study population (n=218) demographic characteristic f % age 18 years old 19 years old 20 years old 21 years old >21 years old gender male female previous course science social non-health science health science the motivation of taking nursing self-motivation parents other people other reasons 22 152 36 5 2 36 182 121 36 20 42 121 89 3 5 10.1 69.7 16.5 2.3 1 16.5 83.5 55.5 16.5 9.17 19.3 55.5 40.8 1.4 2.3 table 2. level of self-efficacy, readiness and pearson correlation test variable low moderate high r p-value self-efficacy 0 4 (1.8%) 214 (98.2%) 0.545** <0.001 readiness 0 5 (2.3%) 213 (97.7%) vol. 5 no. 1 june 2021 17 ijnp (indonesian journal of nursing practices) vol 5 no 1 june 2021: 17-23 yuni astuti1, nur azizah indriastuti1 1school of nursing, universitas muhammadiyah yogyakarta, indonesia corresponding author: yuni astuti email: yuni.astuti@umy.ac.id the factors influencing fatigue of postpartum mothers article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v5i1.10134 : 03 october 2020 : 17 april 2021 : 23 april 2021 abstract background: postpartum mothers are likely to experience physical and psychological changes. a new role as a parent provides new tasks for mothers in baby care. most postpartum mothers experience fatigue after labor. postpartum fatigue is affected by the baby and family. this study aims to identify factors associated with postpartum fatigue. method: a cross-sectional study was designed. the sample in this research was 102 postpartum mothers who lived with her family in bantul yogyakarta. they were taken by using simple random sampling. the data were collected through the postpartum fatigue scale (pfs), infant characteristic questionnaire (icq), and social support questionnaire. factors associated with postpartum fatigue were analyzed using multiple logistic regressions. results: most of the respondents had a moderate level of fatigue (48%). social support was found significant as the determinant factor of postpartum mother (aor=4,38, 95% ci 1,709 – 11,256, p= 0,002). conclusion: respondents with a low social support level showed a significantly higher level of postpartum fatigue than respondents with good social support. it is essential to assist the family in helping mothers in infant care and postpartum care in the postpartum period. the factor associated with postpartum fatigue included infant temperament and family income. keywords: postpartum, postpartum fatigue, risk factors introduction postpartum mothers experience fatigue in the postpartum period. the data showed that 88,5% of postpartum mothers have fatigue (kılıç et al., 2015), and 60% of postpartum mothers in yogyakarta experience fatigue (saragih et al., 2015). fatigue is a decreased capacity for mental health and physical due to an imbalance in the utilization and restoration of resources needed to perform an activity (aaronson et al., 1999). postpartum fatigue begins after childbirth. the level of postpartum fatigue decreased with a day of postpartum; it is highest in the first month after childbirth and decreases along with the age of the baby (henderson et al., 2019; iwata et al., 2018). postpartum fatigue may be a result of the new role of the mother. postpartum mothers are reported to have frequent nighttime awakenings and a decrease in sleep efficiency (wilson, wynter, et al., 2019). the night-time sleep duration of postpartum mothers was 5 hours, and 48,5% had dissatisfied with sleep quality (iwata et al., 2019). the postpartum with sleep disturbance influenced postpartum fatigue (henderson et al., 2019). the fatigue that occurs in postpartum mothers is influenced by various factors. a study by kusumasari (2018) revealed that primiparous mothers experience higher fatigue than multiparous, besides social support, which also influences the incidence of fatigue in postpartum mothers (yesilcinar et al., 2017). mothers with http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/10134 indonesian journal of nursing practices 18 partners in postnatal care include changing nappies, supporting feeding, helping when the baby cried, bathing, and playing with the baby. all of those aspects were mild fatigue in 1 month postpartum (henderson et al., 2019). social support for infant care and house chores may influence postpartum fatigue. chen & schmidt (2015) stated that fatigue is related to the breastfeeding process and the baby's temperament. mothers who have fussy babies are likely to experience fatigue. a baby with a large dose of crying can influence parents (zeifman & st james-roberts, 2017). postpartum fatigue can lead to serious health problems for the mother and her baby. it can affect the mother’s physical, psychological, and mental health (badr & zauszniewski, 2017). khatun et al. (2018) stated that mothers who experience fatigue have a decrease in meeting their babies' needs and responsibilities toward other family members. the postpartum mother with fatigue becomes irritable, decreased ability to care for babies, and satisfaction in their role as mothers (giallo et al., 2015). untreated postpartum fatigue can increase the incidence of postpartum depression (wilson, lee, et al., 2019) and affect breastfeeding self-efficacy (fata & atan, 2018). therefore, this study aims to determine the prevalence and factors related to postpartum fatigue. methods this study used a cross-sectional design. the samples’ inclusion criteria of this study were 1 – 6 weeks postpartum mothers, healthy, living with husband, and gave birth to a healthy infant. the sample of this study was 102 samples recruited by purposive sampling. the samples were taken around the area of primary health care kasihan 1 bantul. this study used a demographic questionnaire developed by the researcher to collect the characteristics of postpartum mothers, including age, parity, method of labor, feeding, and economic status. the postpartum fatigue used the indonesian version of the postpartum fatigue scale (pfs) (saragih et al., 2015), consisting of 10 question items in the form of a likert scale from 1 4. this questionnaire contained six questions related to mental symptoms and four questions about physical symptoms regarding the intensity of postpartum. the possible score ranged from 10 to 40 with three categories; namely, a total score of 10 – 14 was mild fatigue, 15 – 20 was moderate fatigue, and 21 – 40 was severe fatigue (milligan et al., 1997). infant temperament was measured using the indonesian version of the infant characteristic questionnaire (icq) (astuti et al., 2017) with six questions with a 7 likert scale. the possible score was 6 to 42; namely, a total score of < 21 was ‘not difficult temperament’, and ≥ 21 was ‘difficult temperament’ (bates et al., 1979). this instrument was valid and reliable (cronbach’s alpha 0,851) (astuti et al., 2017). the social support measurement used a questionnaire developed by the researcher. this questionnaire had four components: emotional support, appreciation support, instrumental support, and information support. the questionnaire had 32 questions and grades using a 4-point scale with a likert scale. the total score was 32 – 128, and participants were grouped as “low social support” (32 – 64 point), “intermediate social support” (65 – 96 point), and “high social support” (97 128). this questionnaire was a validity and reliability test with cronbach alpha 0,92. this research obtained approval from the universitas aisyiyah yogyakarta ethics commission with the number 1417/kepunisa/i/2020. all participants had written consent in the informed consent. data analysis used chisquare and multiple logistic regression. results the total of postpartum mothers who participated in this study was 102. the result of the study showed that most of the postpartum age characteristic was 20 – 34 years old which was 80,4%. most of the postpartum mothers were vaginal birth, with a total of 84,3%. 64,7% of them had a family income of more than rp1.800.000 rupiah. more than half of the participants in this research were multipara (64,7%). almost all postpartum mothers in this study were given breast only for the baby. 74,5% of postpartum mothers in this research had a baby with a difficult temperament. the result of analysis with chi-square showed that postpartum mothers correlated with family income (p=0,016), infant temperament (p=0,005), and social support (p=0,000) (table 1). this study showed that 55 postpartum mothers within 20 – 35 years old had postpartum fatigue. 9% of the postpartum mother with a family income of more than one million eight hundred thousand had fatigue. the postpartum mother that breastfed only to her baby had fatigue (94,1%). moreover, the 57 vol. 5 no. 1 june 2021 19 postpartum mothers with vaginal birth in this research had fatigue. the postpartum mothers with a not-difficult infant temperament had fatigue (57). 49 postpartum mothers in this study with high social support have fatigue (table 1). this study showed that 48% of the postpartum mothers had a moderate fatigue scale (table 2). the result from logistic regression analysis showed social support as the determinant for postpartum fatigue with the adjusted odds ratio of 4.38 and 95% ci (1.709 – 11.256). the interpretation of the aor value was that postpartum mothers with low social support had a risk of 4.38 for postpartum fatigue (table 3). discussions table 1 reported that most of the postpartum mothers' age is 20 – 35 years old. it confirmed the previous study showing that the risky age of maternal to childbirth ranged from 20 – 30 years old (bellieni, 2016). when women are pregnant over 40 years old, they are likely to increase their risk of preeclampsia (having a baby after age 35, n.d.). therefore, there is a statistically significant association between postpartum fatigue and family income, infant temperament, and social support. it is correlated with other findings that individual, couple, and community-level interventions in the case to give enlisting support might be valuable components for reducing the complications after birth, such as postpartum fatigue (gudayu & araya, 2019). this study showed that 48% of the postpartum mothers had a moderate fatigue scale. it aligns with another study that postpartum mothers have postpartum fatigue (giallo et al., 2015; khatun et al., 2018; kılıç et al., 2015; saragih et al., 2015). postpartum mothers have fatigue in the first six months, and the level of fatigue will decrease along with the increase of the baby’s age (iwata et al., 2018). research by henderson et al. (2019) showed that the level of postpartum mothers was highest on day one after delivery. fatigue occurs due to change in new roles; mothers frequently wake up at night at the first two months of postpartum. they had a sleep duration of 6,29 hours with a mean of 2 – ½ sleep episodes and under 1-hour sleep during the day (creti et al., 2017). postpartum mothers often wake up at night to carry out new activities. mothers wake up within an average of 3 times at night. during maternal nocturnal awakening, they carry out infant feeding (49%), general infant care (18,5), and infant diaper changing (12%) (insana et al., 2014). on the contrary, this research showed that the association between age and postpartum fatigue was negative. although maternal age had not been previously recognized as one of the risk factors for postpartum fatigue (henderson et al., 2019; molina-garcía et al., 2019), older women are more likely to be at risk for postpartum fatigue because they may have more difficulties or take longer to recover from pregnancy and delivery (badr & zauszniewski, 2017). the postpartum mother with age more than 35-year-old experience more severe fatigue (senol et al., 2019) this study showed that mothers aged less than 20 years had mild fatigue because the mother obtained good family support. mothers with a good partner and family support for six weeks postpartum can reduce postpartum fatigue (huang et al., 2013). the research by henderson et al. (2019) strengthened that low education and low socioeconomic status were previously considered more vital risk factors, as described in our findings. moreover, this research also showed that parity, feeding method, birth method, and postpartum fatigue were not statistically significant factors (table 1). in this case, henderson's research is not in line with this study that multiparous women were at a significantly reduced risk of postpartum fatigue. this research has not reported associations between mixed feeding and postpartum fatigue (henderson et al., 2019). this study is in line with other research (iwata et al., 2018; yesilcinar et al., 2017), showing that social support satisfaction had significance with postpartum fatigue. the social support for postpartum mothers includes emotional, informational, instrumental aspects, and appreciation. the social support that came from partners, family, spouse, and friends could increase the mother’s skill in baby caring (erbaba & pinar, 2020). instrumental support like postnatal care from a partner decreased postpartum fatigue. thus, indonesian journal of nursing practices 20 the women with high social support had a lower risk of postpartum fatigue (henderson et al., 2019). moreover, the financial support was highly significant of social support (aytac & yazici, 2020). the postpartum mother believes that support should be provided without asking. they stated that instrumental support is essential to their physical and emotional recovery (negron et al., 2013). conclusions the postpartum mothers in this study had a moderate level of postpartum fatigue (48%). factors affecting postpartum fatigue included family income, infant temperament, and social support. health professionals should provide education about infant temperament and involve the family in infant care in the early postpartum period. author contribution ya contributed to the conception of the work, analysis, and interpretation of the data, revising the draft, approving the final version of the manuscript, and agreed for all aspects of the work. nai contributed to the revision of the draft manuscript and approval of the manuscript before submission. conflict of interest the authors declare that they have no conflicts of interest. acknowledgement we thank postpartum mothers who participated in this study, lp3m universitas muhammadiyah yogyakarta, and primary health care in kasihan 1 bantul yogyakarta. references aaronson, l. s., teel, c. s., cassmeyer, v., neuberger, g. b., pallikkathayil, l., pierce, j., press, a. n., williams, p. d., & wingate, a. 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(2017). parenting the crying infant. current opinion in psychology, 15, 149–154. https://doi.org/10.1016/j.copsyc.2017.02. 009 https://doi.org/10.3390/jcm8050672 https://doi.org/10.1007/s10995-012-1037-4 https://doi.org/10.1007/s10995-012-1037-4 http://etd.repository.ugm.ac.id/home/detail_pencarian/86536 http://etd.repository.ugm.ac.id/home/detail_pencarian/86536 https://doi.org/10.4103/njcp.njcp_576_18 https://doi.org/10.1016/j.jad.2018.12.032 https://doi.org/10.1016/j.sleep.2019.01.012 https://doi.org/10.1016/j.sleep.2019.01.012 https://doi.org/10.1080/14767058.2016.1209649 https://doi.org/10.1080/14767058.2016.1209649 https://doi.org/10.1016/j.copsyc.2017.02.009 https://doi.org/10.1016/j.copsyc.2017.02.009 vol. 5 no. 1 june 2021 23 table 1. the characteristics of the respondents and factors influencing the postpartum fatigue variable all n=102 (%) fatigue n=68 (%) non-fatigue n=34 (%) p-value age < 20 years 20 – 35 years >35 years 1(1) 82 (80.4) 19 (18.6) 0 (0) 55 (80,9) 13 (19,1) 1 (2,9) 27 (79,4) 6 (17,6) 0.362 family income < rp1.800.000 ≥ rp1.800.000 36 (35.3) 66 (64.7) 30 (44,1) 38 (55,9) 6 (17,6) 28 (82,4) 0.016 parity primipara multipara 35 (34.3) 67 (15.7) 20 (29,4) 48 (70,6) 15 (44,1) 19 (55,9) 0.210 feeding method breastfeeding only combined 97 (95.1) 5 (4.9) 64 (94,1) 4 (5,9) 33 (97,1) 1 (2,9) 0.662 birth method vaginal birth caesarean section 86 (84.3) 16 (15.7) 57 (83,8) 11 (16,2) 29 (85,3) 5 (14,7) 1.000 infant temperament difficult not difficult 76 (74.5) 26 (25.5 11 (16,2) 57 (83,8) 15 (44,1) 19 (55,9) 0.005 social support intermediate high 42 (41.2) 60 (58.8) 19 (27,9) 49 (72,1) 23 (67,6) 11 (32,4) 0.000 table 2. the prevalence of postpartum fatigue level of fatigue n % mild moderate severe 34 49 19 33.3% 48.0% 18.6% table 3. logistic regression analysis for selected factors for postpartum fatigue in yogyakarta variable or (ci 95%) p-value family income 0.364 (0.126 – 1.056) 0.063 infant temperament 3.064 (1.073 – 8.750) 0.036 social support 4.386 (1.709 – 11.256) 0.002 3. 10134-yuni astuti; bookmark_clean.pdf 3. 10134-yuni astuti-lampiran_clean.pdf vol. 3 no. 2 december 2019 99 ijnp (indonesian journal of nursing practices) vol 3 no 2 december 2019 : 99-104 titih huriah1, ika fauziyah rahmawati1 1universitas muhammadiyah yogyakarta corresponding author: titih huriah email: titih.huriah@umy.ac.id description of the characteristics of nutritional status based on food intake in school-age children article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.3299 abstract background: one of the factors that influence nutritional status is food intake. imbalance of food intake in school-age children causes nutritional problems occurring due to the decline in the immune system. objective: this study aims to determine the description of the characteristics of nutritional status based on the school-age children's intake of food. method: this study used a cross-sectional design with a random sample size of 84 students from grade 1 to grade 6 in sonosewu bantul elementary school. the instruments used in the study were school-age, weight scales, and food records. the variable in this study was the description of nutritional status characteristics based on food intake in school-age children. the data analysis used frequency distribution. result: the results showed that 57 school-age children (67.85%) had a normal nutritional status. respondents in this study had less carbohydrate intake (n=64; 76,2%), more protein intake (n=47; 56%), less fat intake (n=56; 66,7%), less vitamin intake (n=49; 58,3%), less mineral intake (n=84, 100%). in children with normal nutritional status, the researcher found that 34 (40,5%) had more protein intake. conclusion: the majority of school-age children in sonosewu bantul elementary school had normal nutritional status with excessive protein intake. however, their nutrient intake in the form of calories, carbohydrates, fats, minerals, and vitamins were less. this fact may have an impact on the growth and development of school-age children. keywords: food intake; nutrition, nutrition status; school-age children introduction school-age children are individuals who are in the age range of 7 to 12 years (marisa & nuryanto, 2014). indonesia health profile of 2018 states that the prevalence of the number of school-age children in indonesia is quite a lot, namely 28.1 million children (ministry of health of the republic of indonesia, 2019). the age of school-age children has progressed the development of skills so that schoolage children need optimal and balanced nutrition. proper nutrition is also needed for children to concentrate, brain growth, and improve memory, which can affect the quality of human resources in the future. at this time, adequacy and nutritional balance is an essential factor that must be considered by parents as a foundation for children's health (irmilia, herlina, hasneli, 2015; hidayati, 2012; soetjiningsih & ranuh, 2014). world health organization (who) in 2016 reported the prevalence of malnutrition status in children in the world reached 14.0% or around 94.5 million children, the prevalence of fat nutritional status reached 6.0% or around 40.6 million children, and http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& http://journal.umy.ac.id/index.php/ijnp/article/view/6767 indonesian journal of nursing practices 100 low prevalence reached 22.9% or around 154.8 million. basic health research data (riskesdas) in 2013 reported that the problem of nutritional status based on bmi/a in children aged 5-12 years was divided into two results (ministry of health of the republic of indonesia, 2013). the first was the prevalence of thinness of 11.2%, which consisted of 4.0%, very thin, and 7,2% are thin, and the second was the prevalence of fat by 18.8%, consisting of 10.8% fat and 8.8% very fat (obese). meanwhile, the prevalence of nutritional status problems in children aged 5-12 years based on height was 30.7%, which consisted of 12.3% very short and 18.4% short. in addition, other nutritional problems that often occur in school-age children are nutritional deficiency anemia, iodine deficiency disorders (idd), and dental caries (adriani & wirjatmadi, 2012). problems with nutritional status can be caused by two factors, namely, directly and indirectly. direct factors are such as food intake and infectious diseases. indirect factors are such as the family economy, parenting, closest health services, and sanitation (alatas, 2011 in latifah, 2015). school-age children have begun to possess an active consumer characteristic that is starting to choose foods that are only preferred (iklima, 2017; karaki, kundre, & karundeng, 2016). in indonesia, most school-age children live in environments that offer a lot of high-energy foods that are cheap, tasty, and have little nutritional content, such as foods and drinks that contain large portions of sugar (warkentin, mais, latorre, carnell, & taddei, 2018). it causes school-age children to eat less fibrous foods, such as fruits and vegetables, and tend to consume fast food frequently (utari, ernalia, & suyanto, 2016). the recommended proportion of energy and carbohydrates, protein, and fat in children aged 418 years is 55%, 15%, and 20% (rahman, dewi, & bohari, 2017). food consumption that does not vary for food intake is not in accordance with the recommended dietary allowances (rdas), and the imbalanced food intake in school-age children can result in a child experiencing a decrease in endurance, making it vulnerable to disease and experiencing nutritional status problems (utari, ernalia, & suyanto, 2016). it makes children a group that is vulnerable to nutritional problems. the purpose of this study is to determine the nutritional status based on food intake in school-age children. method this type of research was a quantitative study with a cross-sectional design to reveal the characteristics of nutritional status based on the food intake of school-age children. the picture studied was a picture of the nutritional status of school-age children, a description of nutrient intake, and an overview of nutritional status based on calorie intake. the population in this study were students of first grades until sixth grades in sonosewu bantul elementary school, totaling 322 people who were included in the inclusion criteria. the sample in the study was calculated using the slovin’s formula and anticipated dropout. the calculation results obtained 84 respondents of school-age children selected by simple random sampling. this research was conducted in november 2018 february 2019. the research variable was a description of the characteristics of nutritional status based on food intake in school-age children. the instruments used in this study were microtoise for the measurement of the height of school-age children, the scales to measure the weight of schoolage children, and food records to see the intake of school-aged children. microtoise and scales have been calibrated at the metrology center, and the food record is a standardized research instrument from instruments for clinical health research (varricchio, frank-stromborg, & olsen, 2004). the analysis of research used frequency distribution. results this study involved 84 respondents from students and parents of sonosewu bantul elementary school students. the research data on the characteristics of the respondents used to find out the general description of the respondents in this study were the nutritional status of the respondents and the gender demographic data of the research respondents, with the following explanation: vol. 3 no. 2 december 2019 101 table 1. distribution of respondent characteristics based on age, gender, and nutritional status (n=84) characteristics of respondents f (%) age 7 9 years 10 12 years 44 (52.4) 40 (47.6) gender male female nutritional status thin normal fat obese 34 (40.5) 50 (59.5) 2 (2.4) 57 (67.85) 12 (14.28) 13 (15.47) table 1 shows that the frequency of the 7-9-year-old group of children is more than the group of 10-12year-old children with the majority is female and with the normal nutritional status. table 2. distribution of frequency of nutrient intake (carbohydrate, protein, fat, vitamins, and minerals) in elementary students (n = 84) nutrient intake f (%) carbohydrate intake less enough more 64 (76.2) 9 (10.7) 11 (13.1) protein intake less enough more 34 (40.5) 3 (3.6) 47 (56) fat intake less enough more 56 (66.7) 1 (1.2) 27 (32.1) vitamin intake less enough more 49 (58.3) 2 (2.4) 33 (32.1) mineral intake less 84 (100) based on table 2, the majority of respondents' carbohydrate intake is in less category with 64 students (76.2%). meanwhile, for protein intake, most of the respondents are in more category, namely 47 students (56%). then, for the data on fat and vitamin intake, most of the respondents have less fat and vitamin intake, consisting of fat with 56 students (66.7%) and vitamins with 49 students (58.3%). also, for mineral intake, all respondents have less mineral intake. table 3. cross-tabulation of nutrients (carbohydrates, proteins, fats, vitamins, and minerals) on the nutritional status of children calorie intake nutritional status thin normal fat obese f % f % f % f % less 1 1.2 40 47.6 8 9.5 8 9.5 enough 0 0 9 10.7 1 1.2 0 0 more 1 1.2 8 9.5 3 3.6 5 6 based on table 3, the results show that, of the 84 respondents, most of the respondents have less carbohydrate intake of 45 students (53.6%) that occur in respondents with normal nutritional status. meanwhile, for protein intake, most of them have more protein intake, namely 34 students (40.5%), and experienced by respondents with normal nutritional status. respondent data, which has an intake of fat, vitamins, and minerals, also mostly have less intake for fat, vitamins, and minerals. table 4. cross-tabulation of calorie intake on nutritional status of elementary school students (n = 84) nutrient intake nutritional status thin normal fat obese f % f % f % f % carbohydrate intake less enough 1 0 1.2 0 45 5 53.6 6 9 1 10.7 1,2 9 3 10.7 3.6 more 1 1.2 7 8,3 2 2.4 1 1.2 protein intake less enough 1 0 1.2 0 22 1 26.2 1,2 4 2 4.8 2,4 7 0 8.3 0 more 1 1.2 34 40.5 6 7.1 6 7.1 fat intake less enough 2 0 2.4 0 38 1 45.2 1.2 8 0 9.5 0 8 0 9.5 0 more 0 0 18 21.4 4 4.8 5 6 vitamin intake less enough 1 0 1.2 0 35 1 41.7 1.2 8 1 9.5 1.2 5 0 6 0 more 1 1.2 21 25 3 3.6 8 9.5 mineral intake less 2 2.4 57 67.9 12 14.3 13 15.5 based on table 4, most respondents with normal nutritional status have less intake of carbohydrates, fats, vitamins, and minerals, and have more intake for protein. indonesian journal of nursing practices 102 discussion normal nutritional status can occur if the child gets adequate and proper nutrition and is used efficiently to enable physical growth, brain development, workability to reach optimal health levels. other factors that influence nutritional status are the level of maternal knowledge, the level of parental education, the number of family members which causes a reduction in the amount of food consumed, parental income, and improper parenting (lestari, ernalia, & restuastuti, 2016; siregar, ernalia, & restuastuti, 2016). school-age children are considered to have normal nutritional status if the z-score of bmi/a is between 2 sd to 1 sd, and if they have a z-score of more or less than that number, they are considered to have nutritional status problems. based on the results of the study, it found that, of the 84 respondents, most respondents had less carbohydrate intake of 64 students (76.2%) in this study, the carbohydrate intake of students who were often consumed were white rice, porridge, and “nasi uduk“ (influence rice). white rice has the highest carbohydrate content; however, students often skipped breakfast and reduced the amount of carbohydrate intake. it was because children were afraid to arrive late, and they started thinking about their appearance. carbohydrates have the primary function as a provider of the main energy intake in the body. the average carbohydrate requirement needed by school-age children is around 50%-60% of the nutritional needs (rda). carbohydrate requirements for children aged 7-9 years are 254 grams, for males aged 10-12 years are 289 grams, and for females aged 10-12 years are 275 grams (hardiansyah, riyadi, & napitupulu, 2013). factors that can be the cause of the lack of carbohydrate intake are lack of parental knowledge and the amount of carbohydrate intake consumed by students that are not in accordance with the needs of children, and the child's excessive preference for a type of food and lack of energy consumption will result in the body not getting all the nutritional status that is needed (rauf, dewi, & syafei, 2015; utari, ernalia, & suryanto, 2016). for the protein intake in school-age children, the majority had excess protein intake. it can be caused by the distribution of protein foods consumed by respondents were quite good. in this study, students more often consumed foods, such as tempe, tofu, and eggs, as a source of their protein intake. tempe is a processed soybean that has a high enough animal protein content. the body needs protein for the development of body and brain, growth, immunity, and muscle growth. at one gram of protein is the same as containing four calories the contribution of energy needs in protein in children aged 5-18 years is 15% of the body's needs (hardiansyah & napitupulu, 2012). the need for protein intake in children aged 7-9 years is 49 grams, for female aged 10-12 years is 60 grams, and for male aged 10-12 years is 56 grams (hardiansyah & napitupulu, 2012). excessive protein causes deamination/release of amino groups (nh2) from amino acids. nitrogen will be removed from the body, and the remaining carbon bonds will be converted into acetyl coa. acetyl coa can, then, be synthesized into triglycerides through the process of lipogenesis. therefore, excess protein intake from needs in children will be stored in fat (kharismawati, 2011). the majority of fat intake in school-aged children is lacking. it happens because the intake of fat consumed is only limited to fried and stir-fried foods (rauf, dewi, & syafei, 2015). in this study, students got fat intake from foods that were processed by frying. fat has a function that is the reserve of energy in the body. at one gram of fat is the same as containing nine calories. the contribution of energy from fat for children aged 5-18 years is around 30% of the total body needs (hardiansyah & napitupulu, 2013). the need for fat intake for children aged 7-9 years is 72 grams, for female aged 10-12 years old is 67 grams, and for male aged 1012 years old is 70 grams. lack of consumption of fat intake can cause a reduction in energy availability because energy must be fulfilled, so a catabolism/protein breakdown process occurs. if it continues, fat reserves will decrease and result in weight loss (manuhutu, purnamasari, & dardjito, 2017). the majority of vitamin intake in school-aged children experiences less intake. it is due to the lack vol. 3 no. 2 december 2019 103 of consumption of fruits and vegetables in schoolage children. in this study, not all vitamin content in fruits and vegetables was seen because it adjusted to the results or vitamin content contained in the software used. vitamins are organic substances that are needed by the body, and together with enzymes are useful in the process of metabolism and conversion of proteins and carbohydrates into energy. vitamins have a role in several stages of the reaction of energy metabolism, growth, and maintenance of the body (rahmawati, 2012). the need for good vitamins for school-age children aged 7-9 years is 55.5 mg, while for females aged 10-12 years is 65 mg, and for males, there is 65.3 mg (almatsier, 2010). these vitamin intake needs are based on the sum of vitamins a, b1, b2, b3, b6, c, and e, at each age (almatsier, 2010). each vitamin has its function. all school-age children in this study experienced insufficient mineral intake. it can be caused by the lack of respondents' intake of plant foods. minerals are parts of the body that play an essential role in maintaining body functions at the cellular, tissue, and organ levels. besides, minerals also play a role in the metabolic stage. the mineral is one of the micronutrient substances needed by the body and has a different function between one mineral and the other minerals. the best mineral source is animal food, except magnesium, which is more abundant in plant foods (almatsier, 2010). mineral needs for children aged 7-9 years, namely 7341 grams, for males aged 10-12 years is 8577 grams, and for females aged 10-12 years is 8588 grams. minerals that are important for school-age children are iron, calcium, and zinc, and if these minerals are lacking, it can cause disruption to children's growth and development, children's performance at school, and experience diseases, such as iron deficiency anemia (sari, juffrie, nurani, & sitaresmi, 2016). mineral intake requirements differ for each age and depend on the mineral type. nursing implications related to the results of the research are that nurses must pay attention to nutritional needs, especially in school-age children, because nutritional needs are basic human needs. this study presents the characteristics of each nutrient intake based on the nutritional status of children. these data make it easy for nurses to develop more specific intervention plans related to a nutrient deficiency in school-age children. conclusion the nutritional status of respondents in this study mostly had normal nutritional status, with a number of 57 students (67.9%). the most nutrient intake based on nutritional status was the intake of carbohydrates, fats, vitamins, and minerals. the category of more protein intake in the normal nutritional status was 34 students (40.5%). calorie intake based on the nutritional status of respondents, in this study, had less calorie intake, and most experienced by children with normal nutritional status, with the number of 43 students (51.2%). references adriani, m., & wirjatmadi, b. 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(2014). pengaruh pendidikan gizi melalui komik gizi seimbang terhadap pengetahuan dan sikap pada siswa sdn bendungan di semarang. journal of nutrition college, 3(4), 925-932. rahman, n., dewi, n., & bohari. (2017). kebiasan sarapan pagi, asupan gizi dan status gizi murid sdn inpres 3 tondo, kota palu. jurnal preventif, 8 (1), 14-20 rahmawati, m. (2012). hubungan antara asupan vitamin dan mineral dengan morbiditas pada siswa di smpn 5 bogor dan smpn 2 cibinong. skripsi. institut pertanian bogor. bogor rauf, s., dewi, t., & syafei, a. (2015). gambaran asupan zat gizi makro dan status gizi anak sd inpres pajjaiyang kelurahan sudiang raya kecamatan biringkanaya kota makassar. media gizi pangan, 19(1). sari, e. m., juffrie, m., nuraini., sitaresmi, m. n., (2016). asupan protein, kalsium dan fosfor pada anak stunting dan tidak stunting usia 24-59 bulan. jurnal gizi klinik indonesia, 12 (4), 152-159. siregar, y. h. w., ernalia, y., & restuastuti, t. (2016). gambaran status gizi pada siswa sekolah dasar di desa teluk kiambang kecamatan tempuling kabupaten indragiri hilir. jurnal online mahasiswa fakultas kedokteran universitas riau, 3(2), 1-13. soetjiningsih., & ranuh, i.g.n.g., (2014) tumbuh kembang anak edisi 2. jakarta: egc. utari, l. d., ernalia, y., & suyanto, s. gambaran status gizi dan asupan zat gizi pada siswa sekolah dasar kecamatan sungai sembilan kota dumai. jurnal online mahasiswa fakultas kedokteran universitas riau, 3(1), 1-17. varricchio, c. g., frank-stromborg, m., & olsen, s. j. (2004). instruments for clinical health research. 3rd edition. canada. jones and bartlett publishers. warkentin, s., mais, l. a., carnell, s., latorre, m. r., & taddei, j. a. a. c. (2018). parents matter: associations of parental bmi and feeding behaviors with child bmi in brazilian preschool and school-aged children. frontiers in nutrition. 5 (69). 15 vol. 1 no. 1 desember 2016 abstrak masalah gizi kurang balita merupakan masalah aktual di wilayah kulon progo, yogyakarta. tujuan penelitian ini untuk mengetahui faktor yang mempengaruhi status gizi balita. penelitian ini menggunakan cross sectional, sampel balita 12-59 bulan sebanyak 155 orang. data diperoleh melalui kuesioner, status gizi diukur dengan indeks berat badan/umur. hasil menunjukkan terdapat hubungan bermakna antara usia balita, riwayat pemberian asi, asupan makanan, persepsi ibu, pola pengasuhan dengan status gizi balita. faktor dominan yang mempengaruhi status gizi adalah asupan makanan. diperlukan peran perawat komunitas dalam edukasi dan pemberdayaan untuk meningkatkan status gizi balita. kata kunci: faktor status gizi, gizi kurang, balita abstract undernutrition was still a prior problem in kulon progo,yogyakarta. the objectives of this study were to determine nutritional status in children under five years and related factors. cross sectional study was conducted with 155 children under five years. nutritional status was assessed using anthropometric measurement. there was a significant association between child’s age, exclusife breastfeeding, child’s dietary intake, caregivers’ practice and mother’s perception with child’s nutritional status and child’s dietary energy intake was the most factor that significant correlated. these findings indicates that the roles of community nurses are needed to improves children nutritional status using education and partnership. keywords: factors of nutritional status, undernutrition, children under five years nina dwi lestari departemen jiwa dan komunitas, program studi ilmu keperawatan, fakultas kedokteran dan ilmu kesehatan, universitas muhammadiyah yogyakarta jl. lingkar selatan, tamantirto, kasihan, bantul, yogyakarta, indonesia email: gavinnaufal@yahoo.com analisis determinan gizi kurang pada balita di kulon progo, yogyakarta info artikel: masuk : 2 september 2016 revisi : 21 november 2016 diterima : 28 november 2016 doi number : 10.18196/ijnp.1146 16 pendahuluan masalah gizi kurang pada balita masih menjadi masalah mendasar di dunia. who (2013), jumlah penderita kurang gizi di dunia mencapai 104 juta anak. riskesdas (2013), prevalensi balita dengan berat kurang (under weight) adalah berjumlah 19,6%. sebanyak 13,9% balita memiliki status gizi kurang. dinkes kab. kulon progo (2014) melaporkan jumlah balita gizi kurang adalah sebanyak 10,13%. kondisi gizi kurang pada balita, dimungkinkan terjadi karena interaksi dari beberapa faktor diantaranya asupan makanan yang tidak adekuat, pemberian asi yang tidak ekslusif, penyakit infeksi yang diderita balita, pola pengasuhan keluarga, pelayanan kesehatan, jumlah anggota keluarga, tingkat pendidikan ibu, persepsi ibu terkait gizi, sosial ekonomi yang rendah dan budaya (unicef, 2013, naghaspour et al, 2014). penyebab dasar terjadinya gizi kurang pada balita adalah status ekonomi yang rendah (unicef, 2013). kondisi kemiskinan mempengaruhi kondisi ketahanan pangan dalam keluarga (almatsier, 2009). penyebab dasar lain yang berkontribusi dalam terjadinya masalah gizi kurang pada balita adalah pendidikan (unicef, 2013). hasil penelitian handono (2012), menunjukkan bahwa pendidikan orang tua terutama ibu berpengaruh secara signifikan terhadap status gizi balita. wong et al (2014), masalah gizi kurang pada balita secara langsung disebabkan oleh anak tidak mendapatkan cukup asupan makanan yang mengandung gizi seimbang. gizi kurang juga diakibatkan oleh adanya infeksi pada balita. infeksi akan mengganggu metabolisme, keseimbangan hormon dan fungsi imunitas (bantamen, belaynew, & dube, 2014). faktor lain yang erat kaitannya dengan gizi kurang adalah pola pengasuhan anak dalam keluarga. penelitian yang dilakukan oleh maseta, makau dan omwega (2008) menunjukkan bahwa terdapat hubungan yang signifikan antara pola pengasuhan anak dan praktik perawatan kesehatan anak dalam keluarga dengan status nutrisi pada anak usia 6-36 bulan di tanzania. faktor selanjutnya adalah pelayanan kesehatan. rendahnya pemanfaatan pelayanan kesehatan berpengaruh sebesar 60-70% kematian balita dengan gizi kurang (unicef, 2013). melihat jumlah angka kejadian gizi kurang pada balita di wilayah kulon progo, yogyakarta yang masih tinggi dan masalah gizi disebabkan oleh multifaktorial, oleh karena itu diperlukan penelitian mengenai determinan gizi kurang pada balita di wilayah ini. penelitian ini bertujuan untuk menganalisis faktor-faktor yang berpengaruh terhadap status gizi balita di wilayah kulon progo, yogyakarta. metode desain penelitian yang digunakan adalah cross sectional dengan jumlah sampel 155 orang yang terdiri dari balita usia 12-59 bulan beserta keluarganya, yang diambil dengan metode proportional cluster sampling. variabel bebas pada penelitian ini adalah usia balita, jenis kelamin, riwayat penyakit infeksi, pendidikan ibu, status perekonomian keluarga, jumlah anggota keluarga, asupan makanan, persepsi ibu terkait status gizi, pola pengasuhan keluarga terkait gizi, pelayanan kesehatan dan budaya. variabel terikat pada penelitian ini adalah status gizi. instrumen pengambilan data variabel terikat menggunakan kuesioner yang dikembangkan peneliti yang telah dinyatakan valid dan reliable melalui uji validitas dan reliabilitas. variabel asupan makanan diukur menggunakan foodrecords selama 2 hari berturutturut. variabel status gizi diukur berdasarkan indeks antropometri bb/u, dengan klasifikasi status gizi baik: -2 sd s.d +2 sd. status gizi kurang: <-2 sd s.d <-3 sd, status gizi buruk: d” -3 sd. status gizi dikelompokkan menjadi gizi baik dan gizi kurang (gizi kurang dan gizi buruk). analisis data meliputi univariat, bivariat dan multivariat. analisis bivariat menggunakan chi square, dan analisis multivariat menggunakan regresi logistik berganda. penelitian ini memperhatikan aspek etik dalam pengambilan data meliputi menghargai harkat dan martabat manusia, kemanfaatan, keadilan dan informed consent dan telah lolos kaji etik dengan no 0231/ un2. f12.d / hkp. 02.04/ 2015 hasil berdasarkan tabel 1 dapat disimpulkan bahwa mayoritas balita yang menjadi responden adalah berusia 17 vol. 1 no. 1 desember 2016 pra sekolah. berdasarkan jenis kelamin, prosentase lakilaki dan perempuan hampir sama. responden lebih banyak yang memiliki riwayat asi ekslusif dibandingkan yang tidak ekslusif. sebagian besar responden pernah mengalami penyakit infeksi dalam 6 bulan terakhir dan mayoritas memiliki status gizi baik. tabel 1. karakteristik balita 16 memiliki riwayat asi ekslusif dibandingkan yang tidak ekslusif. sebagian besar responden pernah mengalami penyakit infeksi dalam 6 bulan terakhir dan mayoritas memiliki status gizi baik. tabel 1. karakteristik balita karakteristik balita frekuensi prosentase usia balita todler (12-36 bulan) 65 41,9% preschool (37-59 bulan) 90 58,1% jenis kelamin perempuan 78 50,3% laki-laki 77 49,7% riwat pemberian asi nonekslusif 64 41,3% ekslusif 91 58,7% riwayat penyakit infeksi ada 103 66,5% tidak ada 52 33,5% status gizi gizi baik 131 84,5% gizi kurang 24 15,5% tabel 2. karakteristik keluarga karakteristik keluarga frekuensi prosentase pendidikan ibu rendah 58 37,4% tinggi 97 62,6% status ekonomi <umk 81 52,3% ≥umk 74 47,7% jumlah anggota keluarga besar 65 41,9% kecil 90 58,1% tabel 3. analisis bivariat faktor yang mempengaruhi gizi kurang balita variabel or p value usia balita 3,347 0,014 jenis kelamin 0,662 0,484 riwayat asi 4,340 0,003 riwayat infeksi 0,661 0,496 pendidikan ibu 0,646 0,497 status ekonomi 0,737 0,643 jumlah anggota keluarga 1,795 0,273 asupan makanan 9,677 0,000 persepsi ibu 3,742 0,017 pola asuh 2,955 0,045 pelayanan kesehatan 1,379 0,621 budaya 1,442 0,571 berdasarkan tabel 2, dapat dilihat bahwa mayoritas ibu memiliki pendidikan tinggi, dengan status ekonomi lebih banyak yang kurang dari upah minimum kabupaten. jumlah anggota keluarga yang dimiliki mayoritas adalah kurang dari 4 orang. tabel 3 menunjukkan bahwa variabel yang berhubungan secara bermakna dengan gizi kurang balita adalah variabel usia balita, riwayat pemberian asi, asupan makanan, persepsi ibu terkait status gizi balita, dan pola pengasuhan keluarga terkait gizi (p value<0,05). tabel 4 hasil akhir analisis multivariat regresi logistic variabel b (koefisien) p value or (ci 95%) usia balita 2,406 0,001 11,093 (2,804-43,883) riwayat pemberian asi 2,259 0,001 9,572 (2,439-37,576) asupan makanan 2,479 0,000 11,927 (3,467-41,029) persepsi ibu terkait status gizi 1,530 0,024 4,619 (1,220-17,487) pola pengasuhan keluarga terkait gizi 1,126 0,084 3,082 (0,861-11,030) constanta -7,126 0,000 0,001 berdasarkan analisis menggunakan regresi logistik berganda diperoleh bahwa variabel yang paling dominan mempengaruhi status gizi balita adalah asupan makanan (or=11,927). asupan makanan yang kurang baik, berpeluang 11,9 kali lebih besar mendapatkan status gizi kurang dibandingkan dengan asupan makan yang baik. pembahasan hasil analisis statistik menunjukkan bahwa terdapat hubungan yang signifikan antara usia dengan gizi kurang pada balita dengan p value 0,014 (p value <0,05) dengan nilai or sebesar 3,347. balita yang berusia 12-36 bulan beresiko 3,34 kali lebih besar mendapatkan gizi kurang dibandingkan dengan balita yang berusia 37-59 bulan. stanhope dan lancaster (2012) menjelaskan bahwa balita memiliki faktor resiko resiko biologi yang meliputi faktor genetik atau fisik yang ikut berperan dalam timbulnya resiko tertentu yang mengancam kesehatan. usia balita yang masih muda menyebabkan sistem kekebalan tubuh yang belum berkembang. hal ini menyebabkan balita lebih mudah terkena masalah nutrisi. tabel 2. karakteristik keluarga 16 memiliki riwayat asi ekslusif dibandingkan yang tidak ekslusif. sebagian besar responden pernah mengalami penyakit infeksi dalam 6 bulan terakhir dan mayoritas memiliki status gizi baik. tabel 1. karakteristik balita karakteristik balita frekuensi prosentase usia balita todler (12-36 bulan) 65 41,9% preschool (37-59 bulan) 90 58,1% jenis kelamin perempuan 78 50,3% laki-laki 77 49,7% riwat pemberian asi nonekslusif 64 41,3% ekslusif 91 58,7% riwayat penyakit infeksi ada 103 66,5% tidak ada 52 33,5% status gizi gizi baik 131 84,5% gizi kurang 24 15,5% tabel 2. karakteristik keluarga karakteristik keluarga frekuensi prosentase pendidikan ibu rendah 58 37,4% tinggi 97 62,6% status ekonomi <umk 81 52,3% ≥umk 74 47,7% jumlah anggota keluarga besar 65 41,9% kecil 90 58,1% tabel 3. analisis bivariat faktor yang mempengaruhi gizi kurang balita variabel or p value usia balita 3,347 0,014 jenis kelamin 0,662 0,484 riwayat asi 4,340 0,003 riwayat infeksi 0,661 0,496 pendidikan ibu 0,646 0,497 status ekonomi 0,737 0,643 jumlah anggota keluarga 1,795 0,273 asupan makanan 9,677 0,000 persepsi ibu 3,742 0,017 pola asuh 2,955 0,045 pelayanan kesehatan 1,379 0,621 budaya 1,442 0,571 berdasarkan tabel 2, dapat dilihat bahwa mayoritas ibu memiliki pendidikan tinggi, dengan status ekonomi lebih banyak yang kurang dari upah minimum kabupaten. jumlah anggota keluarga yang dimiliki mayoritas adalah kurang dari 4 orang. tabel 3 menunjukkan bahwa variabel yang berhubungan secara bermakna dengan gizi kurang balita adalah variabel usia balita, riwayat pemberian asi, asupan makanan, persepsi ibu terkait status gizi balita, dan pola pengasuhan keluarga terkait gizi (p value<0,05). tabel 4 hasil akhir analisis multivariat regresi logistic variabel b (koefisien) p value or (ci 95%) usia balita 2,406 0,001 11,093 (2,804-43,883) riwayat pemberian asi 2,259 0,001 9,572 (2,439-37,576) asupan makanan 2,479 0,000 11,927 (3,467-41,029) persepsi ibu terkait status gizi 1,530 0,024 4,619 (1,220-17,487) pola pengasuhan keluarga terkait gizi 1,126 0,084 3,082 (0,861-11,030) constanta -7,126 0,000 0,001 berdasarkan analisis menggunakan regresi logistik berganda diperoleh bahwa variabel yang paling dominan mempengaruhi status gizi balita adalah asupan makanan (or=11,927). asupan makanan yang kurang baik, berpeluang 11,9 kali lebih besar mendapatkan status gizi kurang dibandingkan dengan asupan makan yang baik. pembahasan hasil analisis statistik menunjukkan bahwa terdapat hubungan yang signifikan antara usia dengan gizi kurang pada balita dengan p value 0,014 (p value <0,05) dengan nilai or sebesar 3,347. balita yang berusia 12-36 bulan beresiko 3,34 kali lebih besar mendapatkan gizi kurang dibandingkan dengan balita yang berusia 37-59 bulan. stanhope dan lancaster (2012) menjelaskan bahwa balita memiliki faktor resiko resiko biologi yang meliputi faktor genetik atau fisik yang ikut berperan dalam timbulnya resiko tertentu yang mengancam kesehatan. usia balita yang masih muda menyebabkan sistem kekebalan tubuh yang belum berkembang. hal ini menyebabkan balita lebih mudah terkena masalah nutrisi. tabel 3. analisis bivariat faktor yang mempengaruhi gizi kurang balita 16 memiliki riwayat asi ekslusif dibandingkan yang tidak ekslusif. sebagian besar responden pernah mengalami penyakit infeksi dalam 6 bulan terakhir dan mayoritas memiliki status gizi baik. tabel 1. karakteristik balita karakteristik balita frekuensi prosentase usia balita todler (12-36 bulan) 65 41,9% preschool (37-59 bulan) 90 58,1% jenis kelamin perempuan 78 50,3% laki-laki 77 49,7% riwat pemberian asi nonekslusif 64 41,3% ekslusif 91 58,7% riwayat penyakit infeksi ada 103 66,5% tidak ada 52 33,5% status gizi gizi baik 131 84,5% gizi kurang 24 15,5% tabel 2. karakteristik keluarga karakteristik keluarga frekuensi prosentase pendidikan ibu rendah 58 37,4% tinggi 97 62,6% status ekonomi <umk 81 52,3% ≥umk 74 47,7% jumlah anggota keluarga besar 65 41,9% kecil 90 58,1% tabel 3. analisis bivariat faktor yang mempengaruhi gizi kurang balita variabel or p value usia balita 3,347 0,014 jenis kelamin 0,662 0,484 riwayat asi 4,340 0,003 riwayat infeksi 0,661 0,496 pendidikan ibu 0,646 0,497 status ekonomi 0,737 0,643 jumlah anggota keluarga 1,795 0,273 asupan makanan 9,677 0,000 persepsi ibu 3,742 0,017 pola asuh 2,955 0,045 pelayanan kesehatan 1,379 0,621 budaya 1,442 0,571 berdasarkan tabel 2, dapat dilihat bahwa mayoritas ibu memiliki pendidikan tinggi, dengan status ekonomi lebih banyak yang kurang dari upah minimum kabupaten. jumlah anggota keluarga yang dimiliki mayoritas adalah kurang dari 4 orang. tabel 3 menunjukkan bahwa variabel yang berhubungan secara bermakna dengan gizi kurang balita adalah variabel usia balita, riwayat pemberian asi, asupan makanan, persepsi ibu terkait status gizi balita, dan pola pengasuhan keluarga terkait gizi (p value<0,05). tabel 4 hasil akhir analisis multivariat regresi logistic variabel b (koefisien) p value or (ci 95%) usia balita 2,406 0,001 11,093 (2,804-43,883) riwayat pemberian asi 2,259 0,001 9,572 (2,439-37,576) asupan makanan 2,479 0,000 11,927 (3,467-41,029) persepsi ibu terkait status gizi 1,530 0,024 4,619 (1,220-17,487) pola pengasuhan keluarga terkait gizi 1,126 0,084 3,082 (0,861-11,030) constanta -7,126 0,000 0,001 berdasarkan analisis menggunakan regresi logistik berganda diperoleh bahwa variabel yang paling dominan mempengaruhi status gizi balita adalah asupan makanan (or=11,927). asupan makanan yang kurang baik, berpeluang 11,9 kali lebih besar mendapatkan status gizi kurang dibandingkan dengan asupan makan yang baik. pembahasan hasil analisis statistik menunjukkan bahwa terdapat hubungan yang signifikan antara usia dengan gizi kurang pada balita dengan p value 0,014 (p value <0,05) dengan nilai or sebesar 3,347. balita yang berusia 12-36 bulan beresiko 3,34 kali lebih besar mendapatkan gizi kurang dibandingkan dengan balita yang berusia 37-59 bulan. stanhope dan lancaster (2012) menjelaskan bahwa balita memiliki faktor resiko resiko biologi yang meliputi faktor genetik atau fisik yang ikut berperan dalam timbulnya resiko tertentu yang mengancam kesehatan. usia balita yang masih muda menyebabkan sistem kekebalan tubuh yang belum berkembang. hal ini menyebabkan balita lebih mudah terkena masalah nutrisi. berdasarkan tabel 2, dapat dilihat bahwa mayoritas ibu memiliki pendidikan tinggi, dengan status ekonomi lebih banyak yang kurang dari upah minimum kabupaten. jumlah anggota keluarga yang dimiliki mayoritas adalah kurang dari 4 orang. tabel 3 menunjukkan bahwa variabel yang berhubungan secara bermakna dengan gizi kurang balita adalah variabel usia balita, riwayat pemberian asi, asupan makanan, persepsi ibu terkait status gizi balita, dan pola pengasuhan keluarga terkait gizi (p value<0,05). tabel 4 hasil akhir analisis multivariat regresi logistic 16 memiliki riwayat asi ekslusif dibandingkan yang tidak ekslusif. sebagian besar responden pernah mengalami penyakit infeksi dalam 6 bulan terakhir dan mayoritas memiliki status gizi baik. tabel 1. karakteristik balita karakteristik balita frekuensi prosentase usia balita todler (12-36 bulan) 65 41,9% preschool (37-59 bulan) 90 58,1% jenis kelamin perempuan 78 50,3% laki-laki 77 49,7% riwat pemberian asi nonekslusif 64 41,3% ekslusif 91 58,7% riwayat penyakit infeksi ada 103 66,5% tidak ada 52 33,5% status gizi gizi baik 131 84,5% gizi kurang 24 15,5% tabel 2. karakteristik keluarga karakteristik keluarga frekuensi prosentase pendidikan ibu rendah 58 37,4% tinggi 97 62,6% status ekonomi <umk 81 52,3% ≥umk 74 47,7% jumlah anggota keluarga besar 65 41,9% kecil 90 58,1% tabel 3. analisis bivariat faktor yang mempengaruhi gizi kurang balita variabel or p value usia balita 3,347 0,014 jenis kelamin 0,662 0,484 riwayat asi 4,340 0,003 riwayat infeksi 0,661 0,496 pendidikan ibu 0,646 0,497 status ekonomi 0,737 0,643 jumlah anggota keluarga 1,795 0,273 asupan makanan 9,677 0,000 persepsi ibu 3,742 0,017 pola asuh 2,955 0,045 pelayanan kesehatan 1,379 0,621 budaya 1,442 0,571 berdasarkan tabel 2, dapat dilihat bahwa mayoritas ibu memiliki pendidikan tinggi, dengan status ekonomi lebih banyak yang kurang dari upah minimum kabupaten. jumlah anggota keluarga yang dimiliki mayoritas adalah kurang dari 4 orang. tabel 3 menunjukkan bahwa variabel yang berhubungan secara bermakna dengan gizi kurang balita adalah variabel usia balita, riwayat pemberian asi, asupan makanan, persepsi ibu terkait status gizi balita, dan pola pengasuhan keluarga terkait gizi (p value<0,05). tabel 4 hasil akhir analisis multivariat regresi logistic variabel b (koefisien) p value or (ci 95%) usia balita 2,406 0,001 11,093 (2,804-43,883) riwayat pemberian asi 2,259 0,001 9,572 (2,439-37,576) asupan makanan 2,479 0,000 11,927 (3,467-41,029) persepsi ibu terkait status gizi 1,530 0,024 4,619 (1,220-17,487) pola pengasuhan keluarga terkait gizi 1,126 0,084 3,082 (0,861-11,030) constanta -7,126 0,000 0,001 berdasarkan analisis menggunakan regresi logistik berganda diperoleh bahwa variabel yang paling dominan mempengaruhi status gizi balita adalah asupan makanan (or=11,927). asupan makanan yang kurang baik, berpeluang 11,9 kali lebih besar mendapatkan status gizi kurang dibandingkan dengan asupan makan yang baik. pembahasan hasil analisis statistik menunjukkan bahwa terdapat hubungan yang signifikan antara usia dengan gizi kurang pada balita dengan p value 0,014 (p value <0,05) dengan nilai or sebesar 3,347. balita yang berusia 12-36 bulan beresiko 3,34 kali lebih besar mendapatkan gizi kurang dibandingkan dengan balita yang berusia 37-59 bulan. stanhope dan lancaster (2012) menjelaskan bahwa balita memiliki faktor resiko resiko biologi yang meliputi faktor genetik atau fisik yang ikut berperan dalam timbulnya resiko tertentu yang mengancam kesehatan. usia balita yang masih muda menyebabkan sistem kekebalan tubuh yang belum berkembang. hal ini menyebabkan balita lebih mudah terkena masalah nutrisi. berdasarkan analisis menggunakan regresi logistik berganda diperoleh bahwa variabel yang paling dominan mempengaruhi status gizi balita adalah asupan makanan (or=11,927). asupan makanan yang kurang baik, berpeluang 11,9 kali lebih besar mendapatkan status gizi kurang dibandingkan dengan asupan makan yang baik. pembahasan hasil analisis statistik menunjukkan bahwa terdapat hubungan yang signifikan antara usia dengan gizi kurang pada balita dengan p value 0,014 (p value <0,05) dengan nilai or sebesar 3,347. balita yang berusia 12-36 bulan beresiko 3,34 kali lebih besar mendapatkan gizi kurang dibandingkan dengan balita yang berusia 37-59 bulan. stanhope dan lancaster (2012) menjelaskan bahwa balita memiliki faktor resiko resiko biologi yang meliputi faktor genetik atau fisik 18 yang ikut berperan dalam timbulnya resiko tertentu yang mengancam kesehatan. usia balita yang masih muda menyebabkan sistem kekebalan tubuh yang belum berkembang. hal ini menyebabkan balita lebih mudah terkena masalah nutrisi. hasil analisis hubungan antara jenis kelamin dengan gizi kurang balita menunjukkan bahwa tidak terdapat hubungan yang signifikan antara jenis kelamin dengan status gizi balita (p value= 0,528). hal ini disebabkan karena tidak adanya perbedaan pandangan nilai yang dianut keluarga terhadap keberadaan seorang anak lakilaki dan perempuan di wilayah ini, sehingga perlakuan keluarga dalam hal pola asuh, pemberian makan, kesempatan mengakses sumber-sumber kesehatan adalah sama untuk anak laki-laki dan perempuan. m e n u r u t u n i c e f ( 2 0 1 1 ) , g e n d e r s a n g a t berkaitan dengan nilai (value) terhadap seorang anak. ketidaksetaraan gender terjadi apabila terdapat penilaian yang berbeda antara anak laki-laki dan perempuan dalam suatu komunitas yang menyebabkan anak lakilaki dan perempuan mendapatkan perlakuan yang berbeda, perawatan kesehatan yang berbeda, dan perbedaan aksesibilitas terhadap sumber-sumber. hal ini menyebabkan ketidaktepatan dalam pengasuhan anak dan rendahnya kemampuan dalam mengakses pelayanan kesehatan. hasil analisis mengenai hubungan riwayat pemberian asi dengan gizi kurang balita menunjukkan bahwa terdapat hubungan yang signifikan antara riwayat pemberian asi dengan status gizi balita (p value=,003). balita dengan riwayat asi nonekslusif berpeluang mengalami gizi kurang sebanyak 4,34 kali lebih besar dibandingkan dengan balita dengan riwayat asi ekslusif. hasil penelitian ini didukung oleh nakamori et al (2010), bahwa bayi yang tidak mendapatkan asi ekslusif memiliki peluang 3,95 kali mengalami underweight dibandingkan dengan bayi yang mendapatkan asi ekslusif. hal ini disebabkan karena pemberian asi ekslusif menurunkan angka kejadian penyakit infeksi yang berhubungan dengan kondisi status gizi balita. asi ekslusif akan meningkatkan sistem imunitas bayi, sehingga daya tahan tubuh terhadap infeksi akan meningkat. hasil analisis mengenai hubungan riwayat penyakit infeksi dengan gizi kurang pada balita menunjukkan tidak ada hubungan yang signifikan antara riwayat penyakit infeksi dengan gizi kurang balita (p value=0,496). hal ini disebabkan karena upaya pencegahan terhadap kasus gizi kurang sudah dilaksanakan dengan baik oleh keluarga balita, misalnya dengan pemberian asi secara ekslusif. hasil penelitian ini sejalan dengan penelitian nakamori et al (2010) bahwa penyakit infeksi tidak berpengaruh terhadap kejadian underweight disebabkan adanya tindakan pencegahan yang secara dini dilakukan untuk mencegah balita mendapatkan underweight seperti melalui pemberian asi ekslusif. hasil analisis menunjukkan bahwa tidak terdapat hubungan yang bermakna antara pendidikan ibu dengan gizi kurang balita (p value=0,497). ini disebabkan karena ibu tidak mendapatkan pendidikan mengenai status gizi di pendidikan formal. ibu dengan pendidikan rendah bisa mendapatkan informasi terkait gizi melalui pendidikan informal melalui petugas kesehatan di posyandu, puskesmas atau rumah sakit dengan kemasan informasi yang mudah diserap dan dimengerti tanpa harus dengan pendidikan tinggi. penelitian ini didukung oleh hasil penelitian charmarbaglawa, ranger, waddington, dan white (2010), bahwa pendidikan ibu tidak berpengaruh terhadap status gizi balita. kondisi ini disebabkan oleh kualitas pendidikan yang ditempuh dalam pendidikan formal yang kurang baik dan ibu tidak mendapatkan informasi terkait gizi di pendidikan formal, akan tetapi terdapat informasi gizi yang mudah diserap oleh ibu meskipun dengan pendidikan rendah di luar pendidikan formal. hasil analisis statistik menunjukkan tidak ada hubungan yang signifikan atara status ekonomi dengan gizi kurang balita (p value=0,643). hal ini disebabkan keluarga dengan status perekonomian rendah justru mampu mengalokasikan keuangan keluarga dengan lebih teliti dan hati-hati. berusaha mengatur pengeluaran dengan alokasi utama adalah untuk kebutuhan primer seperti kebutuhan makanan. charmarbaglawa, ranger, waddington, dan white (2010) mengemukakan bahwa dalam mengalokasikan penghasilan, keluarga dengan 19 vol. 1 no. 1 desember 2016 penghasilan yang kurang akan lebih hati-hati dalam pengeluaran sehingga pengeluaran tidak melebihi dari pendapatan. status perekonomian keluarga tidak memiliki hubungan yang signifikan dengan status gizi disebabkan oleh adanya pemanfaatan lahan yang baik oleh keluarga dalam menunjang nutrisi anak. hal ini sesuai dengan penelitian annim dan imai (2014) bahwa terdapat hubungan yang signifikan antara kepemilikan lahan pertanian dengan kondisi malnutisi. meningkatnya ukuran lahan pertanian akan menurunkan insiden malnutrisi. hasil analisis statistik menunjukkan tidak ada hubungan yang yang signifikan antara jumlah anggota keluarga dengan gizi kurang pada balita (p value=0,273). hal ini disebabkan karena terdapat keluarga balita dengan komposisi jumlah anggota keluarga yang produktif bekerja lebih banyak, sehingga akan meningkatkan pendapatan keluarga yang menyebabkan kondisi status gizi anak menjadi lebih baik. hasil penelitian ini didukung oleh charmarbaglawa, ranger, waddington, dan white (2010) menunjukkan bahwa pada keluarga dengan jumlah anggota keluarga yang besar akan tetapi memiliki lebih banyak anggota keluarga yang bekerja (rasio antara anggota keluarga yang tidak bekerja dibandingkan yang bekerja lebih kecil) menyebabkan pendapatan keluarga dan status ekonominya meningkat. hal ini menyebabkan kondisi kesehatan anak dan status gizinya menjadi lebih baik. hasil analisis statistik menunjukkan bahwa terdapat hubungan yang signifikan antara asupan makanan dengan gizi kurang balita (p value=0,000). balita dengan asupan makanan yang kurang memiliki peluang 9,677 kali lebih besar mendapatkan gizi kurang dibandingkan dengan balita yang mempunyai asupan makanan yang baik (or=9,677). makanan yang seimbang dibutuhkan tubuh untuk pemeliharaan, perbaikan sel-sel tubuh, pertumbuhan dan perkembangan (unicef, 2013). hasil analisis variabel persepsi ibu balita terhadap gizi kurang balita menunjukkan bahwa terdapat hubungan yang signifikan antara persepsi ibu terkait status gizi dengan status gizi balita (p value=0,017). ibu dengan persepsi yang kurang baik terhadap status gizi berpeluang 3,7 kali lebih besar mendapatkan gizi kurang dibanding ibu dengan persepsi yang baik terkait status gizi (or=3,742). persepsi orang tua yang merasakan bahwa kondisi gizi kurang pada balita itu merupakan kondisi rentan dan serius yang berpotensi menimbulkan dampak buruk bagi balita, akan melakukan tindakan pencegahan ataupun pencarian pengobatan apabila orang tua tersebut memiliki persepsi yang kuat terhadap manfaat yang dirasakan dari tindakan yang diambil dibandingkan persepsi hambatan yang akan dihadapi. orang tua yang memiliki persepsi manfaat yang kuat terhadap manfaat tindakan pencegahan gizi kurang, akan selalu membawa balitanya ke posyandu atau puskesmas untuk melakukan kontrol status gizi anak balitanya ke pelayanan kesehatan, memberikan asupan makanan yang baik, dan melakukan pola asuh nutrisi yang baik (hayati, 2014) hasil analisis menunjukkan terdapat hubungan yang signifikan antara pola asuh keluarga terkait gizi dengan gizi kurang pada balita (p value=0,045). pola asuh keluarga terkait status gizi yang kurang baik berpeluang 2,96 kali lebih besar mendapatkan gizi kurang dibanding dengan pola asuh keluarga yang baik (or=2,955). hasil penelitian ini didukung oleh penelitian kartika et al (2000) bahwa terdapat hubungan antara pola asuh makan dengan status gizi balita. kondisi usia balita yang masih berada pada tahap ketergantungan dalam pemenuhan kebutuhan dasarnya terhadap orang tua atau pengasuh, membuat asupan makanan sangat tergantung dengan bagaimana cara pengasuhan, cara memberi makan dan cara perawatan kesehatan oleh orang tua atau pengasuh. hasil analisis menunjukkan tidak ada hubungan yang signifikan antara pelayanan kesehatan dengan gizi kurang pada balita (p value =0,621). hal ini disebabkan karena kondisi status perekonomian keluarga balita yang sebagian besar memiliki penghasilan kurang dari umk, yang menyebabkan kurangnya akses keluarga terhadap pelayanan kesehatan. kemampuan keluarga untuk mengakses pelayanan kesehatan berkaitan 20 dengan ketersediaan sarana pelayanan kesehatan dan kemampuan ekonomi untuk membayar biaya pelayanan kesehatan (sartika, 2010). hasil penelitian ini menunjukkan tidak ada hubungan antara budaya dengan gizi kurang pada balita (p value= 0,571). kondisi ini disebabkan oleh terpaparnya keluarga balita dengan informasi kesehatan terkait gizi yang dilakukan oleh tenaga kesehatan. hasil penelitian ini didukung oleh penelitian mirayanti (2012), bahwa tidak ada hubungan yang signifikan antara nilai dan keyakinan keluarga terhadap pola nutrisi dengan status gizi balita. faktor dominan yang mempengaruhi status gizi balita hasil analisis multivariat menunjukkan bahwa variabel yang paling berpengaruh terhadap gizi kurang pada balita adalah asupan makanan. balita dengan asupan makanan yang kurang, berpeluang 11,9 kali untuk status gizi kurang dibandingkan dengan asupan makanan yang baik. penelitian ini didukung oleh putri dan wahyono (2013), bahwa faktor langsung yang dominan berpengaruh terhadap kejadian wasting pada anak usia 24-59 bulan adalah asupan karbohidrat dengan or 1,29. anak dengan asupan karbohidrat yang kurang, beresiko menderita wasting 1,3 kali lebih besar dibandingkan dengan anak dengan asupan karbohidrat yang cukup. penelitian ini memiliki keterbatasan, diantaranya adalah dalam hal variabel asupan makanan. variabel ini pengukurannya baru terbatas pada kecukupan kebutuhan energi saja, oleh karena itu diperlukan penelitian selanjutnya mengenai variabel asupan makanan yang dilihat dari kecukupan zat gizi lain seperti protein, vitamin dan mineral. penelitian dengan metode kualitatif juga diperlukan untuk penelitian selanjutnya guna mendapatkan hasil penelitian yang lebih mendalam mengenai dimensi budaya kaitannya dengan status gizi balita. kesimpulan faktor-faktor yang berhubungan secara bermakna dengan status gizi balita di wilayah kulon progo, yogyakarta adalah usia balita, riwayat pemberian asi, asupan makanan, persepsi ibu terkait status gizi dan pola pengasuhan keluarga terkait gizi. hasil penelitian ini menunjukkan angka kejadian gizi kurang di wilayah kulon progo masih cukup tinggi bila dibandingkan dengan data kejadian gizi kurang balita dalam cakupan wilayah provinsi d.i.yogyakarta. oleh karena itu angka kejadian gizi kurang di wilayah ini perlu mendapatkan perhatian bagi tenaga kesehatan. hasil penelitian ini dapat memberikan sumbangan informasi bagi pelayanan kesehatan dan keperawatan untuk dapat meningkatkan program gizi di masyarakat. perlunya dilakukan penyuluhan secara berkala di pelayanan kesehatan dasar mengenai gizi pada balita sehingga dapat memperbaiki pola asuh, persepsi ibu yang kurang baik mengenai gizi pada balita dan perubahan perilaku keluarga menuju keluarga sadar gizi. ucapan terimakasih ucapan terimakasih disampaikan kepada kepala puskesmas sentolo1, keluarga balita yang berpartisipasi dan memberikan dukungan dalam penelitian ini. referensi almatsier. s. (2009). prinsip dasar ilmu gizi (edisi ketujuh). jakarta: gramedia pustaka utama annim, s.k.,&imai k.s.,(2014. nutritional status of children, food consumtion diversity and ethnicity in lao pdr. economics school of social sciece. university of manchaster. uk bantamen, belaynew, & dube (2014). assessment of factors associated with malnutrition among under five years age children at machakel woreda, northwest ethiopia: a case control study. journal nutrition food science vol 4 no 1 2014 charmarbaglawa,r.,ranger.,m.,waddington h, white h (2010). the determination of child health and nutrition: a meta analysis. departemen of economic, university of maryland and operation evaluation departement, world bank dinkes kab kulon progo (2014). profil kesehatan kabupaten kulon progo tahun 2014 (data tahun 2013). kulon progo, diy 21 vol. 1 no. 1 desember 2016 handono, n.p (2010). hubungan tingkat pengetahuan pada nutrisi, pola makan, dan tingkat konsumsi energi dengan status gizi anak usia lima tahun di wilayah kerja puskesmas selogiri, wonogiri. jurnal keperawatan vol 1 no.1, juli 2010. hayati (2014). analisis faktor orang tua terhadap status gizi balita. pendekatan teori health belief model. program studi ners fakultas keperawatan universitas airlangga. kartika, et al (2000). pola pemberian makan anak (6-18 bulan) dan hubungannya dengan tumbang anak pada keluarga miskin dan tidak miskin. jurnal penelitian gizi dan makanan jilid 23 tahun 2000 hal 37-47 maseta, e., makau k.w., & omwega a.m., (2008). childcare practice and nutritional status of children aged 6-36 months among short ang long term beneficiaries of the child survival protection and development programmes (the case morogoro, tanzania). south africa journal of clinical nutrition. vol 21, no 1, 2008 mirayanti, n. (2012). hubungan pola asuh pemenuhan nutrisi dalam keluarga dengan status gizi balita di kelurahan pasir gunung selatan kecamatan cimanggis kota depok. tesis. fakultas ilmu keperawatan magister ilmu keperawatan: depok. naghashpour et al (2014). nutrition education based on health belief model improves dietary calcium intake among female students of junior high schools. journal of health population nutrition. vol 32 , no 3, 420429p. 2014 nakamori et al (2010). nutritional status, feeding practice and incidence of infectious disease among children aged 6 to 18 months in northern mountainous vietnam. the journal of medical investigations vol. 57.2010 putri, d.s.k & wahyono,t.y.m (2013). faktor langsung dan tidak langsung yang berhubungan dengan kejadian wasting pada anak umur 6-59 bulan di indonesia tahun 2010. media litbangkes vol 23, no 3, september 2013, 110-121 riskesdas. (2013). riset kesehatan dasar 2013. kementerian kesehatan ri. https://www.litbang.depkes.go.id salehi et al (2004). asessing the impact of nutrition education on growth of iranian nomadic children: an application of a modified beliefs, attitudes, subjectives norms and enabling factors model. the british journal of nutrition, vol 91, 779p sartika, r. (2010). an anlysis on the usage of health service related to nutritional status of under five years old children. jurnal kesehatan masyarakat nasional vol 5, no.2, oktober 2010 stanhope, m. & lancaster, j. (2012). public health nursing population centered health care in the community . (8th e). missouri: elsevier. unicef (2011). gender influences on child survival, health and nutrition:a narative review. new york united nations children’s fund (unicef) (2013). improving child nutrition: the achievable imperative for global progress, unicef, new york, 2013. who (2013). the millenium development goals (mdgs) report 2013. united nation new york.diperoleh tanggal 25 desember 2013 dari http://www.who.int/ nutrition/publications/severemalnutrition wong et al.(2014). risk factors of malnutrition among preschool children in terengganu, malaysia: a case control study. bmc public health journal 2014, 14: 785 vol. 5 no. 2 december 2021 112 ijnp (indonesian journal of nursing practices) vol 5 no 2 december 2021: 112-122 risna devi yuniasti*, arif setyo upoyo, agis taufik universitas jenderal soedirman, indonesia corresponding author: risna devi yuniasti email: risna.yuniasti@mhs.unsoed.ac.id the effect of hypnotherapy on pain intensity in postoperative patients: a systematic review article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v5i1.10938 : 22 january 2021 : 14 july 2021 : 08 december 2021 abstract background: pain is a common problem in patients undergoing surgery. the constant postoperative acute pain can affect the physiological and psychological aspects of the patient. objective: non-pharmacological therapy is widely used for the treatment of chronic pain. non-pharmacological therapy needs to be developed in acute postoperative pain due to concerns about the side effects of pharmacological treatment. there is non-pharmacological management that effectively reduces pain intensity, namely hypnotherapy. methods: the systematic search for this review used the google scholar database, directory of open access journal (doaj), proquest, and pubmed using keywords (hypnosis or hypnotism or hypnoanalysis or hypnotherapy or hypnotherapies or mesmerism) and (post-surgical pain or post surgical pain or postsurgical pain or post-operative pain or post operative pain or post-operative pains or postoperative pain or acute postoperative pain or acute postoperative pain or acute post operative pain). the quality of journals was assessed using the critical appraisal skills program (casp) instrument. the synthesis method used was narrative synthesis (narrative synthesis). results: 10 articles were fully reviewed from 2010-2020. the visualization technique with rapid conversational induction has the best effect than other techniques. the most effective way of conveying suggestions is indirect with a permissive approach. the study results showed that hypnotherapy tended to reduce postoperative pain in minor surgical procedures than in major surgeries. conclusion: hypnotherapy affects reducing the pain intensity of postoperative patients. the results of this study recommend that hypnotherapy suggestions and pain measures must be tailored to the patient's condition. keywords: hypnotherapy; pain; postoperative introduction pain is a common problem in patients undergoing surgery. acute pain occurs after tissue injury associated with surgery and must be resolved during healing. surgery causes tissue injury. surgical injury triggers various responses in the pain matrix, from sensitization of peripheral and central pain pathways to feelings of fear, anxiety, and frustration (small & laycock 2020). according to world health organization (who), surgery rates significantly increased globally. total http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/9558 indonesian journal of nursing practices 113 surgeries in 2012 were estimated at 312.9 million, an increase of 38.2% from the estimated 226.4 million operations in 2004. the estimated global surgical rate averaged 4,469 operations per 100,000 people per year. the largest increase in operating rates occurred in very low-spending and lowspending countries (69.0%; from 394 to 666 operations per 100,000 populations per year and 114.6%, from 1851 to 3973 operations per 100,000 populations per year. the number of surgical procedures in indonesia in 2012 reached 1,839 operations per 100,000 populations per year (weiser et al., 2016). the constant pain after surgery can affect the patient's physiological and psychological aspects. effective postoperative pain management is the task of the health care provider. nurses are key figures in this process (bach et al., 2018). nurses can take two treatments or approaches to deal with pain, namely pharmacological and non-pharmacological approaches. a non-pharmacological approach is an independent approach that nurses can take. however, many of these non-pharmacological therapies are used to treat chronic pain. due to concerns with the side effects of pharmacological treatment, non-pharmacological therapies need to be increasingly developed in various aspects, including acute postoperative pain (small & laycock 2020). according to a study of the basic theories of complementary, alternative, and integrative medicine by micozzi (2018), hypnotherapy effectively reduces pain intensity. it is stated that hypnotherapy can reduce the fear and anxiety that goes along with the pain. hypnotherapy can reduce pain intensity as there is a strengthening of impulses or modulation in the process. weak stimuli or impulses can be strengthened to reach the brain, and then it is perceived to respond to a stimulus immediately. affirmative sentences in the form of commands are always used to give advice. it is carried out to allow the patient to enter the subconscious mind and then suggest acting according to the advice given after the operation. hypnotherapy stimulates the brain to release neurotransmitters, encephalin, and endorphins that function to improve mood to change the individual's acceptance of pain or other physical symptoms (prasetyo & ervin 2010). research conducted by sumarwanto (2015) on "the effect of hypnotherapy on reducing pain intensity in post-operational patients with moderate-severe pain scale at bhayangkara polda west kalimantan hospital in 2015" which was carried out on the second postoperative day in 16 patients with purposive sampling technique showed the value of which can significantly reduce the pain that is equal to p> 0.05. in line with it, the results of research conducted by aini & pratidina (2017) on "the influence of hypnotherapy on pain intensity in post sectio caesarea patients at pku muhammadiyah hospital, temanggung regency" on post section cesarean patients on the day i with quasiexperimental techniques showed a significant effect of hypnotherapy on pain intensity in post-cesarean section patients with p<0.05. the analysis results of these two non-random sampling studies showed that hypnotherapy had a significant effect on postoperative pain in patients. based on these descriptions, the authors are interested in analyzing the effect of hypnotherapy on acute pain intensity in postoperative patients using a systematic review method of various relevant research results. thus, a systematic review can summarize research results and present comprehensive and balanced facts. besides, the results of this study give a summary of evidence regarding hypnotherapy treatment against acute pain intensity in postoperative patients to clinicians and policymakers. methods this study used a systematic review method. inclusion criteria for the article in this study included an article from 1 january 2010 to 1 december 2020, the randomized controlled trial (rct), research articles, full text, and english. the systematic search for this review used the google scholar database, directory of open access journal (doaj), proquest, and pubmed using keywords (hypnosis or hypnotism or hypnoanalysis or hypnotherapy or hypnotherapies or mesmerism) and (post-surgical pain or post surgical pain or postsurgical pain or post-operative pain or post operative pain or postoperative pains or postoperative pain or acute postoperative pain or acute post-operative pain or acute post operative pain). the study design with randomized controlled trials was assessed for vol. 5 no. 2 december 2021 114 quality using the critical appraisal skills program (caps) instrument. the purpose of using this instrument is to identify whether the journal's quality is good, sufficient or insufficient to be used as relevant materials. the synthesis method used was narrative synthesis (narrative synthesis). the narrative synthesis method is a methodology that uses a text or word-based approach for systematic review and synthesis of findings. result the results of the search using keywords, phrases, document subjects, using boolean operators (or, and, not), and the search facilities available in each database found 38,354 articles (proquest found 33,589 articles, cochrane found 521 articles, google scholar found 1,900 articles, and pubmed found 2,344 articles). furthermore, article screening was carried out by reading the title and abstract as well as selecting the full-text category so that 73 articles were obtained. there was a filter for duplicate articles as many as 10 articles. a total of 47 articles was rejected as the research variables hypnotherapy was not in patients with pain postoperative. furthermore, there was screening for articles not relevant to the purpose and inclusion and exclusion criteria of 6 articles. the final results obtained 10 articles that fit the inclusion criteria, and the articles were then analyzed and performed a critical appraisal. the search results for the article are described in figure 1. moreover, the list of articles from the search was described in table 1. there were five good quality articles; 11 questions were submitted, 10 questions were answered with the answer "yes" with a score of 90.9%, namely articles by efsun ozgunay et al. (2019) and 9 questions were answered with the answer "yes" with a score of 81.8%, namely the article by montgomery et al. (2010), akgul et al. (2016), amraoui et al. (2018), and duparc alegria et al. (2018). five articles were of sufficient quality, where from 11 questions submitted, 8 statements were answered with a "yes" answer with a score of 72.7%, namely articles by lew et al. (2011), leyvavillanueva, and mackey (2018) and 7 statements were answered with the answer "yes " with a score of 63.6 %, namely articles by joudi et al. (2016) and rousseaux & dardenne (2020). hypnotherapy techniques were used in the studies reviewed in the form of visualization techniques (eight studies) and verbal (two studies). as induction technique was relaxation or fatigue of the nervous system, eye fixation, and rapid conversation, two kinds of approaches were made when the induction was authoritarian and permissive. how to convey the suggestion was done directly and indirectly. the visualization technique with rapid conversational induction was more effective than other techniques. the most effective way of conveying suggestions was indirect with a permissive approach. there are several hypnotherapy combinations with other interventions, namely virtual reality (one study) and soothing background music (one study). this combination technique aims to determine the additional effects of hypnotherapy rather than single hypnotherapy. in this case, the study found that the additional intervention of soothing background music had a better effect than virtual reality. based on several studies, hypnotherapy intervention was given before surgery (five studies), during the surgery (two studies), and post-surgery (one study). only two studies applied more than one hypnotherapy session, namely 2 sessions (before and after surgery) and 3 sessions (1 day and 3 days before surgery and on the day of surgery). hypnotherapy sessions have varying durations, including 5 minutes, 15 minutes, 20 minutes, 30 minutes, 40 minutes, and during the procedure. the hypnotherapy group with one session during which the procedure was carried out had the highest effectiveness compared to the other groups. hypnotherapy is used for the management of pain in patients with post-knees arthroscopic surgery, cardiac surgery, breast cancer surgery (three studies), operating large both fusion of the bones back to scoliosis or osteotomy that may be combined with tenotomy, open septorhinoplasty, arteries coronary, coronary artery bypass grafting (cabg), cholecystectomy, laparoscopic, underwent oral and maxillofacial surgery. this hypnotherapy showed a decrease in pain postoperatively on oral and maxillofacial surgery, cabg, cholecystectomy, laparoscopic, breast cancer surgery, arthroscopic knee, and open septorhinoplasty. based on reviewed studies, two sizes were used to assess pain intensity subjectively. they were measured by visual analog scale (vas) in most cases (eight studies) and numerical rating scales (two studies). most studies compared the effectiveness of hypnotherapy with indonesian journal of nursing practices 115 standard care (eight studies), one study compared the effectiveness of hypnotherapy with an intervention of relaxing music played through headphones, and another study compared it with attention control. hypnotherapy compared to standard care had significantly lower pain levels in six of the eight measures (75%). hypnotherapy was significantly lower when compared to the addition of relaxing music played through headphones and 100% attention control. some studies also examined issues related to the use of analgesics (four studies), the level of sedation, anxiety (five studies), fatigue (two studies), relaxation, duration of icu, fibrillation atrium, the need to support inotropic, relief vents, nausea, and vomiting. the future inpatient hospitalization was also investigated in several studies. the study results stated that in addition to reducing pain, hypnotherapy also reduced the use of analgesics, anxiety, fatigue, assisted ventilation, and hospitalization time. discussion this systematic review provides evidence that hypnotherapy effectively reduces the intensity in postoperative patients. there are two hypnotherapy techniques found in this systematic review: visualization and verbal techniques. mechanical visualization is the ability to create ideas, images, or shadows and bring them to mind. visualization activity is to imagine a desire/something by optimizing the involvement of the roles of all senses (if possible) and accompanied by strong emotional intentions (subiyono et al., 2015). in contrast, the verbal technique is a message or programmed plan proposal made to influence responses in speech, feelings, thoughts, and actions (aman 2010). visualization techniques are more effective at reducing pain intensity as visual suggestions combine relaxation and distraction techniques. this technique results in muscle relaxation and perceptual changes to reduce pain (joudi et al., 2016). induction techniques that can be given are relaxation-based, eye fixation, and rapid conversational. finkelstein's study in mackey (2018) revealed that therapeutic suggestions could provide relaxation, relieve and prevent pain, accept procedures and situations that involve whole-body discomfort. hence, it insisted on using rapid conversational rather than lengthy induction protocols in clinical settings; thus, it can save time and money. the approaches taken at induction were authoritarian (paternal) and permissive (maternal). erickson explained that the hypnotherapist approach permissive within indirect technique immediately provides a sense of comfort and calm and produces pain control better (akgul et al. 2016). based on this review, the addition of relaxing music interventions to hypnotherapy is more effective than the virtual reality hypnosis combination (vrh). the results of setiawan's (2015) research revealed that music has a complex function for hypnotherapy activities. apart from being a hypnotherapist partner, music supports communication between the hypnotherapist and the client as an expression of the client's emotions and as a client's physical response. in the study of rousseaux & dardenne (2020), due to the lack of differences between groups, the results did not provide value in adding vr to hypnotherapy in terms of clinical effectiveness. hypnotherapy interventions during surgical procedures reported a more significant effect than those administered preoperatively and postoperatively. interventions with more than one hypnotherapy session reported a more significant effect than a study involving only two sessions. furthermore, hypnotherapy interventions shorter than 30 minutes provide the best results. however, the adjustment of individual suggestions allows for variable results in hypnosis and suggestion adherence. this hypnotherapy showed a decrease in postoperative pain in oral and maxillofacial surgery, cabg, laparoscopic cholecystectomy, breast cancer surgery, arthroscopic knee, and septorhinoplasty open. the study results showed that hypnotherapy tended to reduce postoperative pain in minor surgical procedures than in major surgeries. the effects of hypnotherapy may not be effective enough to control the pain intensity in major surgery. a critical review by kendrick et al. (2017) recently showed that hypnotherapy reduces postoperative pain for minor procedures. pain is most frequently measured with the vas and nrs instruments. both of these instruments have vol. 5 no. 2 december 2021 116 been valid and used in nursing and medicine for many years to measure pain (mackey 2018). pain is most often measured by a vas score. according to kendrick et al. (2017), vas is easy to do and requires low time, acceptability, and psychometrics. results obtained from the analyzed article mentioned that hypnosis effectively reduces pain in postoperative patients. thus, hypnotherapy becomes a therapy to reduce postoperative pain based on strong evidence and has additional advantages in postoperative patients, such as reducing analgesics, anxiety, fatigue, assisted ventilation, and hospitalization time. in addition, hypnotherapy showed effectiveness in depression, nausea, adherence to stressful medical procedures, dysmenorrhea, chronic pain, and burns. conclusion based on the review results of ten articles, hypnotherapy reduced postoperative patients' pain intensity. thus, hypnotherapy becomes a therapy to reduce postoperative pain with powerful evidencebased. the visualization technique with rapid conversational induction had better effectiveness than other techniques. the most effective way of conveying suggestions is an indirect technique with a permissive approach. furthermore, the study results showed that hypnotherapy tended to be more effective in reducing postoperative pain in minor surgical procedures than in major surgeries. the hypnotherapy intervention during the procedure is the most effective session. however, further rigorous methodological studies were applied under conditions of minimally effective control and systematic control of intervention dose and time. hypnotherapy interventions can affect the subjective intensity of pain and discomfort in different ways. thus, hypnotherapy suggestions and pain measures must be tailored to the patient's condition. the results of this study are expected to be in addition to the reference and knowledge related to the effect of hypnotherapy on the intensity of the patient's pain after surgery. further, researchers can carry out similar research by adding other databases, multiplying the articles analyzed, and identifying costs and resources used in the articles analyzed. references aini, f. & pratidina, e.s.g. 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(2011). use of preoperative hypnosis to reduce postoperative pain and anesthesiarelated side effects. international journal of clinical and experimental hypnosis, 59(4), 406–423. https://doi.org/10.1080/00207144.2011.594 737 leyva-villanueva, g., huerta-estrada, m. & villegasdominguez, j. (2018). hypnotherapy, coadjuvant treatment in the management of pain. international journal of recent advances in multidisciplinary research, 5(10), 4180–2. mackey, e.f. (2018). an extension study using hypnotic suggestion as an adjunct to intravenous sedation. american journal of clinical hypnosis, 60(4), 378–385. https://doi.org/10.1080/00029157.2017.141 6279 micozzi, m. (2018). fundamentals of complementary, alternative and integrative medicine, 6th edn, elsevier. montgomery, g.h., hallquist, m.n., schnur, j.b., david, d., silverstein, j.h. & bovbjerg, d.h. (2010). mediators of a brief hypnosis intervention to control side effects in breast surgery patients: response expectancies and emotional distress. journal of consulting and clinical psychology, 78(1), 80–88. https://doi.org/10.1037/a0017392 prasetyo, b.p. & ervin, r. (2010). cara cepat menguasai hypno healing hipnosis untuk penyembuhan, leutika, yogyakarta. rousseaux, f.m. & dardenne, n. (2020). virtual reality hypnosis for anxiety and pain management in intensive care units . a prospective randomized trial amongcardiac surgery patients. bmc research notes, 21(330), 1–19. https://doi.org/10.1097/eja.0000000000001 633 setiawan, a. (2015). fungsi musik dalam proses hipnoterapi arnold meka di jaten karanganyar. institut seni indonesia (isi) surakarta. small, c. & laycock, h. (2020). acute postoperative pain management. bjs (british journal of surgery), 107(2), 70–80. https://doi.org/10.1002/bjs.11477 subiyono, hariono, a., wiryawan, a. & surati, n. (2015) afirmasi visualisasi dan kekuatan pikiran, k-media, yogyakarta. sumarwanto, s.f. (2015). pengaruh hipnoterapi terhadap penurunan intensitas nyeri pada pasien post operasi dengan skala nyeri sedang-berat di rumah sakit bhayangkara polda kalbar tahun 2015. univeritas tanjungpura. weiser, t.g., haynes, a.b., molina, g., lipsitz, s.r., esquivel, m.m., uribe-leitz, t., fu, r., azad, t., chao, t.e., berry, w.r. & gawande, a.a. (2016) no size and distribution of the global volume of surgery in 2012. bulletin of the world health organization, 3(94), 201-209f. https://doi.org/10.2471/blt.15.159293 https://doi.org/10.1080/00207144.2019.1612670 https://doi.org/10.1080/00207144.2019.1612670 https://doi.org/10.1080/00207144.2015.1099405 https://doi.org/10.1080/00207144.2015.1099405 https://doi.org/10.1080/00207144.2011.594737 https://doi.org/10.1080/00207144.2011.594737 https://doi.org/10.1080/00029157.2017.1416279 https://doi.org/10.1080/00029157.2017.1416279 https://doi.org/10.1037/a0017392 https://doi.org/10.1097/eja.0000000000001633 https://doi.org/10.1097/eja.0000000000001633 https://doi.org/10.1002/bjs.11477 https://doi.org/10.2471/blt.15.159293 vol. 5 no. 2 december 2021 118 figure 1. articles selection process keyword : (hypnosis or hypnotism or hypnoanalysis or hypnotherapy or hypnotherapies or mesmerism) and (post-surgical pain or post surgical pain or postsurgical pain or postoperative pain or post operative pain or post-operative pains or postoperative pain or acute postoperative pain or acute post-operative pain or acute post operative pain) searching in database proquest (n = 33.589) google scholar (n = 1.900) cochrane library (n = 521) pubmed (n = 2.344) total : 38.354 article number of articles screened (n = 63) exclusion irrelevant studies (n = 47) full text articles assessed for eligibility (n = 16) not meeting inclusion criteria (n = 6) studies included in the systematic review (n= 10) in d e n ti fi ca ti o n s cr e e n in g e li g ib it y in cl u d e d removal of duplicates (n = 10 ) screening of articles by title and abstract (n = 73) indonesian journal of nursing practices 119 table 1. articles in study author title methodology population intervention outcome montgomery et al. (2010) " mediators of a brief hypnosis intervention to control side effects in breast surgery patients: response expectancies and emotional distress " randomized study a sample of 200 women was scheduled fo r breastconserving surgery. hypnotherapy intervention was performe d 15 minutes led by a psychologist before breast cancer surgery on the morning of the operation. the effects of hypnotherapy on postoperative pain are partly influenced by the expected pain ( pain expectancy ) but not by distress. influence intervention hypnothera py on postoperative pain is not fully considered by the mediator, p = 0, 04. this model accounted for 33% of the intensity of postoperative pain. lew et al. (2011) " use of preoperative hypnosis to reduce postoperativ e pain and anesthesiarelated side effects " randomized clinical trial breast cancer surgery patients were recruited for this study (n = 36). study participants were at least 18 years of age, spoke and read english and agreed to participate. the hypnother apy interventi on consisted of a 15-minute hypnosis script administered within one preoperative hour from the operating room. significant reductions in anxiety, worry, and nervousness were found in addition to decreases in sadness, irritability, and feelings of distress in the intervention group. in our study, only two symptoms were not relieved (postoperative pain and nausea). akgul et al. (2016) " the benefi cial effect of hypnosis in elective cardiac surgery: a doubleblind, randomi zed clinical trial patients were eligible for inclusion if they underwent c oronary artery bypass the patients received hypn otherapy tech niques, indirect permissive approach, conclusion sessions of pre-operative hypnotherapy can be an effective complement method in reducing preoperative anxiety, better pain vol. 5 no. 2 december 2021 120 author title methodology population intervention outcome preliminary study” grafting (n = 44). technique, pre procedural for 30 minutes by an anesthesiologi st. control, reduction of ventilator assistance. joudi et al. (2016) " an evaluation of the effect of hypnosis on postoperativ e analgesia following la paroscopic cholecystect omy " randomly divided into experimental and control groups one hundred and twenty patients were scheduled for laparoscopic cholecystect omy. hypnotic suggestions are provided by audio recordings containing verbal suggestions of hypnothera py followed by conditioning suggestions for postoperative analgesia. chi-square test results showed a significant difference between hypnotherapy abdominal pain and the control group. amraoui et al. (2018) " effects of a hypnosis session before general anesthesia on postoperativ e outcomes in patients who underwent minor breast cancer surgery " randomized cl inical trial in this multicenter study in france, 150 women were scheduled to undergo bre ast cancer surgery or surgery. a hypnotherapy session within 15 minutes before general anesthesia in the operating room was done. at pacu discharge and with longer follow-up, no statistically significant differences in breast pain were reported duparc alegria et al. (2018) " assessment of short hypnosis in a pediatric operating randomized clinical study this study was aimed at all children with large op the “ hypnotherap y ” group received brief hypnotherapy postoperative pain scores were low and did not differ between groups (median [q1q3]: 2 [0; 3] in the indonesian journal of nursing practices 121 author title methodology population intervention outcome room in reducing postoperativ e pain and anxiety: a randomized study. " erations (n = 118). (5 minutes) before surgery as an additional experimental analgesic procedure. control group versus 3 [1; 3] in the hypnotherapy group , p = 0.57). leyvavillanueva, huertaestrada & villegasdominguez (2018) " hypnothera py, coadjuvant treatment in the managemen t of pain " an experimental, longitudinal, exploratory and descriptive study postoperativ e knee arthroscopy patient from naval hospital of veracruz specialties (n = 22) intervention in postoperative knee arthroscopy patients was then evaluate d in both groups for pain intensity 24 hours after the first evaluation. the final measure of pain level in the hypnotherapy group (group "a") obtained a mean of 3.1, sd ± 1.0 against a mean of 4.2 sd ± 0.6. from group "b" with a statistically significant value (p <0.01) mackey (2018) " an extension study using hypnotic suggestion as an adjunct to intravenous sedation " few randomized, controlled, and blind studies the sample consisted of 143 patients aged between 18 and 25 who underwent oral and maxillofacial surgery to extract third molars. the treatment group received standard iv sedation with soothing background music playing through the headphon es and prerecorded rapid induction and therapeutic suggestions during the entire surgical procedure. these statistics show a reduction in postoperative pain, a decrease in intraoperative propofol use, and a decrease in the number of postoperative narcotic use. efsun ozgunay et al. (2019) " the effect of hypnosis on intraoperativ prospective observational twenty-two patients who underwent septorhinopl patients in the hypnotherapy group (hg) received the use of hypnotherapy before surgery decreased during surgery the need vol. 5 no. 2 december 2021 122 author title methodology population intervention outcome e hemorrhag e and postoperativ e pain in rhinoplasty " asty (srp) under general anesthesia were included and divided equally into two groups (n = 22). three induction hypnotherapy sessions with the eye fixation technique. for remifentanil and postoperative pain relief rousseaux & dardenne (2020) “ virtual reality hypnosis for anxiety and pain managemen t in intensive care units. a prospective randomized trial among cardiac surgery patients " prospective ra ndomized and controlled clinical trial in french, participants were adults who underwent heart surgery at the university hospital of liege (belgium), 100 patients (66.38 ± 11.48 years; 76 men, 24 women). participants were randomly entered in the following conditions: 1) control group: standard daily maintenance. 2) hypnothera py technique s oothing white clouds 3) virtual reality (vr) 4) virtual realit y hypnosis combination (vrh ) the results showed that anxiety decreased from baseline to postoperative days in all groups. there were no significant results for pain and f vol. 4 no. 2 december 2020 77 ijnp (indonesian journal of nursing practices) vol 4 no 2 december 2020 : 77-86 sirli agustiani1, arlina dewi2 1magister keperawatan, universitas muhammadiyah yogyakarta 2magister administrasi rumah sakit, universitas muhammadiyah yogyakarta corresponding author: sirli agustiani email: sirliagustiani0@gmail.com fulfillment of safety and comfort needs in patients with urinary catheter: literature review article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v4i2.10243 abstract background: discomfort often occurs when catheter placement and also the removal of catheter. in health sector, nursing practice focus on patient quality and safety. feeling safe is a form of feeling that if not controlled of anxiety. using urinary catheter will affect to quality of life of patients such as physical, psychological, socio cultural, environmental and spiritual aspects. objective: the aims of this study was to describe how the fulfillment of safety and comfort needs in urinary catheter patients. method: this study used literature review. the database were pubmed, google scholar and proquest. the search was restricted to english language articles and limited to last 5 years (2014-2019). articles should be related to research. this study use main keywords experience and “urinary catheter*”. only fourteen journals met the eligbility criteria and were review by two researchers. result: the results of article that urinary catheter impact on several aspect of patients such as social aspect patient have limited social interaction, and difficult to adaptation. in psychological aspect, patient feel embarrassed, dissatisfaction, frustation, anxiety, and low self esteem. in physical aspect, patient feel blocking their movement, increase the risk of infection, painful, discomfort, and iritation. in other aspect, the patient has economic problem. conclusion: the findings of articles show positive and negative impact for patient’s life when urinary catheter inserted. the review provides insight that can be useful for nurses in concerning patient’s need about safety and comfort especially patients with urinary catheters. keywords: comfort, experience, safety, urinary catheter. introduction elimination is a human basic need that can be interrupted and cause discomfort in life and activities (siregar, 2004). one of nursing actions that can be done by nurses for fullfilment of elimination need is by catheter placement (prastia, 2015). catheter is a tube, hollow, flexible tube that is inserted into the urinary tract and bladder to drain urine (sunshine coast hospital and health service, 2017). around 15-25% patients treated in the hospital recieve urinary catheter intervention while in the hospital (centers for disease control and prevention [cdc], 2015). in nhsn 2011 surveillance report, about 45-79% patients treated in critical care unit used indwelling catheters, 17% in general wards, 23% in surgical wards and 9% in rehabilitation units (nicolle, 2014). urinary catheter placement indication is urinary retention, for urine culture, inserting contrast material as radiological examination, monitoring urine production or fluid balance, http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://doi.org/10.18196/ijnp.v4i2.10243 indonesian journal of nursing practices 78 measuring urine residue. urinary catheter placement has contraindications such as urethral stricture, urethral rupture, and urinary tract infection, etc (nuari & widayati, 2017). patients are felt discomfort from urinary catheter. about 75% patients with catheter are discomfort, and a half report pain. patients many activities feel more discomfort, especially in men (wilde, 2002). discomfort often occurs when urinary catheter placement and also removal of catheter (canterbury continence forum, 2013). using urinary catheter will affect to quality of life of patients such as biological or physical, psychological, socio cultural, environmental and spiritual (fumincelli et al., 2017). in general, the effect of catheter use on life has an impact on the physical domain of patients such as patients complaining of pain, sick and discomfort (bai et al., 2015; wilde, 2002). the psychological aspect for users to make adaptation of psychologically, impact on selfesteem (someone's intimate relationship). social aspects, patients feel that something is blocking and does not enjoy do social activities, embarrassment when meet other people (mcclurg et al., 2018). patient also need safety according to basic human need of abraham maslow consists of pyhsiological need, love, self esteem, self actualization and safety (kemenkes ri, 2016). feeling safe is a form of feeling that if not controlled, it can raises of anxiety. various effort need to be implement to meet the patient’s need for safety and comfort. therefore, nurses must concerning patient’s need and patient priorities (prinjha & chapple, 2013). researchers focus on nursing articles because researchers to know and summarize patient’s need about comfort and safety for urinary catheter’s patient that are reviewed from nursing research. based on this background, researchers have not found any literature review articles that discuss specifically about fulfillment of safety and comfort needs in urinary catheter patients. only one review article (systematic review design and a qualitative metasynthesis review) that discusess the experience of urinary catheter patients inserted, especially psychososial aspects and has not discusses the patient’s need for safety and comfort. so, researchers have the desire to conduct literature review about it. method a. search method a search was carried out for articles containing the keywords “((((experience or impression or expression or fulfillment or need or satisfaction or perception)) or (convenience or comfort or ease)) or (secure or safe or calm or peace)) and (urinary catheter or urinary catheterization or urine cath or self catheterization)”. using pubmed, google scholar and proquest. the search was restricted to english language articles. articles should be original research and limited to last 5 years (2014-2019). articles should be related to research about fulfillment of safety and comfort needs in urinary catheter patients. b. extraction and data review method 1) article selection two researchers performed an inital literature screen independently. articles did not meet the search eligbility criteria were excluded. articles that meet the inclusion criteria reviewed to see the quality of the research articles. 2) evaluation of articles the findings were discussed until the researchers final selection articles. results a. search results from total database, only fourteen articles enrolled inclusion criteria. this figure 1 is article search process from identification, screening, eligbility, and include. vol. 4 no. 2 december 2020 79 figure 1. article search process. b. patient’s experience this literature review focuses on patient’s need about safety and comfort especially patients with urinary catheters. the studies were heterogeneous. there were 8 quantitative studies and 6 qualitative studies. the themes were generally similar between those using indwelling and intermitten catheter. there are several categories found in the finding articles such as in physical aspect, psychological aspect, social aspect and other aspect. in physical aspect, patient feel blocking their movement, increase the risk of infection, painful, discomfort, and iritation. in psychological aspect, patient feel embarrassed, dissatisfaction, frustation, anxiety, and low self esteem. in social aspect, patient have limited social interaction, and difficult to adaptation. in other aspect, the patient has economic problem. two articles discuss how the patient’s experiences based on the type of urinary catheter and patient’s reason using catheter. the result show the patient’s reason using urinary catheter are urinary retention, post stroke or trauma, incontinence, and post urology surgery (darbyshire et al., 2016; laan et al., 2019). the details of these studies are presented in table 1. patients say using urinary catheter feel embarrassed, discomfort, painful, unfree, blocking their movement (darbyshire et al., 2016; laan et al., 2019; trautner et al., 2019). this in supported by research from safdar et al., (2016). articles are valued by abstract (n=62) articles selected by inclusion criteria (n=25) identification screening eligbility include articles identified through the search (n= 12.642) a. pubmed : 1.499 b. google scholar : 6.190 c. proquest :4.953 articles were excluded by title (12.400 articles) a. not related to nursing b. not match with topic (safety and comfort needs in urinary catheter patients) a. duplicate data b. journals cannot be accessed in full text, only abstract c. abstract does not match (n=37) the literature which we used for literature review (n=14) exluded by full text (n=11) indonesian journal of nursing practices 80 patients also feel with urinary catheter will increase the risk of infection. with insertion of foley catheter, patient feel dissatisfaction, barriers to social interaction, frustation and pain (gidaszewski et al., 2018; kandadai et al., 2016). other hand, some patients feel comfortable with urinary catheter because they have difficulty urinating (cobussenboekhorst et al., 2016; trautner et al., 2019). some patients have intermittent catheterization this that it is scary and painful. but it did not turn out as thought (cobussenboekhorst et al., 2016). according to logan (2017) that when inserting, 81% feel pain, 59% describe more comfortable, while 70% said it was comfortable when catheter was removed. according to logan (2015), 93% had no pain during catheter placement, 93% had no pain when removing, 86% rarely or never experience discomfort. compared with male patients, women report greater comfort when use urinary catheter (hu et al., 2019). on the other hand, respondent assume that they do not need to go to bathroom to urinate (safdar et al., 2016). patients prefer suprapubic catheter than urethral catheter (chapple et al., 2015). that is supported by fowler et al (2014), female patients feel urethral catheter cause discomfort when sitting so they turn to suprapubic catheter. single use catheter (suc) is more convenient than multiple use catheter (muc). but patients who have stoma in abdomen are more comfortable using muc than suc (park et al., 2017). patients have experienced infections when this catheter is inserted, such as fever, pain, fatigue, spasms in the leg area so they have to go back and forth to the hospital. initially, some patients said they were afraid the first time they would undergo the catheterization process. the catheter insertion process scared her because there were several catheter products that were stiff so that when the catheter was inserted it caused blood to flow in the urethra. with a community, patients feel more open, share information with each other so that patients can share knowledge as long as they do the catheterization themselves and how the catheter is processed. patients can travel to places they want to go (goldstine et al., 2019). all patients said their level of activity was disturbed (atakro et al., 2017). the patient said it was uncomfortable and painful with this catheter inserted. the patient says that his sexual life is limited. patients feel that their sexual activities are impeded by the presence of a catheter. the patient also tries to hide the catheter from his partner. with the catheter in place, patients reduce their social activities for fear of creating odors that can cause embarrassment. patient preferred to stay at home. in the work environment patients say the catheter has a negative effect for them. many patients experience economic hardship due to the insertion of this catheter so they have to depend on their family and partner. so that patients feel that this catater makes the role of patients seeking money obstructed. even though the patient is elderly, the patient says that he wants to work. discussion a. types of catheter single use catheter (suc) is more convenient than multiple use catheter (muc). but patients who have stoma in abdomen are more comfortable using muc than suc (park et al., 2017). patients reported that spc (suprapubic catheter) more comfortable than urehtral catheter. usually, urethral is first choice in necessary. suprapubic catheter low of risk of infection, more hygienic, comfort, increase of self image, good sexual relation (chapple et al., 2015). kandadai et al (2016) explain that catheter with valve (vc) and foley catheter (fc) users report that it has similar catheter related pain. b. physical aspect patients have experienced infections when the catheter inserted. patients with urinary vol. 4 no. 2 december 2020 81 catheter feel discomfort, painful, unfree, blocking their movement. the patient also said that it was difficult to determine the position of the catheter or urine bag because of the fear of falling. the patient thinks that the urinary catheter is addictive and this makes the patient obstructed in physical activity (jaquet et al., 2009). for men, pain during sexual activity is because something sticks to the penis area. for female, catheter moves during activity, so it causes friction in genitalia and make sore (wilde, 2002). in contrast, respondent assume that they do not need to go to bathroom to urinate. the patient does not experience pain, especially the patient feels safe at night (ramm & kane, 2011). patients feel free because their urinary problems are resolved. urinary catheter is advantageous for patients in need of elimination (physiological) (nyman et al., 2013). c. psychological aspect patients fear for first time and when the catheter was inserted it caused blood to flow in the urethra, so it increases the patient’s fear. patient also feel dissatisfaction, frustation, and anxiety. anxiety happened when the urinary catheter leaks so that the patient does not feel free (kelly et al., 2014). the patient says that his sexual life is limited. patients say their sexual activity is impaired, so it make the patient's self-esteem decreased. some patients say sex is very important and the catheter really affects it. when inserting a catheter, the opposite sex makes the patient uncomfortable because it shows the intimate part (nyman et al., 2013). catheter affects selfesteem, loss of confidence in sexual activity. the disease can causes disability, loss of bladder muscle strength, disturbances in urination and sexual activity (chapple et al., 2014). patient also tries to hide the catheter from his partner. so that when the partner finds out the situation the patient often quarrels with his partner. with the catheter in place, patients reduce their social activities because fear of creating odors that can cause embarrassment (chapple et al., 2015). in contrast to the study of godfrey (2008), catheters as part of life without harming their identity, remain confident, feel more relieved, and describe urinary catheters as their friends and become more satisfied, patients initially considered having a catheter inserted is bad but after some time the catheter was a gift. d. social aspect patient have barriers to social interaction. (kralik et al., 2007) said urinary catheters make patients embarrassed by their social environment. so the patient tries to hide the presence of the catheter. the patient also tries not to tell his friends and neighbors about the existing catheter. the patient said that as long as the catheter was in place, the patient became social isolation. this is supported by shaw et al. (2008), some patients find it difficult to socialize and become obstacles to socializing. in contrast to the study of (goldstine et al., 2019), patient says there needs to be a community for people who have urinary catheters in life. with a community, patients feel more open, can share information with each other so that patients can share knowledge as long as they do the catheterization themselves and how the catheter is processed. e. other aspect in the work environment patients say the catheter has a negative effect for them. patients experience economic hardship due to the insertion of this catheter so they have to depend on their family and partner. so that patients feel that this catater makes the role of patients seeking money obstructed.some patients want to get a lot of information from their doctor regarding the catheter (logan et al., 2008). in contrast to study of (shaw et al., 2008b), in the work environment, some patients do not experience difficulties with this catheter, instead catheters help the patient. indonesian journal of nursing practices 82 table 1. data analysis matrix for articles used in literature review. autors types of catheter design sample result darbyshire et al (2016) urinary catheter (general) survey research 50 patients from 17 different ward patients feel leaking (32%), embarrassement (24%), discomfort (26%), , pain (26%), blocking their movement (24%), 8% finding their catheters restrictive. 14% felt have coped without catheter. reason for using catheter include urinary retention, post injury or post stroke, urological surgery and incontinencia urine. hu et al (2019) urinary catheter (general) survey research or study investigated 321 patients women report easier and more comfortable use of urinary catheter. laan et al (2019) urinary catheter (general) ricat-study 49 patients had urinary catheter symptoms from insertion, patients reported no symptom (75%), pain (14,6%), restriction in daily activities (31,3%). statements from urinary patients feel satisfied (63,8%), no symptom (50%), rather have no urinary catheter (65,2%). it’s no difference in outcomes of statements and symptoms between age and gender. more than half of the patients would rather have a urinary catheter for urinary incontinence. trautner et al (2019) indwelling urinary catheter descriptive analysis (part of prospective observational study) 2.819 enrolled to study. but 2.276 patients with indweling urinary catheter. positive comments by patients with catheter, patient can sleep at night and sit was a relief to have the catheter. more than 80% negative comments about urinary catheter (pain, irritation, discomfort, interference with activities of daily living) because many patients mentioned the trouble were made by health care provider when insertion and removal. chapple et al (2015) long term catheter narrative interviews 36 users (men and women) some respondents said that spc (suprapubic catheter) more comfort, hygiene, better for sexual than urethral catheter.it also cause of pressure sores. patient reported symptoms show that a spc is more comfortable and better tolerated than a urethral catheter. cobussen-boekhorst et al (2016) indwelling catheter qualitative multicentre 124 inclusion criteria patients of a quantitative study with variety diagnoses. patients need take a rest, less incontinence material. pain has disappeared. before catheterization, patients thought it would be painful but it just expected. fowler et al (2014) indwelling catheter qualitative research 27 community indwelling long term catheter. 14 females (4 urethral, 10 suprapubic) and 13 males (6 urethral, 7 suprapubic). respondents linked indwelling catheter to physical discomfort. women particularly found the urethral catheter uncomfortable beacuse they felt they sat on it for much of the day. this was cited as one of the reasons to change suprapubic catheter. participants also reported pain when the catheter blocked. logan (2015) intermitten catheter survey research 99 male when removing the urinary catheter, 93% patients no pain. when removing the catheter ,93% experience no pain. after catheterization, 86% rarely experienced discomfort. logan (2017) intermitten catheter survey research 49 participants were recruited. 9 were not new to isc. 81% participants did not feel pain when inserting catheter, describe comfortable (59%) and discomfort (27%). 70% vol. 4 no. 2 december 2020 83 participants were no discomfort after catheter removed. comparing the result , felame patients had discomfort than men when insertion of catheter and remove it. safdar et al (2016) indwelling catheter qualitative study 20 patients with indwelling urinary catheter (9 men, 11 women) 30% patients reported indwelling catheter increase of infection. 25% patients get limitation to mobility, patients also feel pain and discomfort. but other hand, 45% patients reported that catheter more comfortable because they did not to go to bathroom in the night and not to get up. (goldstine et al., 2019) intermitten catheter qualitative study 25 adult patient, ≥18 years old patients have experienced infections when this catheter is inserted, such as fever, pain, fatigue, spasms in the leg area so they have to go back and forth to the hospital. patients say catheters are very helpful to them and more practical. initially, some patients said they were afraid the first time they would undergo the catheterization process. the catheter insertion process scared her because there were several catheter products that were stiff so that when the catheter was inserted it caused blood to flow in the urethra. with a community, patients feel more open, share information with each other so that patients can share knowledge as long as they do the catheterization themselves and how the catheter is processed. patients can travel to places they want to go. (atakro et al., 2017) indwelling catheter qualitative 19 patients (men) were interviewed all patients said their level of activity was disturbed. the patient said it was uncomfortable and painful with this catheter inserted. the patient says that his sexual life is limited. the patient also tries to hide the catheter. with the catheter in place, patients reduce their social activities for fear of creating odors that can cause embarrassment. in the work environment patients say the catheter has a negative effect for them. many patients experience economic hardship due to the insertion of this catheter so they have to depend on their family and partner. so that patients feel that this catater makes the role of patients seeking money obstructed. even though the patient is elderly, the patient says that he wants to work. park et al (2017) intermitten catheter survey research 45 pediatric patients who underwent cic for neurogenic bladder. result that patients in all group, gave higher scores in favor of suc (ease of use, convenience, discreetness, symptomatic benefit), even though they may or may not significant. single use catheter (suc) is more convenient than multiple use catheter (muc). but patients who have stoma in abdomen are more comfortable using muc than suc. kandadai et al (2016) foley catheter and valve catheter rct 49 subjects. 24 use foley catheter and 25 valve catheter. catheter with valve (vc) and foley catheter (fc) users report that it has similar catheter related pain. feeling of frustation and limited social activities have significant results. indonesian journal of nursing practices 84 conclussion conclussion of this literature review show that patients feel shy when using urinary catheter, discomfort, painful, unfree, and there are obstacle to their movement. it also can cause irritation, increase the risk of infection, cause dissatisfaction, disruption of social interaction, frustation when using the urinary catheter. but there are several articles found that patient feel comfort because they don’t need to go to bathroom to urinate and catheter is useful for patients. the role of nurses in providing nursing care is needed, especially handling negative experiences of patients urinary catheter inserted. so that, patient feel safe and comfort using catheter. the nurse should provide holistic care for urinary catheter patient inserted. ethical approval this research does not require ethical approval. references atakro, c. a., boni, g. s., & gross, j. (2017). socioeconomic impact of indwelling urethral catheter: the experiences of patients discharged from the volta regional hospital of ghana. 1(2), 9. canterbury continence forum. (2013). catheter care guidelines 2013. centers for disease control and prevention [cdc]. (2015). catheter-associated urinary tract infections (cauti). u.s. department of health & human services. chapple, a., prinjha, s., & feneley, r. (2015). comparing transurethral and suprapubic catheterization for long-term bladder drainage: a qualitative study of the patientsʼ perspective. journal of wound, ostomy and continence nursing, 42(2), 170–175. https://doi.org/10.1097/won.00000000 00000096. chapple, a., prinjha, s., & salisbury, h. (2014). how users of indwelling urinary catheters talk about sex and sexuality: a qualitative study. british journal of general practice, 64(623), e364–e371. https://doi.org/10.3399/bjgp14x680149 cobussen-boekhorst, h., hermeling, e., heesakkers, j., & van gaal, b. (2016). patients’ experience with intermittent catheterisation in everyday life. journal of clinical nursing, 25(9–10), 1253–1261. https://doi.org/10.1111/jocn.13146. darbyshire, d., rowbotham, d., grayson, s., taylor, j., & shackley, d. (2016). surveying patients about their experience with a urinary catheter: urinary catheter experience. international journal of urological nursing, 10(1), 14–20. https://doi.org/10.1111/ijun.12085. fowler, s., godfrey, h., fader, m., timoney, a. g., & long, a. (2014). living with a longterm, indwelling urinary catheter: catheter usersʼ experience. journal of wound, ostomy and continence nursing, 41(6), 597–603. https://doi.org/10.1097/won.00000000 00000069. fumincelli, l., mazzo, a., martins, j. c. a., henriques, f. m. d., & orlandin, l. (2017). quality of life of patients using intermittent urinary catheterization. revista latino-americana de enfermagem, 25(0). https://doi.org/10.1590/15188345.1816.2906. gidaszewski, b., khajehei, m., & mcgee, t. 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(2015). perbandingan respon nyeri pada prosedur kateterisasi urin pria dengan teknik pengolesan jelly pada kateter dan penyemprotan jelly langsung ke dalam urethra di instalasi gawat darurat rsud dr. soedarso. 12. ramm, d., & kane, r. (2011). a qualitative study exploring the emotional responses of female patients learning to perform clean intermittent self-catheterisation: cisc: the emotional response of female adults. journal of clinical nursing, 20(21–22), 3152–3162. https://doi.org/10.1111/j.13652702.2011.03779.x. safdar, n., codispoti, n., purvis, s., & knobloch, m. j. (2016). patient perspectives on indwelling urinary catheter use in the hospital. american journal of infection control, 44(3), e23–e24. indonesian journal of nursing practices 86 https://doi.org/10.1016/j.ajic.2015.10.01 1. shaw, c., logan, k., webber, i., broome, l., & samuel, s. (2008a). effect of clean intermittent self-catheterization on quality of life: a qualitative study. journal of advanced nursing, 61(6), 641–650. https://doi.org/10.1111/j.13652648.2007.04556.x. shaw, c., logan, k., webber, i., broome, l., & samuel, s. (2008b). effect of clean intermittent self-catheterization on quality of life: a qualitative study. journal of advanced nursing, 61(6), 641–650. https://doi.org/10.1111/j.13652648.2007.04556.x. sunshine coast hospital and health service. (2017). home management of your catheter. queensland government. trautner, b. w., saint, s., fowler, k. e., van, j., rosen, t., colozzi, j., chopra, v., lescinskas, e., & krein, s. l. (2019). what do patients say about their experience with urinary catheters and peripherally inserted central catheters? american journal of infection control, 47(9), 1130– 1134. https://doi.org/10.1016/j.ajic.2019.05.03 1 wilde, m. h. (2002). understanding urinary catheter problems: from the patient’s point of view. home healthcare nurse: the journal for the home care and hospice professional, 20(7), 449–455. https://doi.org/10.1097/00004045200207000-00010. vol. 6 no. 1 june 2022 57 ijnp (indonesian journal of nursing practices) vol 6 no 1 june 2022: 57-64 resti yulianti sutrisno1*, dewi rossytalia widiyastuti2, arif wahyu setyo budi1, bertha tesma wulandari3, kellyana irawati1, passakorn suanrueang3 1school of nursing, faculty of medicine and health sciences, universitas muhammadiyah yogyakarta, indonesia 2sammarie family healthcare, indonesia 3master of nursing, faculty of medicine and health sciences, universitas muhammadiyah yogyakarta, indonesia 4college of medical and health science, asia university, taiwan corresponding author: resti yulianti sutrisno email: restiyulianti@umy.ac.id patient experience in the healing process of tuberculosis: a phenomenology study article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v6i1.15662 : 01 august 2022 : 16 august 2022 : 31 august 2022 abstract background: indonesia has the third rank of the highest tuberculosis (tb) incidents globally. the complete treatment of the disease could not be more urgent. the duration of tb treatment for at least six months, and other factors can lead to depression. depression in tb patients is significantly associated with poor adherence to tb treatment, higher rates of treatment failure, and higher mortality rates. objective: exploring the experience of tuberculosis patients during the healing process related to the risk factors that cause depression in patients. method: a qualitative study with a phenomenological approach was implemented. the purposive sampling collected nine participants from five public health centers in the sleman district. they were patients with pulmonary tuberculosis who underwent treatment in the intensive or the continuous phase, presence of depression based on screening with the beck depression inventory-ii questionnaire. data were collected by conducting in-depth interviews and were analyzed using inductive content analysis. result: five themes were found as the factors causing depression in patients with pulmonary tuberculosis: a) denial of destiny, b) stigma about tuberculosis, c) comorbidities, d) no family support, and e) losing a job. conclusion: factors causing depression in tb patients involved denial of destiny, stigma about tuberculosis, comorbidities, no family support, and losing a job. health workers must provide health education, counseling, and psychotherapy communitybased intervention related to disease, stigma prevention, and family support to reduce depression to help complete treatment. keywords: depression; experience; factor; pulmonary; patient; phenomenology; tuberculosis http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/15662 vol. 6 no. 1 june 2022 58 introduction pulmonary tuberculosis (tb) is one of the global infectious diseases. an estimated 10.0 million (8.911.0 million) people suffered from tb. in 2020, indonesia was the third contributor to tb cases (8.4%) after indians (26%) and then china (8.5%). from 2017-2019 there was a significant increase in the number of new cases of tuberculosis patients from 6.4 million new cases in 2017 to 7.1 million new cases in 2019, then decreased to 5.8 million in 2020. the covid-19 pandemic has reduced new patients diagnosed worldwide, including in indonesia, which was reported in 2020. the relatively significant reduction occurred in the southeast asia and west pacific regions. the two areas combined accounted for 84% of the global decrease in new case notifications. indonesia was the second country that contributed to the reduction in the number of new cases of tuberculosis in 2019, which is 14%, with the first being india (41%) and the third being the philippines (12%), then china (8%) (world health organization, 2020) (who, 2021) this decline in cases deserves special attention because the most direct consequence of the massive decrease in the number of new patients diagnosed with tb in 2020 will be an increase in the number of people who die from tb. by 2020, the global number of deaths was officially classified as caused by tb. tb (1.3 million) in 2020 was almost double that of hiv/aids (0.68 million), and deaths from tb were more severely affected by the covid19 pandemic than hiv/aids. tb was the 13th leading cause of death worldwide and the top single infectious agent. by 2020, tb was estimated to be the second leading cause of death from a single infectious agent after covid-19 (who, 2021). the director of infectious disease prevention and control of the indonesian ministry of health said that of the estimated 824 thousand tb patients in indonesia, only 49% were found and treated, and 500 thousand people have not been treated and risk becoming a source of transmission. tb that is not appropriately treated is also a risk of disease severity and even death. deaths due to tb in indonesia reach 93,000 per year, equivalent to 11 deaths per hour (widyawati, 2022). indonesia, as a country with the third largest number of tb cases and the increasing number of deaths due to tb, is undoubtedly a serious concern from the government to overcome it with complete treatment and new issues. the duration of tb treatment for at least six months, and various factors can affect mental health to the occurrence of depression. based on a study conducted on 4903 participants in seven countries, the prevalence of depression in tb patients was 45.19%. the majority was higher in mdr-tb, 52.34% than in non-mdr-tb patients, 43.47%. depression is higher among women (51.54%) compared to men (45.25%) (duko et al., 2020). depression in tb patients is significantly associated with poor adherence to tb treatment, higher rates of treatment failure, development of antimicrobial resistance, and higher mortality rates (ugarte-gil et al., 2013) (ruiz-grosso et al., 2020). patients with depressive symptoms are likelier to have low adherence than those without depressive symptoms (yan et al., 2018). therefore, it is essential to know in-depth factors that influence depression in tuberculosis patients, especially pulmonary tuberculosis; as a result, it can be a reference for health workers, families, and the community to provide support for tuberculosis patients and not fall into depression. it will have implications for increasing drug adherence, treatment success, and the recovery of tuberculosis patients. moreover, in providing holistic nursing care, it is a philosophy that guides the care received by patients that emerges from the concepts of humanism and holism. it refers to providing care to patients based on a shared understanding of their physical, psychological, emotional, and spiritual dimensions. therefore, health does not only refer to the biological dimension but also psychological, sociological, and spiritual to achieve a harmony that goes beyond physical health (jasemi et al., 2017). patients with tuberculosis are not only seen in the biological aspect of physical complaints or due to mycobacterium tuberculosis but also in psychological aspects, including depression that can appear in patients with social, spiritual, and social risk factors. methods this research used a qualitative study with a phenomenological approach. nine participants indonesian journal of nursing practices 59 were collected using the purposive sampling technique. the inclusion criteria of this study were patients with pulmonary tuberculosis who underwent treatment in the intensive or continuous phase, depression based on screening with the beck depression inventory-ii questionnaire and could communicate well. the exclusion criteria for this study were extrapulmonary tuberculosis patients and pediatric patients. this research settings were in five public health centers in the sleman district. researchers obtained data on prospective participants based on inclusion and exclusion criteria from the nurse in charge of the tuberculosis program at five public health centers in sleman. the researcher then contacted the prospective participants to explain the research objectives and procedures. if participants agreed to the process and agreed to be involved in the study, participants were asked to sign an informed consent form and set a time for collection. thirty-four patients were willing to participate in this quantitative and qualitative study, and nine refused and were then screened using the beck depression inventory-ii questionnaire. based on the screening results, the participants included in the criteria for depression were then carried out further qualitative research. the researcher made an appointment to come to the participant’s house to collect data. in this study, nine participants were used. participants in this study were determined by whether the number had reached data saturation (data saturation) or no new data was found. data were collected by conducting in-depth interviews. the interview duration ranged from 30 minutes to 60 minutes. researchers used an interview guide with several questions. data analysis used inductive content analysis. the process of analyzing the data involved several steps, including 1) listening to the interview results, writing a transcript of the results, scanning the data, dividing the data, and organizing the data; 2) rereading the entire data set and analyzing and coding it; 3) analyzing the keywords, categories, and themes after coding; and 4) performing data analysis. this data study employed the atlas.ti program. interview transcripts were returned to participants to increase the research trust. it was done so that participants could assess how closely the transcript matched their intentions. many authors independently read the transcripts and held talks to build the conceptual framework. this research has received ethical approval from the ethics committee of the faculty of medicine and health sciences universitas muhammadiyah yogyakarta with the number 030/ep-fkikumy/i/2019. the participants also gave their written informed consent to the researchers. result the participants’ characteristics in this study can be seen in table 1. the longest time to undergo tuberculosis treatment in the intensive and continuation phases is eight months. the age range of participants is from 28 to 63 years old. participants consist of five men and four women. the participant’s education backgrounds are elementary school (2 participants), junior high school (1 participant), senior high school (4 participants), and graduate student (1 participant). (see table 1) five themes were obtained based on in-depth interviews conducted with the respondents, which can be summarized into two themes (seen in figure 1). internal factors consist of two factors, and external factors consist of three-factor. (see figure 1) the factors that cause depression in tuberculosis patients have two themes: internal and external. there are two categories for the theme of internal factors: feelings of disappointment in god for suffering from tuberculosis and comorbidities. while on the external factors, there are three categories: stigma about tuberculosis, no family support, and losing their job. the explanation of each category is as follows. theme 1. denial of destiny (feeling disappointed in god) based on the finding, the first factor causing depression in tuberculosis patients is denial or not accepting suffering from tuberculosis. the patient feels disappointed in god for his illness, as seen from what was conveyed by the participants. vol. 6 no. 1 june 2022 60 “yes, why do i have this disease, why is it (slow voice)… i often in prayer, why is it that i am sick like this? i have a disease like this, while my descendants don’t have this kind of disease. maybe i’m afraid of destiny in my life to have a disease like this” (participant 7) “i took three medicines once, where the medicine was huge... oh my god, what kind of punishment did that come from.. lately, i’ve been through it.. yes, in the end, every day i wear the mask, i don’t dare to go out of the house, do i) (participant 3) theme 2. stigma about tuberculosis another risk factor that causes depression in tuberculosis patients is a misperception about tuberculosis, which adds to the burden on the patient’s mind. as stated by the participant from the family or the environment, he should not be close to his family. tb patients were told to stay away from their families, especially their children. then the participants would have psychological stressors leading to depression, as stated by the following participants. “in the beginning, i was confused. i couldn’t be near my child… i couldn’t be near my family, so i slept separately (while holding her baby’s feet) and didn’t want to be separated from her mother, so it felt like… oh my god... having a child, but you can’t be near your child... you can’t kiss your child... moreover this is asking for a kiss (while chuckling)... this can’t be the case, whatever it is, you often give a kiss as a gift, you can’t kiss the child... it feels... (didn’t continue the words, eyes looked teary)” (participant 3) “yeah.. if it’s for the family, you have to be careful, so don’t be too close to your wife so that it doesn’t spread like that, right ........................ …………” (participant 4) theme 3. comorbidities comorbidities are the next risk factors leading to depression for tuberculosis patients, which adds to the burden on the patient’s mind. participants said that since they were exposed to tuberculosis, they were more susceptible to other diseases, even though it was not so before, thus making their hearts more depressed (broken). it is as stated by the following participant: “i keep complaining all the time when my body is tired (while remembering) oh, the last one is different, sis, suddenly i feel tired here (pointing to the back) that’s what the diagnosis is instead of changing” (participant 3) “yes, instead, i changed it. then, after that, it dropped again... it fell in the urinary tract.. keep checking... check back and forth again, finally, it was said to be cervical cancer. wow, it was crushed.. oh allah, ya robbi.. what do you want, the disease that tb has not finished yet there is another disease.. this one has no cure, i thought, it was crushed at that time (participant 5) theme 4. no family support the absence of family support can be a stressor that causes the patient to become depressed. her husband left a participant to return to his parent’s house when he was sick, indicating a lack of family support. “.. now he doesn’t live here... he used to live at his parents’ house while i was sick. as long as i was sick... he said he didn’t want to be a bother. in the end, when he was here, he never did anything… i mean if i want to eat, so i can’t... finally he goes to his parents first... but when the evening comes back here after maghrib or isha, then, at 10 pm or 11 pm he comes home again... but at least, it just once a week or two weeks hehe (laughing small)....” (participant 2) theme 5. losing a job due to tuberculosis, participants may lose their job, which becomes a stressor leading to depression, as stated by the following participants. “well, yes.. there is.. i can’t work, i can’t do anything.. i’m just sleeping like this (answered with a slightly raised tone)” (participant 1) “i stopped working, and now my son is working”(participant 2) discussion depression in tuberculosis patients can worsen the disease because it causes them to drop out of indonesian journal of nursing practices 61 treatment, leading to complications and even death. risk factors for depression in infectious diseases such as tuberculosis can be seen from various aspects, especially with the capacity of humans as bio, psycho, socio, spiritual, and cultural beings. on the natural element, previous studies have shown that patients with chronic inflammatory diseases and depression have reduced tryptophan (trp) circulating levels and increased metabolites of the enzyme indoleamine 2,3-dioxygenase (ido), such as kynurenine. ido is a rate-limiting enzyme in the trp kynurenine pathway. it converts trp, a serotonin precursor, to kynurenine resulting in reduced serotonin synthesis. pro-inflammatory cytokines such as ifn-g and tnf-a regulate ido expression and activate the kynurenine pathway. it reduces central serotonin levels. a decrease in serotonin synthesis may explain the development of depressive symptoms (chandra et al., 2019). besides the biological aspects of the disease itself, comorbidities in patients can be a risk factor for depression in tb patients. the participants stated that the comorbidities added to the burden on their minds. other diseases will likely appear when the patient suffers from tb, even though the tb has not been cured. psychological stress further strengthens the risk factors for depression in tb patients. in addition, the stigma of tb patients further adds to the patient’s psychological pressure. patients are increasingly sad when they are not allowed to be near their children and families. a study in southern ethiopia found that patients who experienced tb stigma were about 11 times more likely to experience depression than their counterparts (duko et al., 2015). previous studies have shown that perceived stigma is strongly associated with depression. the prevalence of stigma felt by patients with pulmonary tuberculosis reached 57.1%. stigma is also closely related to feelings of stress and tends to trigger depression (mohammedhussein et al., 2020). people with chronic illness and a sense of stigmatization may have a low self-image and social isolation, which can predispose them to depression (perlick et al., 2001). social factors also increase the burden on tuberculosis patients, becoming a risk factor for depression. tuberculosis affects the patients’ daily abilities, making them unproductive. tuberculosis causes patients to lie down, so they cannot work like healthy individuals. the participants said that their children had to replace them to work. this condition, where the patient cannot work nor cannot provide for his family’s needs, becomes a stressor for the patient and will cause depression. previous studies revealed that in eastern ethiopia, the case and control group in a study of patients with multi-drug resistance tuberculosis (mdr-tb) had quit their jobs due to physical exhaustion (roba et al., 2018). the function of social roles is disrupted and causes them to experience severe financial challenges. low-income and financial patients have an increased risk of anxiety symptoms (wang et al., 2018). this disorder will psychologically make the patient depressed, ultimately affecting the quality of life for a long time (kastien-hilka et al., 2017). the quality of life becomes poor, mainly due to depression and other psychological stresses that can interfere with the immune system response of tuberculosis sufferers, impacting anti-tb medication adherence and, in the worst case leading to death (duko et al., 2015). another social factor that causes depression in tuberculosis patients is the absence of family support. participants who get lousy behavior from their families feel more burdened in undergoing treatment. the impact of lack of support from the family causes participants to feel uncared for by their families when they are sick. they will have low spirits in undergoing the disease and its treatment. a study in southern ethiopia showed that poor social support is significantly associated with depression (duko et al., 2015). lack of (imperfect) social support and somatic illness can lead to increased psychological distress. on the other hand, good social support is essential for those with good health in depression prevention (bøen et al., 2010). positive social support from the surrounding environment, such as family, colleagues, and the community, tends to give patients a better quality of life (zarova et al., 2018). tuberculosis patients who do not get family support also suffer from changes in family behavior towards them. one of these behavioral changes is the family’s attitude away from the patient. as described above, patients with poor social support risk feeling alienated and isolated from the environment, manifested by the family’s refusal to vol. 6 no. 1 june 2022 62 share equipment and food with the patient (tadesse, 2016). this condition can also trigger depression. this avoidance behavior is social discrimination against people with tuberculosis. datiko et al.found severe discrimination with shunned manifestations, explaining that tuberculosis sufferers in ethiopia are often experienced not only in the home environment but in all work and society activities. they may suffer from diseases easily transmitted through air droplets (datiko et al., 2020a, 2020b). another factor is spiritual factors. generally, patients cannot accept reality and feel disappointed with god’s destiny because of the disease. a study in ghana reported that denial behavior was manifested by feelings of hopelessness and worry about symptoms and the long duration of treatment (gyimah & dako-gyeke, 2019). tuberculosis patients often feel stressed and pressured to come to treatment facilities. febi et al. in india reported that about 24% of patients experienced anxiety symptoms at the beginning of their diagnosis of tuberculosis, accounting for 20.9% of patients experiencing depression. anxiety was common among people with tuberculosis and negatively impacted the patient’s quality of life (febi et al., 2021). conclusion the study found five categories causing depression in tuberculosis patients. the feelings of disappointment and rejection by god, because they were diagnosed with tuberculosis and comorbidities are the trigger factors for depression. in addition, the absence of family support, the stigma for patients with tuberculosis, and losing a job may have led to depression in patients with pulmonary tuberculosis. health workers need to provide 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(2019). perspectives on tb patients’ care and support: a qualitative study conducted in accra metropolis, ghana. globalization and health, 15(1). https://doi.org/10.1186/s12992-0190459-9 jasemi, m., valizadeh, l., zamanzadeh, v., & keogh, b. (2017). a concept analysis of holistic care by hybrid model. indian journal of palliative care, 23(1), 71. https://doi.org/10.4103/0973-1075.197960 indonesian journal of nursing practices 63 kastien-hilka, t., rosenkranz, b., sinanovic, e., bennett, b., & schwenkglenks, m. (2017). health-related quality of life in south african patients with pulmonary tuberculosis. plos one, 12(4). https://doi.org/10.1371/journal.pone.01746 05 mohammedhussein, m., hajure, m., shifa, j. e., & hassen, t. a. 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(2018). tuberculosis patients are physically challenged and socially isolated: a mixed methods case-control study of health related quality of life in eastern ethiopia. plos one, 13(10). https://doi.org/10.1371/journal.pone.02046 97 ruiz-grosso, p., cachay, r., de la flor, a., schwalb, a., & ugarte-gil, c. (2020). association between tuberculosis and depression on negative outcomes of tuberculosis treatment: a systematic review and meta-analysis. plos one, 15(1). https://doi.org/10.1371/journal.pone.02274 72 tadesse, s. (2016). stigma against tuberculosis patients in addis ababa, ethiopia. plos one, 11(4). https://doi.org/10.1371/journal.pone.01529 00 ugarte-gil, c., ruiz, p., zamudio, c., canaza, l., otero, l., kruger, h., & seas, c. (2013). association of major depressive episode with negative outcomes of tuberculosis treatment. plos one, 8(7). https://doi.org/10.1371/journal.pone.00695 14 wang, y. y., wang, s. bin, ungvari, g. s., yu, x., ng, c. h., & xiang, y. t. (2018). the assessment of decision-making competence in patients with depression using the macarthur competence assessment tools: a systematic review. perspectives in psychiatric care, 54(2), 206– 211. https://doi.org/10.1111/ppc.12224 who. (2021). tuberculosis country profile 2021 indonesia. https://extranet.who.int/sree/reports?op=r eplet&name=/who_hq_reports/g2/prod/ ext/tbcountryprofile&iso2=am&outtype=h tml widyawati. (2022). tahun ini, kemenkes rencanakan skrining tbc besar-besaran. kementrian kesehatan ri. https://sehatnegeriku.kemkes.go.id/baca/rili s-media/20220322/4239560/tahun-inikemenkes-rencanakan-skrining-tbc-besarbesaran/ world health organization. (2020). global tuberculosis report 2020. http://apps.who.int/bookorders. yan, s., zhang, s., tong, y., yin, x., lu, z., & gong, y. (2018). nonadherence to antituberculosis medications: the impact of stigma and depressive symptoms. american journal of tropical medicine and hygiene, 98(1), 262– 265. https://doi.org/10.4269/ajtmh.17-0383 zarova, c., chiwaridzo, m., tadyanemhandu, c., machando, d., & dambi, j. m. (2018). the impact of social support on the health-related quality of life of adult patients with tuberculosis in harare, zimbabwe: a crosssectional survey 11 medical and health sciences 1117 public health and health services. bmc research notes, 11(1). https://doi.org/10.1186/s13104-018-3904-6 vol. 6 no. 1 june 2022 64 table 1. characteristics of participants category p1 p2 p3 p4 p5 p6 p7 p8 p9 age 50 50 39 42 40 63 43 28 50 gender m f f m m m f f m education senior high school senior high school vocational senior high school bachelor elementa ry school elementary school junior high school senior high school treatment (month) 2 5 3 4 6 2 3 8 1 figure 1. the main findings internal factor external factor • denial of destiny • comorbidities • stigma about tuberculosis • no family support • losing a job factors affecting depression in patients with pulmonary tuberculosis vol. 5 no. 2 december 2021 87 ijnp (indonesian journal of nursing practices) vol 5 no 2 december 2021: 87-96 tri wahyuni ismoyowati, ratna puspita adiyasa, stikes bethesda yakkum yogyakarta, indonesia corresponding author: tri wahyuni ismoyowati email: maya@stikesbethesda.ac.id psychoeducation strategy: acceptance and commitment therapy (act) to improve selfefficacy of stroke patients article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v5i1.10818 : 10 january 2021 : 12 august 2021 : 31 august 2021 abstract background: stroke is the most common cerebrovascular event. stroke patients often have biological, spiritual, and psychosocial changes. psychosocial problems experienced in stroke patients include problems with self-efficacy. acceptance and commitment therapy (act) is commonly used to solve psychosocial problems. objective: this study aims to determine the effect of act on the self-efficacy of stroke patients. methods: this study utilized quantitative and quasiexperimental designs without a control group. the study was conducted in a selected hospital rehabilitation unit in yogyakarta. the respondents were selected via the purposive sampling technique. the self-efficacy was assessed using the strategies used by patients to promote health (supph) questionnaires and statistically tested with the wilcoxon test. the total number of respondents of this study was 33 stroke patients. the characteristic of respondents was mostly 45 – 64 years old (72.73% ), male (57.6%) and, had a history of stroke for 1 – 6 months (39 %). result: wilcoxon test results showed a computed p-value of 0.000 on the effect of act on stroke patients’ self-efficacy; thus, the null hypothesis was rejected. in other words, act proves its effectiveness in improving stroke patients’ self-efficacy. conclusion: based on the data, this research can be concluded that act effectively improved the self-efficacy of stroke patients. the researchers recommend utilizing act as a nursing intervention for stroke patients in the hospital rehabilitation unit. keywords: act; psychoeducation; rehabilitation; stroke; selfefficacy introduction stroke is the most common cerebrovascular event. worldwide, stroke is the second most common cause of death and disability (krishnamurthi et al., 2020). world health organization (2019) stated that one in four people are in danger of stroke in their lifetime. furthermore, there are 87% of strokerelated deaths and disability-adjusted life years. 70% of strokes occur in lowand middle-income countries. the incidence has increased twice in the last four decades, including in indonesia. the data from the ministry of health of the republic of indonesia (2018) shows that the prevalence of people with stroke aged above 15 years old in indonesia increased to 10.9 percent in 2018. furthermore, most stroke patients are over 60 years old. stroke also causes disability among them. http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/9558 indonesian journal of nursing practices 88 stroke is a disease that requires a long treatment and could even cause disabilities that affect a person's physical and psychological condition. in the early stages of a stroke, a patient may experience a difficult situation in adapting to the changes in his life. these changes may affect the level of selfefficacy of these patients. a person’s behavior to maintain their health condition can be affected by their self-efficacy. according to buckworth (2017), self-efficacy is defined as someone’s belief in their capability to organize and take actions that lead to a specific expected outcome. it is an essential aspect that could influence the adoption and maintenance of health behavior, especially for people enduring illness, including stroke patients. for example, stroke patients with low self-efficacy might have difficulties believing they can maintain their daily self-care. in this case, nurses play an important role in stroke patients' rehabilitation and need to provide self-efficacy enhancing programs during their recovery program (korpershoek et al., 2011). one of the psychological therapies that the nurses could do is acceptance and commitment therapy (act). act is an empirically supported psychotherapy that can provide solutions for patients suffering from various mental and physical conditions. act can overcome pain, sadness, disappointment, illness, and anxiety (dindo et al., 2017). in addition, the purpose of act is to help patients accept their health condition and experience and make them commit to changing bad behavior to prevent further health problems (widuri, 2012). the act consists of six principles: acceptance, defusion of cognition, being fully present, value, self as a context, and committed action (ismoyowati, 2018). act already proves its effectiveness and great impact on stroke patients' social and mental problems, but few studies have discussed its relationship with selfefficacy. many other studies describe self-efficacy and act in the health care area, but the research on analyzing the effect of act on the self-efficacy of stroke patients has been rarely conducted. thus, this study aims to determine the effect of act on stroke patients’ self-efficacy. methods research design and samples a pre-post experimental study without a control group was conducted in this research. it was conducted in bethesda hospital of yogyakarta. the population of this study included 33 stroke patients, and purposive sampling technique was utilized following the inclusion criteria: 1) willing to be respondent in the study, 2) being registered as stroke patients at bethesda hospital of yogyakarta, 3) level of consciousness: compos mentis; and 4) aged 20 – 80 years old. meanwhile, the exclusion criteria of this study were: 1) patients with aphasia, 2) increased intracranial pressure, 3) low hemoglobin, 4) had spinal cord injury, 5) had a hearing problem. research instrument and data collection data collection in this study used two types of questionnaires as a research instrument. the first one was a questionnaire to identify respondents' characteristics. the second one was the strategies used by patients to promote health (supph) questionnaire created by prof. dr. ralf schwarzer to measure the stroke patients’ self-efficacy with reliability of 0.908 and validity of 0.6. this questionnaire consisted of twenty questions: reduction of stress (10 items), decisions making (3 items), and positive behaviors (7 items). the data gathering procedure started when the researcher received a permission letter from the person in charge of the research area where this study was conducted. prospective respondents who met the criteria were given informed consent. the researcher described the purpose of the study, the respondents' role, and the other ethical considerations. the ethical considerations included the respondent’s voluntary participation, explanation about the risk and benefit of the study, the right to refuse or withdraw, the guarantee of confidentiality of the information provided, and the respondent's consent. the respondents gave their consent right after agreeing to be included in this study. the next step was giving the self-efficacy questionnaire to the respondents to be answered by them. the researcher also helped the respondent who had difficulty writing down their answer. the researcher ensured that the self-efficacy questionnaire had been fully answered before implementing act. vol. 5 no. 1 june 2021 89 the term of act was three treatment sessions of about 15-20 minutes. the first session consisted of fostering mutual relationships, explaining the research procedure, demographic data collection, and identifying conditions the patient currently conformed to the 6 act principles. the second one consisted of training the respondents to focus on therapy and carry out acceptance therapy. the third session included practicing ways to cope with bad behavior, assigning personal value using the “wheel of live” diagram, encouraging the respondents to commit, and being responsible for that value. there is no limited time for the patient to practice for the third session. it depended on their condition and the problem that they experienced. after act had finished, the self-efficacy questionnaire was given to the respondents again on their next therapy schedule. all data were collected in two weeks. (see figure 1) data analysis the univariate analysis was utilized to show the distribution of frequency of respondents based on their age, gender, and history of stroke. prior to the further analysis with the wilcoxon test, the data were tested for normality, and the result showed that the self-efficacy score before and after the therapy was not normally distributed. furthermore, the data were analyzed using the wilcoxon test to determine the different self-efficacy scores before and after act intervention. ethical consideration this study was registered to the research ethics board of the health research ethics commission bethesda hospital, no. 71/kepk-rsb/v/20, published on may 2, 2020. results characteristics of respondents table 1 shows the characteristics of the respondents involved in this study. the majority of respondents were 45 – 64 years old (72,73 %). most of them were male (57.6 %) and had a history of stroke 1-6 months (39 %). (see table 1) self-efficacy distribution figure 2 shows the self-efficacy distribution before and after receiving act. before receiving act, the majority of respondents had low self-efficacy (21 respondents). in contrast, after receiving act, the majority of respondents had high self-efficacy. (see figure 2) self-efficacy differences table 2 shows the effect of act on the self-efficacy of stroke patients using the wilcoxon test. there was a significant difference in the self-efficacy of stroke patients before and after receiving act (p=0.000), indicating that act increased the selfefficacy of stroke patients. (see table 2) discussion this study showed that the majority of respondents were 45 – 64 years old (72.73 %). they were mostly male (57.6 %) and had a history of stroke 1-6 months (39 %). according to the ministry of health of the republic of indonesia (2018) data, the prevalence of stroke sufferers increases at the age of 45 years and above. based on the pathophysiology associated with the deterioration of the vascular system, it increases along with age and leads to a higher chance of having a stroke. this factor is two times higher at the age of ≥ 55 years in statistics. based on research by amoako et al. (2014), the prevalence of stroke increases in the economically active or working age group. this study explained that more than a third of patients diagnosed with stroke must stop working. it has somewhat worrying implications for the socio-economic welfare of individuals and families. furthermore, this study also showed that the majority of the respondents were male (57.6 %). the result of this study is in line with the research conducted by sianturi et al. (2018), revealing that, out of 33 respondents with stroke, 57.6% were male and 42.4% were female. according to the american heart association (2015), the number of males with stroke increased annually. it indicated that men are considered more at risk of stroke than women. other factors include lifestyles such as smoking, high blood pressure, high cholesterol, and diabetes. the majority of the respondents in this study had a stroke history of 1-6 months (39%). safruddin et al. (2018) stated a significant relationship between stroke duration and someone's cognitive function. indonesian journal of nursing practices 90 the duration of suffering from a stroke also affects a person accepting his physical condition, feeling hopeless and useless. a history of recurrent stroke is a risk factor for stroke. approximately 15% of strokes are caused by a previous stroke and only 3% from the first stroke. stroke cases occurred in men with active smokers and hypertension around 14.2%, a history of the first stroke was 6.9%, and a history of recurrent stroke in smokers was 3.3% (rambe, 2006). according to bourin (2018), stroke patients might experience several changes in terms of personality or behavior. these changes are frequent, relatively unknown and unrecognized. these disorders include attention or concentration disorders; motivation and initiative reduction; emotional lability, hypermobility; depression; anxiety; cognitive deterioration, or dementia. besides, a study conducted by stone et al. (2004) reported that some post-stroke patients had several negative personalities, such as easily feeling bored, unhappy, anxious, depressed, dissatisfied, irritable, unrealistic, angry, withdrawn, useless, and worthless. furthermore, a study conducted by west et al. (2010) concluded that the assessment of psychological distress is concentrated in the first week after stroke. the study also found that result of psychological distress assessment influences functional outcomes. as one of the personality features, self-efficacy plays an important role in eliminating bad health-related behavior in poststroke patients (torrisi et al., 2018). patients with low self-efficacy experience severe depression, starting from the first month until six months after the stroke (korpershoek et al., 2011). a previous study related to self-efficacy has been conducted by lee and young (2018), showing that high physical activity indirectly helps korean young adults be more physically active. it happened by fostering advancement on behavioral change in physical activity. in addition, williams et al. (2008) conducted research to identify the relationship between practice change, motivation and selfefficacy. their research concluded that the sense of efficacy produced a high motivation and contributed to someone’s willingness to change practice patterns to achieve expected goals. the main result of this study showed that act significantly increased stroke patients’ self-efficacy. furthermore, the researchers assumed act has successfully helped respondents accept their health condition, explore positive things in themselves and the respondent's life, and try to rebuild patient confidence to return to optimal health levels. act emphasizes the aspects of acceptance and the values believed by stroke patients, not on rejection or denial of experiences. the purpose of act intervention is as a problem solution to change bad health behaviors and replace them with good behaviors. the patients should do with full awareness and not under the intimidation of nurses (hayes et al., 2013). according to davis & maujean (2013), self-efficacy is the key factor that influences the well-being of stroke patients. those who have high self-efficacy reported a higher level of confidence and ability to undertake daily living activities, such as getting in or out of bed, dressing, taking a shower, toileting, and walking around and doing household. high selfefficacy of stroke patients are better prepared to adapt to their changing circumstances and the body’s functioning. a similar study was conducted by khashouei et al. (2016) on type ii diabetes patients using a control group. the study results indicated that act provides a significant change in self-efficacy in the intervention group. act has also been shown to increase self-efficacy 4 times in the intervention group compared to the control group of chronic renal failure (crf) patients in the hemodialysis unit (ismoyowati, 2018). moreover, according to zhang et al. (2018), act is the most researched intervention model targeting psychological flexibility. it promotes behavior that aligns with someone’s values rather than allowing the thought of events to dominate regardless of their usefulness. psychological flexibility in act consists of six big components: cognitive defusion, acceptance, self as a context, being fully present, values, and committed action. in the defusion process, the patients would be guided to develop an accurate awareness of their thought and emotions (larmar et al., 2014). in addition, snyder et al. (2011) explained that exercise defusion is addressed to reduce unpleasant personal events. defusion would also work together to accept the impact of vol. 5 no. 1 june 2021 91 nonfunctional rule-governance to allow the patients to reach their desires. acceptance is defined as someone's willingness to experience automatic and bad emotion without trying to control it either in the frequency, form or situational experienced (zhang et al., 2018). defusion and experiencing self as a context also work together to enhance patients' ability to choose to take action according to their values, discomfort experience, or other events (ruiz, 2010). moreover, hoffmann et al. (2019) identified that self-as-context is opposite to self-ascontent. self-as-context is the experience that the patients are not the content of their thoughts but the ones experiencing it. in the act, the patients also should be guided to contact the present moment. the present moment could be defined as full awareness of psychological experience and environmental events in the present (fung, 2015). these first four aspects discussed above are a kind of operational mindfulness definition (chin & hayes, 2017). furthermore, chin and hayes (2017) explained two other primary components of act, which were values and committed action. values in the act are the quality chosen by the patients about what to be and what to do. it would direct the therapist to train the patient to choose their value rather than upon values. the last, committed action, is defined as the patient's ability to develop consistent behaviors patterns. these behaviors are filled with values, not actions driven by unworkable internalized rules and schemas (fung, 2015). moreover, from an act perspective, commitment is defined as moment-tomoment decisions to build patterns of meaningful action. it is not a promise of several actions to be made in the future. furthermore, the success of act is also influenced by the process and the therapist's role as a person who helps patients develop positive values in themselves; thus, they do not only focus on reducing symptoms due to a disease (khashouei et al., 2016). moreover, elita et al. (2017) explained that a patient was not recommended to control and avoid their traumatic personal experiences because these experiences would come and go in thoughts or feelings when act was carried out. the patient would be guided to identify their values and life goals based on their personal experience and making decision to take action consistently. the patient would not be viewed as an unhelpful person, instead, a meaningful, loveable, valuable person who could give their impact to family and society (mohabbat-bahar et al., 2015). apart from being proven to increase self-efficacy, act has also shown several positive effects on health. the study conducted by suhardin et al. (2016) concluded that act affects the quality of life of cancer patients. their study found that the respondents improved optimistic feelings and increased the canter patient functional scale. the functional scale consisted of physical, role, emotional, cognitive, and social functions. in addition, the cancer patients reported reducing several symptoms after the implementation of act, such as fatigue, loss of appetite, pain, insomnia, nausea, and vomiting. act also proved its effectiveness in reducing anxiety in the previous studies. in a study conducted by hasheminasab et al. (2015), the respondents showed a clinically significant change in the severity of their anxiety disorders after experiencing 10 sessions of act. act is effective in helping patients diagnosed with anxiety disorder and shows its benefits to reduce extreme struggle with anxiety. moreover, through act, the patients would have better control of the unwanted private events. unlike the current research conducted with 3 sessions of act, this study was conducted with 10 sessions to indicate the effect of this therapy on generalized anxiety disorders. the result of a study conducted by saedy et al. (2015) is that act is also effective in lowering anxiety in participants treated with both medication and act, instead of those treated only with medication. act helps patients have better attitudes towards their thoughts and feelings related to their anxiety states. through daily practice on mindfulness, the patients would develop their ability to use control solution strategies for anxiety. reducing negative thoughts would automatically be done when the patients begin to accept the feelings and emotions. better behavior such as an effective action would be more dominant than anxious reactions (heydari et al., 2018). a study conducted by maria et al. (2020) used tbhiv patients as their respondents and found that act significantly reduces depression in the experimental group rather than in the control group where act was not implemented. they also explained that when the depressive person is willing indonesian journal of nursing practices 92 to face and undergo the consequences obtained through act, there is a change in the cognition process where appraisal of situations that cause depression is no longer seen as negative. when the appraisal changes, the depression will also decrease. in a literature review study, including 19 intervention studies in the systematic review process, salari et al. (2020) indicated that act significantly affects insomnia problems and person sleep quality. moreover, act also shows its effectiveness to promote health-related lifestyle and behavior changes (lbcs), such as weight management, physical activity, lower emotional distress, and reduction in smoking addictive problems (lillis & kendra, 2014)(maghsoudi et al., 2019)(yıldız, 2020). conclusion based on the result of this study, it can be concluded that act significantly increased the self-efficacy of stroke patients. the researchers recommend utilizing act as a complementary therapy for stroke patients in a hospital rehabilitation unit in clinical practice. for further research, a larger number of respondents should be involved, and the effect of act on other psychosocial problems of stroke patients should be identified. acknowledgments the researchers would like to show their gratitude and appreciation to “the ministry of research and technology/ national agency for research and innovation of the republic of indonesia” for funding this study. references american heart association. 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(2018). acceptance and commitment therapy for health behavior change: a contextuallydriven approach. frontiers in psychology, 8(jan), 1–6. https://doi.org/10.3389/fpsyg.2017.02350 https://doi.org/10.1186/s12883-020-01883-1 https://doi.org/10.1186/s12883-020-01883-1 https://doi.org/10.1016/s1130-8621(18)30045-7 https://doi.org/10.1016/s1130-8621(18)30045-7 https://doi.org/10.1007/bf03391779 https://doi.org/10.1136/jnnp.2004.037887 https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.07.021 https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.07.021 https://doi.org/10.1161/strokeaha.110.583351 https://doi.org/10.1161/strokeaha.110.583351 https://doi.org/10.1002/chp https://www.who.int/southeastasia/news/speeches/detail/world-stroke-day-2019 https://www.who.int/southeastasia/news/speeches/detail/world-stroke-day-2019 https://doi.org/10.1111/ppc.12482 https://doi.org/10.3389/fpsyg.2017.02350 vol. 5 no. 1 june 2021 95 figure 1. patients’ flow chart table 1. characteristics of respondents based on age, gender and history of stroke (n=33) characteristic frequency percentage (%) age 25 – 44 years old 4 12,12 45 – 64 years old 24 72,73 ≥ 65 years old 5 15,15 gender male 19 57.6 female 14 42.4 history of stroke 1-6 months 13 39 7-12 months 9 27 >1 year 11 33 primary data source (2020) stroke patients inclusion criteria respondents (n=33) implementing act analysis (n=33) self-efficacy of stroke patients (pre test) self-efficacy of stroke patients (post test) indonesian journal of nursing practices 96 figure 2. self-efficacy distribution tabel 2. the effect of act on self-efficacy of stroke patients (n = 33) variable frequency percentage (%) p-value self-efficacy at pre intervention 0,000 low 21 63,6 high 12 36,4 self-efficacy at post intervention low 4 12,1 high 29 87,9 primary data source (2020) 21 (63.6%) 4 (12.1%) 12 (36.4%) 29 (87.9%) 0 5 10 15 20 25 30 35 before act after act low high indonesian journal of nursing practices 94 ijnp (indonesian journal of nursing practices) vol 4 no 2 december 2020 : 94-103 wantonoro wantonoro1, suarse dewi2, endang koni suryaningsih1, edy suprayitno1 1universitas 'aisyiyah yogyakarta 2akper fatmawati corresponding author: wantonoro email: oneto_ns@yahoo.com physical rehabilitation outcomes in patients with dementia following hip fracture surgery: a review article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v4i2.10240 abstract background: dementia patients were reported of having high risk for hip fracture. rehabilitation programs were still being debated for this vulnerable population and the recovery outcomes in this frail elderly population are varied, thus evidenced-based outcomes for this issue are needed. objective: to investigate rehabilitation programs, especially on physical function outcomes in patients with dementia following hip fracture surgery. method: pubmed, scopus and medline (ebsco) databases were searched from january 2000 to june 2020 concerning rehabilitation intervention program in dementia patients who received hip surgical treatment. the studies included have the following criteria, (1) investigating physical outcomes of rehabilitation programs (2) randomized controlled trials (rcts) study design, (3) study involving dementia patients following hip fracture surgery (4) english full-text journal. results: six studies were included in this review. most study focused on interdisciplinary or multidisciplinary rehabilitation program. physical outcomes of rehabilitation programs seem to improve physical function, maintaining physical ability for ambulation, and decrease the risk of falls in mild or moderate dementia patients following hip fracture surgery. however, the physical function of older persons with dementia confirmed to be lower than those without dementia. conclusion: rehabilitation may show benefit for physical function in elderlywith mild or moderate dementia following hip fracture surgery, and this population needs to be included in the clinical rehabilitation program. investigating and establishing the strategies to improve outcomes for dementia population is needed for future study. keywords: rehabilitation, dementia, hip fracture, surgery, randomized controlled trials, review introduction hip fracture is increasing as the aging population trend get bigger (nations, 2020). the worldwide hip fracture incidence is expected to rise for more than 4 million (rapp et al., 2019), and projected over 50% of all hip fractures in asia on 2050 (cheung et al., 2018). hip fracture incidence increased for elderly with dementia (friedman et al., 2010; jeon et al., 2019), about 55% of hip fracture incidence was associated with dementia (tsai et al., 2014; wang et http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://doi.org/10.18196/ijnp.v4i2.10240 vol. 4 no. 2 december 2020 95 al., 2014). surgical treatment for hip fractures represents the standard of treatment (lee & elfar, 2014). however, successful surgical treatment in older persons who have hip fracture surgery often result in permanent disability and dependency (toussant & kohia, 2005). in addition, moderate dementia patients often become dependent and require long term care facilities (e.g., nursing homes care), and resulted in the longest hospital care and family’s economic burden (kim et al., 2016; maravic et al., 2005). dementia patient who require hip-fracture surgery should be carefully monitored for the initial 4-month period following the surgical treatment (wantonoro et al., 2020) studies have shown that the effectiveness of rehabilitation program for dementia patients who received hip surgical treatment is varied. rehabilitation was reported to improve the recovery following hip surgery (bandholm et al., 2018; di monaco et al., 2009) including physical function in hip fractured person with dementia status (van wyk et al., 2014). however, another studies reported that dementia patient with hip fracture were reported to have less favorable outcomes (gruber-baldini et al., 2003), and higher surgical complications (kassahun, 2018) such as infection, joint problem, and second surgery (wantonoro et al., 2020). other studies have also suggested that this vulnerable group was excluded from intensive rehabilitation programs (larsson et al., 2019; peeters et al., 2016). thus, evaluation of rehabilitation program of dementia patients following hip fracture surgery has become increasingly important. therefore, the purpose of this study was to review the rehabilitation programs, especially the physical outcomes in dementia patients following hip fracture surgery and make evidence-based conclusions. methods search strategy: pubmed, scopus, and medline (ebsco) databases were searched from january 2000 to june 2020 regarding rehabilitation approach in dementia patients following hip fracture surgery, using the following keywords: “rehabilitation” or “intervention” and “cognitive impairment” or “dementia” and “older” or “elderly” and “hip fracture” or “femoral neck fracture” or “femoral head fracture” or “sub capitals fracture” and “surgery”. the studies were included in our research if they met the following criteria (1) investigating rehabilitation interventions program (2) there were restrictions on the study design, randomized controlled trials (rcts) study design only, (3) evaluating at least physical function outcomes (4) the study included dementia patients following hip fracture surgery (5) english full-text journal. the study was registered with the international prospective register of systematic reviews (prospero) with registration number crd42020143516. article evaluation: the title of the articles was identified by two independent reviewers (w and es). abstracts and full texts of potential studies were screened to be included in this review by two independent reviewers (w and eks). one researcher (sw) checked the uncertainty concerning the inclusion of the studies. data extraction and validity assessment: the included articles were extracted using a standardized data-extraction form (table 1). newcastle–ottawa quality assessment scale for cohort studies (nos) was used for the validity assessment of the studies included (allen et al., 2012; wells ga, 2011). all studies included in this review were in a good-quality study level. strategy for data synthesis: narrative approaches adopting popay et al. (2006) were conducted, by simply describing and summarizing the main features of included studies, investigation of similarities and differences between studies, assessing the results of each study systematically and comprehensively, highlighting the important characteristics of the studies which were relevant, such as important similarities or differences (for example, in study design, populations, interventions or other elements) (popay et al., 2006) indonesian journal of nursing practices 96 pubmed, scopus, medline (ebsco) was searched (n = 384) record after duplicates were removed (n = 208) abstract was identified for review (n = 89) full text journal was assessed for eligibility (n =19) studies included (n = 6) rct study design involving dementia article was excluded based on the abstract (n =70) studies excluded (n =13) reason: review of article, letter, did not apply rct study design without dementia duplicated (n = 176) figure 1. flow diagram of the review process article was excluded based on the title (n = 119) id e n ti fi ca ti o n s cr e e n in g e li g ib il it y in cl u d e d vol. 4 no. 2 december 2020 97 table 1 studies included in the review study/authors/ye ar intervention sample size mean age, y dementia assessment follow-up outcome (huusko et al., 2000) geriatric program rehabilitation inpatient vs. usual postoperative care n = 243 (132 with cognitive problem [68 mild, 36 moderate, 28 severe]; 97 normal) control: 80 (66– 97). intervention: 80 (67–92); mmse 3rd months and 1st year discharge location; mild to moderate cognitive problem was improved to independent living. (karlsson et al., 2016) geriatric interdisciplinary home rehabilitation n = 205 (103 (50.2%); dementia: 57 (53, 3%) intervention group; 46 (46,9%) control group) intervention: 83.2 (sd 6.9) control: 82.6 (sd 6.4) mmse 3rd month and 1st year there were benefits of the rehabilitation program for older person with dementia including the increased functional performance and ambulation, and the decreased risk of falls (naglie et al., 2002) in-patient interdisciplinary vs. usual postoperative care n = 280 (205 normal cognition; 74 impaired cognition) interdisciplinary care: 83.8 (sd 6.9); usual care: 84.6 (sd 7.3) spmsq 3rd and 6th months ambulation; dementia patients were stable for ambulation or transfers (stenvall et al., 2007) multidisciplinary intervention program n =199 (135 normal: 64 cognitive problem) intervention: 82.3 (sd 6.6); control: 82.0 (sd 5.9) mmse hospitalizatio n period patients with dementia showed significantly lower fall incidence (uy et al., 2008) in-patient multidisciplinary rehabilitation program n =10 (10 impaired cognition) intervention group 83 control group: 80 spmsq 1st and 4th months barthel index and gait velocity were not significantly improved for intervention group (vidan et al., 2005) intensive multidisciplinary geriatric intervention n = 319 (241 normal cognition; 78 impaired cognition) intervention: 81.7 (sd 7.8); usual care: 82.6 (sd 7.4) goldman scale 3rd, 6th months and 1st year function; those with cognitive problem had lower improvement in function than those with intact cognitive function, however both groups showed improvement. ambulation; those with cognitive problem had lower improvement in ambulation than those with intact cognitive function, but both groups improved. spmsq=short portable mental status questionnaire; mmse = mini mental state exam; results based on the initial search of the database more than 384 articles were identified. the abstracts of the articles were reviewed, and we excluded articles which were not matched with the inclusion criteria (figure 1). finally, six studies were included in this study review. the extracted elements includeing the characteristics such as intervention approach, study objectives, dementia assessment, follow-up period, and the results/outcomes of the study were summarized (popay et al., 2006) in table 1. cognitive impairment: cognitive impairment included in the studies were assessed using three types of instruments (see table 1). the mini mental state examination (mmse) was used in three studies (huusko et al., 2000; karlsson et al., 2016; stenvall et al., 2007), two studies were assessed using the short portable mental status questionnaire (spmsq) (naglie et al., 2002; uy et al., 2008) and one study used goldman scale to measure elderlycognitive impairment condition (vidan et al., 2005). five studies were included both with and without cognitive problem in their study. (huusko et al., 2000; karlsson et al., 2016; naglie et al., 2002; stenvall et al., 2007; vidan et al., 2005). there was only one study having all participants with cognitive problem (uy et al., 2008) interventions: interdisciplinary intervention (karlsson et al., 2016; naglie et al., 2002) and multidisciplinary intervention care program (stenvall et al., 2007; uy et al., 2008; vidan et al., indonesian journal of nursing practices 98 2005) are the most used types of intervention for elderly who have cognitive problem and received hip fracture surgical treatment which were used in the included studies, however the detail of the types of interventions were not well described. the geriatric team consisted of geriatrician internist, nurses, social worker, neuropsychologist, occupational therapist, and physiotherapists. the interventions performed includes providing advice, physical training, listening to the patients, drug treatment, physiotherapy, occupational, speech therapy, helping with use of assistive equipment, and daily living aids (huusko et al., 2000). the rehabilitation was individually designed according to the participant’s own goals (karlsson et al., 2016). the two studies included used interdisciplinary intervention program (karlsson et al., 2016; naglie et al., 2002) and another three studies included used multidisciplinary intervention care program (stenvall et al., 2007; uy et al., 2008; vidan et al., 2005), and one of the study used geriatric rehabilitation program without stating the interdisciplinary intervention or multidisciplinary intervention care program (huusko et al., 2000). home based rehabilitation (karlsson et al., 2016) and hospital setting (huusko et al., 2000; stenvall et al., 2007) confirmed as the place of the rehabilitation. study sample size was from 10 respondents (uy et al., 2008) to 132 respondents (huusko et al., 2000). elderly means someone aged between 80 years old (huusko et al., 2000) and 84.6 years old (naglie et al., 2002) in this included review study. the study follow-up period was varied among studies between hospitalization period (stenvall et al., 2007) and one year of follow-up (karlsson et al., 2016; vidan et al., 2005). intervention program outcomes: generally, the included studies informed that there were benefits of both interdisciplinary intervention and multidisciplinary intervention care program for elderly with cognitive problem and received hip fracture surgical treatment such us patients with mild to moderate dementia recovered the ability of activity of daily living, decrease the length of hospital stay (huusko et al., 2000), improved functional recovery and ambulation, and decreased risk of falls (karlsson et al., 2016; naglie et al., 2002; stenvall et al., 2007), and the studies confirmed those with dementia showed lower improvement in physical function than those without dementia, but both groups improved in functional and ambulation performance (vidan et al., 2005); it indicated that the programs improved the physical function of older persons with dementia problem and it also means that the intervention program had benefit for this vulnerable population, including older person with mild to moderate cognitive problem (huusko et al., 2000). however, one study (which solely included the cognitive problem in the sample) informed that there was non-significant improvement in gait velocity and barthel index for intensive multidisciplinary geriatric intervention compared to usual treatment (uy et al., 2008). this systematic review found the evidence of the benefit of the rehabilitation program for this population, especially in ambulation. three studies with and without cognitive impairment confirmed the interdisciplinary or multidisciplinary intervention (including geriatric team) improved the ambulation of older person who received hip surgical treatment with cognitive impaired problem (karlsson et al., 2016; naglie et al., 2002; vidan et al., 2005), and decrease the length of hospital stay resulting in the patients returned to their independent living faster (huusko et al., 2000). in addition, based on the setting of the intervention program, both hospital setting and home-based program intervention (home visit follow-up) were found to be beneficial for older person with dementia (mild to moderate) who had received hip surgery, such as improved functional recovery and ambulation, and decreased risk of falls (huusko et al., 2000; karlsson et al., 2016; stenvall et al., 2007). in addition, different types of rehabilitation and outcome measures were found. geriatric program rehabilitation of in-patient with mild to moderate cognitive problem increased the independency of daily living ability (huusko et al., 2000). geriatric interdisciplinary rehabilitation increased functional performance, ambulation or transfer also decreased the risk of falls (karlsson et al., 2016; naglie et al., 2002). multidisciplinary rehabilitation showed significantly lower fall incidence, improved physical function and ambulation (stenvall et al., 2007; uy et al., 2008; vidan et al., 2005). discussion hip fracture incidence is increasing in aging global vol. 4 no. 2 december 2020 99 population, meanwhile there is lack of evidence in optimizing the recovery through rehabilitation of hip surgical treatment among older person with cognitive problem. our review found six randomized controlled trials studies examining physical functional including subjects with some degree of dementia. however, if the studies were not homogeny in types of rehabilitation interventions program, variety of assessment tools, study settings, outcome measures, and follow-up periods, then meta-analysis could not be performed. despite this heterogeneity, however, the randomized controlled trials studies have shown that the rehabilitation program for older person with mild to moderate dementia seem to have benefit in functional performance. this review study informed that the rehabilitation program gave positive impact to this vulnerable population especially in early mobilization or ambulation. almost all of studies included, concludes that the intervention programs have benefit for older person who had received hip surgery, including older person with dementia (mild to moderate level of cognitive problem); where it shown an improvement in the ambulation. ambulation is the ability to move from place to place, with or without assistive devices with lowintensity activity, ideal for recovery condition from a surgery or other hospitalization. ambulation is very important in reducing complication (kenyon-smith et al., 2019), while delayed ambulation is associated with poor function, pneumonia and increase in the length of hospital stay (kamel et al., 2003); early mobilization would accelerate functional recovery after hospital discharge. however, the previous study stated that worse cognitive problem was a negative predictor for the success of the ambulation program (cecchi et al., 2018). all studies included in this review involved mild to moderate cognitive problem, therefore, older person with severe cognitive problem needed to be evaluated by the future studies. in addition, hospital and home-based settings were found as the setting type used in this review. it indicate that imminence action and follow-up intervention program are needed and are beneficial for this population. older person with cognitive impairment who received hip surgical treatment and received specialized inpatient multidisciplinary or interdisciplinary rehabilitation intervention showed an improved physical daily living ability and had stable condition for ambulation and transfers compared to usual postoperative treatment (allen et al., 2012; huusko et al., 2000; vidan et al., 2005). this study findings are supported by the recent review of allen et al., (2012); muir and yohanes (2009) who found that people with cognitive problem who received intensive inpatient rehabilitation after surgical treatment of a hip fracture had improvement in physical function (allen et al., 2012; muir & yohannes, 2009). another study reported, that home based exercise program (follow-up) shown an improvement in physical function (latham et al., 2014). this result proved the benefit of follow-up rehabilitation for older person with dementia problem and hip surgery after hospital discharge. we need to consider developing immediate (wantonoro et al., 2020) intervention and long term care program for this population in order to improve general physical functions. this review found only one study by uy et al., (2008) which solely focused on cognitively impaired individuals. this study compared older person with cognitive problem in the intervention group and control group and reported that the trend for improvement in barthel index and gait velocity in the intervention group compared to the control group (uy et al., 2008) was not significant. however, the numbers of sample were too small (3 respondents in intervention group and 7 respondents in control group), in this case the author decided that strong conclusion cannot be made. indeed, the study informed to develop feasible protocol to provide an interdisciplinary rehabilitation for older people with hip fracture and cognitive problem. howeverthis study implied that, there were no positive impact of interdisciplinary rehabilitation for older persons with cognitive problem following surgical hip treatment and thus no strong conclusion was made in this study (uy et al., 2008). other study reported unclear outcomes in which treatment and rehabilitation interventions achieved the best outcomes for dementia population (smith et al., 2020). then future study with randomized control trial in all cognitive problem respondents is needed to be done in order to make strong conclusion. indonesian journal of nursing practices 100 the limitations of our review; although rcts study provide the highest level of evidence, however five relevant rcts studies in this review did not onelyinclude cognitive problem in the study. they included patient with intact cognitive condition in the study, and in this case strong conclusion cannot be drawn for older person with cognitive problem. however, our review highlighted the paucity of information; the intervention program for older persons with cognitive problem following surgical hip treatment are proven to be beneficial for them. we found that most of the research focused on interdisciplinary or multidisciplinary rehabilitation of hospital and home base setting. moreover, the protocol was found to be varied among study and the detail of types interventions were not well described. this review study would help to guide further research, in specific strategy programs for older person with dementia following surgical hip treatment. conclusions this study reported the effectiveness of intervention program for older person with dementia who received hip surgery (mild to moderate dementia status). both interdisciplinary or multidisciplinary rehabilitations improved patient’s ambulation, decreased in risk of fall and finally improved physical function including the dementia patients, but the current finding is insufficient to determine the benefit for people with moderate to severe dementia with post hip fracture surgery. the best strategies between interdisciplinary and multidisciplinary outcomes cannot be concluded in this study. however, due to some benefits of the treatment, this frail population (mild to moderate dementia patients) needs to be included in the rehabilitation or intervention program. investigating and establishing the strategies to improve outcomes for dementia population are needed for future study. acknowledgment this research was supported by lppm universitas ‘aisyiyah yogyakarta, indonesia references. allen, j., koziak, a., buddingh, s., liang, j., buckingham, j., & beaupre, l. a. 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(2014). increased risk of hip fractures in patients with dementia: a nationwide populationbased study. bmc neurology, 14, 175-175. https://doi.org/10.1186/s12883-0140175-2 wantonoro, w., kuo, w. y., & shyu, y. l. (2020). changes in health-related quality of life for older persons with cognitive impairment after hip fracture surgery: a systematic review. j nurs res, 28(3), e97. https://doi.org/10.1097/jnr.00000000000 00371 wells ga, s. b., o’connell d, et al. (2011). the newcastle–ottawa scale (nos) for assessing the quality of nonrandomised studies in metaanalyses http://www.ohri.ca/programs/ clinical_epidemiology/oxford.htm https://doi.org/10.1186/s12883-014-0175-2 https://doi.org/10.1186/s12883-014-0175-2 https://doi.org/10.1097/jnr.0000000000000371 https://doi.org/10.1097/jnr.0000000000000371 http://www.ohri.ca/programs/ indonesian journal of nursing practices 24 ijnp (indonesian journal of nursing practices) vol 5 no 1 june 2021 : 24-35 sadarwati sadarwati1, warih andan puspitosari2 1rsj grhasia yogyakarta 2universitas muhammadiyah yogyakarta, indonesia corresponding author: sadarwati email: sadarwati0707@gmail.com a literatur review of common outcome in cognitive remediation for schizophrenia article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v5i1.10391 : 25 november 2020 : 25 march 2021 : 07 april 2021 abstract background: people with schizophrenia experience a change especially in the cognitive aspect, and therefore require immediate intervention to improve their cognitive and other aspects. cognitive remediation is a program that has been developed with promising results. objective: to review the literature on outcomes in general from the provision of cognitive remediation in people with schizophrenia. method: searching relevant literature on relevant databases, i.e., pubmed, ebsco, cochrane, jstor, and the google scholar search engine, using keywords: cognitive remediation, schizophrenia, therapy. result: taken from reviewing 21 relevant articles. cognitive remediation affects cognitive function, functional ability and problem-solving, social skill and cognition, clinical symptoms, neural outcome, quality of life, self-esteem, and cost-utility analysis. conclusions: common outcomes in crt (cognitive remediation therapy) administration in people with schizophrenia have been identified. improvement of cognitive function was defined to be the most commonly measured outcome in the study. keywords: cognitive remediation, schizophrenia, outcome, literature review introduction the american psychiatric association (apa) defines mental disorders as "clinically significant behavioral or psychological syndromes or patterns that occur individually and is associated with current pressure (e.g., pain symptoms) or disability (e.g., decrease in one or more important function areas) or with significantly increased risk of death, pain, disability, or significant loss of freedom." apa also mentions general criteria for diagnosing mental disorders, including dissatisfaction with one's characteristics, abilities, and achievements; unsatisfactory relationship; dissatisfaction with one's place in the world; not effectively overcome life events; and lack of personal growth. in addition, the person's behavior should not be culturally or sanctioned (videbeck, 2011). the schizophrenia spectrum and other psychotic disorders include schizophrenia, other psychotic disorders, and schizotypal (personality) disorder. they are defined by abnormalities in one or more of the following five domains: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms (birx et al., 2011). schizophrenia is a major and complex mental disorder, or disorder group, whose cause is still unknown and involves a complex set of disorders of thought, perception, influence, and http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/10391 vol. 5 no. 1 june 2021 25 social behavior (essali, 2017). schizophrenia research has shown that genetic factors have an important role in aetiology. the main conclusion is that schizophrenia is a polygenic mess. some convergent biological themes emerge. current research efforts seek to link genetic findings to clinical and biological phenotypes. understanding gene-related disease genes will help identify new targets for the detection, prevention, and treatment of schizophrenia (essali, 2017). the burden of mental illness continues to increase, resulting in a significant impact on health and social life, human rights, and the enormous economic impacts in all countries of the world (who, 2017). the provision of inadequate health care services for schizophrenic patients with suggestions is a huge economic burden (chong et al., 2016). the impact of schizophrenia is associated with predicted cognitive deficits in almost all functional domains. the literature on self-care and social function indicate that the nature of cognitive deficits depends on the level of initial cognitive deficits and the phases/stage of certain diseases (rajji et al., 2014). groups of schizophrenic patients still have a very short life expectancy because the mortality rate is very high in all age groups. the risk of suicide contributes to a shorter life expectancy (laursen et al., 2014). patients with schizophrenia have difficulty succeeding in school, obtaining or maintaining a job, having a social relationship, independent living, and even for some, taking care of their basic daily needs (rajji et al., 2014). in the world and including indonesia, mental health is still one of the most significant issues. about 35 million people worldwide are affected by depression, 60 million people are affected by bipolar disorder, 21 million are exposed to schizophrenia, and 47.5 million people have dementia (who, 2017). anti-psychotic drugs, especially new-generation anti-psychotics, have been shown to effectively reduce positive symptoms and have moderate outcomes against negative symptoms with limited outcomes for cognitive impairment and psychosocial function. in most patients, medications help control symptoms but do not restore pre-morbid function levels nor result in a good performance. drugs alone cannot be expected to improve the consequences of learning disabilities, inability to perform tasks, and social withdrawal (drake & bellack, 2005). the latest therapeutic approaches to schizophrenia include multidimensional interventions to reduce multiple power in various domains (drake & bellack, 2005). one such approach is psychiatric rehabilitation. rehabilitation is a process of refunctionalize and development to enable sufferers with disabilities capable of performing their social functions fairly in community life. psychiatric rehabilitation is aimed at improving psychological function, social function, and occupational function (drake & bellack, 2005). cognitive remediation is one form of psychiatric rehabilitation. in general, cognitive remediation or cognitive rehabilitation is a form of rehabilitation therapy used to treat individuals with brain disorders with various diagnoses, such as traumatic brain injury, stroke, and dementia. cognitive remediation aims to help people with schizophrenia develop new skills that they can apply in social, vocational, or academic situations. cognitive remediation is distinguished from cognitive behavioral therapy and cognitive therapy, which focuses on efforts to reduce psychotic symptoms (american medical association, 2006; drake & bellack, 2005). the use of remediation cognition in health services, especially in psychiatric hospitals in indonesia, is still not widely used. this is probably due to the hospital has not been exposed to cognitive remediation methods that can be applied in mental hospitals. from the above problems, the authors intend to identify outcomes that appear after cognitive remediation therapy in people with schizophrenia. method the method of the study used prisma (preferred reporting items for systematic reviews and metaanalyses). search strategy the relevant literature searches on the relevant databases are pubmed, ebsco, cochrane, jstor, and the google scholar search engine, using indonesian journal of nursing practices 26 keywords: cognitive remediation, cognitive remediation, schizophrenia, therapy, outcome. inclusion and exclusion criteria a comprehensive and thorough search for a systematic search includes the gray literature. the searching period from 2013-2017. the author limits searches to english-language articles. each article is identical after cognitive remediation is performed on all people with schizophrenia. results this review identified some outcomes posed by the provision of cognitive remediation in people with schizophrenia. a total of 21 articles are found in accordance with the topic of discussion specified by the author. most of the studies found the effect of cognitive remediation on functional outcomes, and two studies show an influence on neural outcome in people with schizophrenia after cognitive remediation. a study did not identify the outcomes of cognitive remediation because it was a study protocol for the study to be performed (see table 1). the proposed protocol will help answer whether cognitive remediation improves the functional outcomes in forensic mental health in people with schizophrenia or schizoaffective disorder (o'reilly et al., 2016). the key strength of the o'reilly protocol (2016) is offered to a group of people with nationally representative mental health forensic schizophrenia. from studying a randomized control trial, 1 study using a mixedmethod and 1 study is a systematic review. target treatment outcome major findings the findings of this review are found in cognitive remediation in people with schizophrenia are primary aspects of cognitive functions, social skills, problem-solving, social cognition, or metacognition. other findings are on the aspects of self-esteem, physical aspects, and clinical symptoms. the findings will be further explained in the discussion below. cognitive function cognitive improvement increased significantly due to cognitive remediation (tan et al., 2016), particularly in the size of processing speed, executive function and in adaptive competence as well as work skills, and verbal memory (bowie et al., 2014; puig et al., 2014; malchow et al., 2015). improved cognitive functioning occurs in the poor community function group with intrinsic motivation after cognitive remediation (bell et al., 2014). another study found that there was no difference in cognitive function after cognitive remediation (gomar et al., 2015; tan & king, 2013) (kurtz et al., 2015). acceptance and perception that cognitive improvement is due to cognitive remediation have also been found (reeder et al., 2016). cognitive remediation therapy demonstrates increased neurocognitive and cognitive functioning in processing rates, working memory, visual-spatial memory, reasoning, and overcoming cognitive domain problems (garrido et al., 2013; sánchez et al., 2014; fiszdon et al., 2016; rodewald et al., 2014; fan et al., 2016). a systematic review mentions that cognitive deficits in people with schizophrenia vary. not everyone with schizophrenia exhibits a similar cognitive deficit, and they may be different in this disorder (pentaraki et al., 2017). premorbid iq was significantly the result of post-treatment crt, and the working memory performance was significant at younger ages (17-39 years) than the older age of 40-66 years (kontis et al., 2012). social cognition and social skills people with schizophrenia who participated in cognitive remediation showed greater improvement in social skill ability than in physical exercise (tan & king, 2013), improvement in social cognition (peña et al., 2016), and significantly increased in social adjustment activities (malchow et al., 2015; fiszdon et al., 2016). but other studies have found that social skills do not improve significantly from pre and post-training (kurtz et al., 2015; bowie et al., 2014). problem-solving this study shows that the improvement of problem-solving abilities is predicted differently depending on the training program used. in the problem-solving group, people with the most disturbing schizophrenia in this domain show the strongest benefits. in contrast, in the success of basic cognition group training, improvements are vol. 5 no. 1 june 2021 27 predicted with antipsychotic administration (rodewald et al., 2014). the results of the study found that ccrt did not result in significant improvement in problem-solving with the labyrinth test (fan et al., 2017). social cognition and social skills people with schizophrenia who participated in cognitive remediation showed greater improvement in social skill ability than in physical exercise (tan & king, 2013), improvement in social cognition (peña et al., 2016), and significantly increased in social adjustment activities (malchow et al., 2015; fiszdon et al., 2016). but other studies have found that social skills do not improve significantly from pre and post-training (kurtz et al., 2015; bowie et al., 2014). problem-solving this study shows that the improvement of problem-solving abilities is predicted differently depending on the training program used. in the problem-solving group, people with the most disturbing schizophrenia in this domain show the strongest benefits. in contrast, in the success of basic cognition group training, improvements are predicted with antipsychotic administration (rodewald et al., 2014). the results of the study found that ccrt did not result in significant improvement in problem-solving with the labyrinth test (fan et al., 2017). metacognitive four people with schizophrenia who received crt experienced a significant increase in the theory of mind (tom), cognition, and metacognition after three months and one year later (thibaudeau et al., 2017), but this study determined that the crt program did not explicitly target capability social can improve tom. quality of life schizophrenic groups who received cacr (computer-assisted cognitive remediation therapy) showed significant results in their quality of life (garrido et al., 2013). participants who received cr showed that there was an outcome on the measurement of the quality of life scale (fiszdon et al., 2016). functional ability independent living scale in cognitive remediation participants increased significantly compared to physical exercise participants (tan & king, 2013), and the poor community function group who received cognitive remediation showed their results worked significantly more significantly over the number of hours worked within two years than those in the only get support workers only. but other studies have found that people with schizophrenia, after receiving cognitive remediation, do not improve in level of function and work skill (bowie et al., 2014). assessment of performance-based skills, disability assessment schedule scale of the world health organization, and global functional assessment have increased significantly after rehacop therapy (peña et al., 2016; sánchez et al., 2014; fiszdon et al., 2016). after crt is administered at the early onset of schizophrenia, the results show that participants experience improvement in everyday life and adaptive function (puig et al., 2014). physical aspects physical exercise participants experienced better physical fitness compared to participants who received cognitive remediation (tan & king, 2013). self-esteem participants of circuits reported that none experienced a decrease in self-esteem, although their cognitive feelings did not improve after therapy (reeder et al., 2016). other studies have shown participants experiencing a rise in self. neural outcome post-hoc tests show that there is a significant increase in activity in mpfc / acc in ccrt but not in the tau group. in this small sample study, computer cognitive remediation therapy was shown to increase the acc morpho (anterior cingulate cortex) activity even in resting conditions and improve cognitive function in people with schizophrenia (fan et al., 2017). one study found that crt responsiveness was associated with a baseline measure of cortical thickness in the frontal and temporal lobes. positive changes in nonverbal memory were are associated with greater initial thickness in the cortical area involving the right frontal left indonesian journal of nursing practices 28 superior, left caudal frontal, left and paracentral precuneus; frontal superior, caudal middle right frontal gyrus, and pars opercularis. in addition, unconfirmed data also suggest that verbal memory improvements may be associated with cth in some regions of the frontal and temporal lobes (penadés et al., 2016). cost analysis the cacr group showed a clear reduction in overcoming the period of acute psychiatric conditions and may help reduce the cost of health care for people with schizophrenia (garrido et al., 2017). discussion the studies showed significant improvements in cognitive performance after crt treatment. although performance on several social tests also improved in the crt, the benefits conveyed by crt were considerably greater in these instances. crt was implemented here as an alternative nonpharmacological therapy to prevent the decline in the cognitive and social function of schizophrenia patients. this indicates that these non-specific factors have a relatively significant effect on neurocognition in schizophrenia. in this review, it can be seen that most outcomes are generated by cognitive remediation on the cognitive aspect, be it the structure and function. the change in cognitive function in a study determined that there was a change in activity in the cortex even in the resting state (fan et al., 2017), as well as improvements in the verbal memory of people with schizophrenia after crt due to changes in thickness in the cortical region (penadés et al., 2016). besides the crt, cognitive outcomes also affect other aspects in people with schizophrenia, such as social function. in general, cognitive improvement is experienced after obtaining crt, but there are some studies that suggest otherwise. the result of the correlation analysis and the contradictory regression obtain the complex between cognitive and social function (tan et al., 2016). another review also determined that not everyone with schizophrenia exhibited similar cognitive deficits. younger age experienced better cognitive enhancement than older age (pentaraki et al., 2017; kontis et al., 2012). self-esteem assessment was also performed by two studies among 21 studies. the study by reeder et al. (2016) found no decrease in self-esteem, and the study by garrido et al. (2013) found increased self-esteem after therapy. not many studies have examined the outcomes of cognitive remediation of the patient's self-esteem and the duration of the outcomes after therapy (tan et al., 2016). four studies determined that both positive and negative symptoms did not differ significantly after cognitive remediation. however, three studies were suggesting that there was an improvement of negative symptoms in people with schizophrenia after cr. it was from 3 studies that had improved outcomes of negative symptoms, and two studies provided cognitive remediation combined with other therapies, i.e., social cognitive treatment, rc, and functional skill training and rehacop (peña et al., 2016; sánchez et al., 2014). improving the condition of people with schizophrenia after being given rct indirectly reduces the maintenance period of people with schizophrenia, especially when people with schizophrenia in crisis conditions can be traversed with a shorter time. the implication of this is to affect the cost or cost incurred for patient care and treatment, as determined by garrido et al. (2017). limitations to this review are newly analyzed outcomes generated after crt administration in people with schizophrenia. not yet analyzed in depth against each of the more specific outcomes. however, it is expected to provide an overview of outcomes generated by crt in people with schizophrenia. for further study, it is advisable to analyze the specific outcomes in crt administration on each characteristic of people with more homogeneous schizophrenia and further meta-analysis. conclusion the conclusion of this review is a general outcome for crt administration in people with schizophrenia has been identified. improvement of cognitive function was defined to be the most vol. 5 no. 1 june 2021 29 commonly measured outcome in the study. then a functional assessment and its effect on clinical symptoms have also been identified. several things cause differentiation of study results with assessment on the same aspect. the condition of people with schizophrenia who are not always the same to be one cause and age factor apparently affect the improvement of the condition of people with schizophrenia given crt. a combination of crt with therapy or other programs is recommended to be performed because it proves to generate a more significant outcome on the aspects assessed. self-esteem has not been much measured after being given crt, while the results in some studies are substantial. author contribution sadarwati and puspitosari contributed to the design and implementation of the research, to the analysis of the results, and to the writing of the manuscript. conflict of interest the authors declare that there is no conflict of interest. acknowledgments the authors are grateful to dr. warih andan puspitosari, sp.kj, for guidance and input on the writing of this review, as well as at the university of muhammadiyah yogyakarta that provides access to libraries either in the form of literature or library facilities online. references ama confronts the rise of nootropics | american medical association. 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(2016). group cognitive remediation therapy for chronic schizophrenia: a randomized controlled trial. neuroscience letters, 626, 106–111. https://doi.org/10.1016/j.neulet.2015.08.0 36 thibaudeau, é., cellard, c., reeder, c., wykes, t., ivers, h., maziade, m., … achim, a. m. (2017). improving theory of mind in schizophrenia by targeting cognition and metacognition with computerized cognitive remediation: a multiple case study. schizophrenia research and treatment. https://doi.org/10.1155/2017/7203871 videbeck, s. l. (2011). psychiatric–mental health nursing (fifth edit). iowa: lippincott williams & wilkins. who. (2017). mental disorders. who. retrieved from http://www.who.int/mediacentre/factshe ets/fs396/en/ https://doi.org/10.1017/s1352465815000168 https://doi.org/10.1017/s1352465815000168 https://doi.org/10.1017/s1355617714000162 https://doi.org/10.1017/s1355617714000162 https://doi.org/10.1093/schbul/sbt057 https://doi.org/10.1177/0004867413493521 https://doi.org/10.1177/0004867413493521 https://doi.org/10.1016/j.neulet.2015.08.036 https://doi.org/10.1016/j.neulet.2015.08.036 https://doi.org/10.1155/2017/7203871 http://www.who.int/mediacentre/factsheets/fs396/en/ http://www.who.int/mediacentre/factsheets/fs396/en/ indonesian journal of nursing practices 32 figure 1. prisma flow diagram vol. 5 no. 1 june 2021 33 table 1. study of cognitive remediation in people with schizophrenia no author year participants treatment( s) setting (individual/g roup) study design neural treatment outcome(s) functional treatment outcome(s) 1 jesús j. gomar et al 2015 crt: 43 participants cc: 44 participants crt group rct improvements to cognitive functions are not significant compared to the control group. 2 bhing-leet tan and robert king 2013 cr: 36 participants pe: 34 participants cr group rct outcome on physical fitness in pe is more significant living skills in cr increased significantly social skills on cr are more significant recovery of symptoms is better than pe. 3 tan s, et al 2015 crt: 52 mdt: 46 crt individual rct improved cognitive function reduction of clinical symptoms 4 bowie c.r, et al 2014 crt on early term course of illness: 12 crt on long term course of illness: 27 cr group non random ized interven tion study the early term course group improved the cognitive function more significantly 5 bell m.d, et al 2014 se & cr: 86 se: 65 rct group rct social function is increasing significantly. social skills are more significant. significant cognitive function improvements. 6 kurtz m.m, et al 2015 cr: 32 control: 32 cr individual rct cognitive function, social skills, and symptoms are not significant changes 7 thibaudea u e, et al 2017 4 participants crt circuits individual a multiple case study cognitive function tom increased significantly. metacognitive increased significantly 8 reeder c, et al 2016 34 nonclinical participants di study 1. 5 participants in study 1 dan 2. 20 participants in study 4. circuits individual mixed method s acceptability exceeds the target. positive satisfaction analysis of circuits. cognitive function increased significantly 9 fan f, et al 2017 ccrt: 14 tau: 13 ccrt group rct significant increase in activity in the medial prefrontal cortex improved cognitive function. problem-solving increased significantly. indonesian journal of nursing practices 34 (mpfc) / anterior cingulate cortex (acc) and brainstem 10 pena j, et al 2016 rehacop: 52 tau: 52 rehacop group rct significant reductions in neurocognitive, social cognitive, negative symptoms, functional disability, gaf, performance-based skills 11 penades r, et al 2016 crt: 17 sst: 18 crt individual rct the basic size of cortical thickness in the frontal and temporal lobes changes significantly 12 garrido, g., et al 2013 cacr: 38 active control group: 29 cacr individual rct significant improvements in neurocognitive, quality of life, and self-esteem 13 puig o, et al 2014 crt: 25 tau: 25 crt individual rct improved executive / cognitive function, adaptive function, and daily life. 14 sanchez p, et al 2013 rehacop: 38 control group: 54 rehacop group rct improved cognitive function, negative symptoms, disorganization and emotional distress. significant improvements to gaf and who watersheds, social skills. 15 fiszdon j.m, et al 2016 cr :50 tau: 25 cr individual rct significant changes in cognitive and functional function. 16 malchow b, et al 2015 schizophren ia endurance training:25 healthy controls endurance training:27 schizophren ia table soccer:26 endurance training combined with cognitive remediatio n group non random ized interven tion study significant changes in gaf, social cognition, and cognitive function 17 o’reilly k, et al 2016 crt tau crt individual and group clinical trials assessm ent measur e the trial is currently enrolling by invitation vol. 5 no. 1 june 2021 35 18 pentaraki a, et al 2017 crt & tau tau crt individual systema tic reviews cognitive deficits in people with schizophrenia are heterogeneous. not all people with schizophrenia show the same cognitive deficits, and they may vary through the course of the disorder 19 garrido g, et al 2017 cacr:38 active control group: 29 cacr group rct the cost of treating people with schizophrenia declines globally 20 rodewald k, et al 2014 cr cr group dan individual rct changes in working memory and manipulation decreased negative symptoms and disorganization 21 dimitris k, et al 2013 course tau: 42 crt: 92 course group rct premorbid iq significant results posttreatment. working memory performance and premorbid iq results are significant after treatment in younger, not on older patients. abbreviations: crt: cognitive remediation therapy, cc: control condition, pe: physical exercise, tau: treatment as usual, ccrt: computerized cognitive remediation training, circuits (computerized interactive remediation of cognition – a training for schizophrenia, rehacop: the efficacy of an integrative cognitive remediation program, cacr: computer-assisted cognitive remediation, course: cognitive remediation in supported employment, mdt: music and dance therapy. 4. 10391-sadarwati; bookmark_clean.pdf 4. 10391-sadarwati-lampiran_clean.pdf vol. 6 no. 2 december 2022 91 ijnp (indonesian journal of nursing practices) vol 6 no 2 december 2022: 91-99 triana indrayani1, risza choirunnisa1, orachorn lumprom2 1faculty of health science, university nasional jakarta 2faculty of nursing, prince of songkla university, karnjanavanich road corresponding author: triana indrayani email: trianaindrayani@civitas.unas.ac.id effectiveness of combining oketani and oxytocin massage on the breastmilk production article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) :10.18196/ijnp.v6i2.17213 : 17 december 2022 : 11 february 2023 : 11 february 2023 abstract background: the percentage of exclusive breastfeeding for babies aged 0-5 months was 71.58% in 2021. this figure is still below the target of 80%. meanwhile, the coverage of exclusive breastfeeding in west java was recorded at 77.00% in 2022. breastfeeding revolves around two mechanisms, namely, production and release. objective: to determine the effect of the combination of oketani massage and oxytocin massage on breastmilk production in postpartum mothers. methods: this research was conducted from july to november 2022 at the l tpmb. this study utilized a quantitative approach with a quasi-experimental design using a pre and post-test with a control design. the sample consisted of 100 respondents divided into experimental and control groups. in this case, the intervention was given to the experimental group in the form of oxytocin massage and oketani massage 1 to 2 times a day for 3 days for 3-5 minutes. meanwhile, the control group was only given oxytocin massage treatment. the instrument used in this study was the observation sheet procedure to identify the breastmilk production in postpartum mothers on day 1 and was measured again on day 7 through the smooth release of breastmilk. in addition, the instrument was made by the researcher according to standard operation procedures. the analysis used was the man whitney test. result: oketani massage could be performed as an independent and routine prophylactic intervention. conclusion: the combination of oketani massage and oxytocin massage had a significant effect on breastmilk adequacy. keywords: breast milk; oxytocin massage; oketani massage introduction breastmilk is an essential source of nutrition whose production and adequacy require more significant concern from prospective mothers. mother’s own milk is the best source of nutrition for nearly all infants (daud et al., 2020). to ensure the provision of breastmilk, the indonesian government officially enacted a regulation, namely government regulation number 33 of 2012, which contains a statement that newborns have the right to breastfeeding without the addition of other foodstuffs (excluding drugs, minerals, and vitamins) until the baby reaches the age of six months or is referred to as exclusive breastfeeding (farida & ismiakriatin, 2022). in asian countries such as india, 45% of newborns receive breastfeeding within 1 http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/17213 indonesian journal of nursing practices 92 hour of birth, and 65% of infants are exclusively breastfed for the first 6 months (afroze et al., 2021). in the philippines, the prevalence of exclusive breastfeeding in the philippines was 27%, which is much lower than the global average of 40% (ulep et al., 2021). furthermore, the exclusive breastfeeding rate of vietnam and myanmar have reached 46%, 34%, 27%, and 24%, respectively, while indonesia has reached 54.3%. according to the world health organization (who), in 2017, the average rate of exclusive breastfeeding worldwide was only around 48% (bhattacharjee et al., 2019). in this case, there are many methods for improving breastmilk internationally, such as massage (loretta et al., 2019), acupressure (hannan et al., 2023), galactagogues (asztalos & kiss, 2022), ginger (sassanarakkit et al., 2019), and fenugreek herbal tea (ravi & joseph, 2020). breastfeeding revolves around two mechanisms, namely, production and release. breastmilk production is influenced by the prolactin hormone, while the release is influenced by oxytocin (hafid, 2019). oketani massage movement and breast care are beneficial in facilitating the milk discharge reflex, increasing the volume of breast milk, and preventing accumulation in the breasts (mahdizadeh-shahri et al., 2021). oketani massage is a painless breast care method that can stimulate pectoralis muscle strength to increase milk production. it softens the breasts and makes them more elastic. it also can provide comfort and relieve pain in postpartum mothers, make the areola and nipples more elastic, and make it easier for the baby to suckle (alatalo et al., 2019). this massage makes the milk flow smoother due to pressure on the alveoli (faulkner, 2019). in reality, inadequate milk production in the first few days after giving birth hinders breastfeeding as early as possible. whereas breastmilk plays a role in cognitive, sensory, and motoric development as well as protecting against infection and chronic disease (barría, 2022). breastmilk production is influenced by hormonal factors, food intake, and maternal psychological conditions (stress) (grzeskowiak et al., 2019). research has shown that oketani massage effectively addresses breast problems such as low breastmilk supply, retention, and inverted nipples (sweet & vasilevski, 2022). the novelty of this research was combining two methods to facilitate breastmilk production. method this research was conducted from july to november 2022 at the lusiawati tangerang midwife practice center. this study utilized a quantitative approach with a quasi-experimental design using pre and post-tests with a control design. the sample consisted of 100 respondents divided into experimental and control groups. the inclusion criteria in this study were postpartum mothers on days 1-7 who were willing to be given a combination massage of oketani and oxytocin and experienced milk production problems. the intervention was given to the experimental group in the form of oxytocin massage and oketani massage 1 to 2 times a day for 3 days for 3-5 minutes, while the control group was only given oxytocin massage treatment. the instrument used in this study was the observation sheet procedure to identify the milk production in postpartum mothers on day 1 and measured again on day 7 through the baby's weight gain. the researcher adopted several breast care books and a book on oketani massage entitled breastfeeding and human lactation (karen & spencer, 2021) and oketani's breast massage therapy (usnawati et al., 2021) to compile standard operational procedures before carrying out the intervention. meanwhile, the analysis used was the man whitney test. this research passed the ethical test with number 069/ec/kepk_stikes_kendal/xi/2022. the analysis method used was the mann-whitney test. result (see table 1) based on table 1, the majority of respondents were in the age range of 20-35 years old by 76 respondents (76%) and were in the multipara category by 58 respondents (58%). (see table 2) based on table 2, the average milk production in the experimental group before treatment was 10.34 with a standard deviation of 1.697. meanwhile, after the treatment was provided, the average milk production was 3.96, with a standard deviation of 0.879. based on the results of statistical tests, a p069/ec/kepk_stikes_kendal/xi/2022 vol. 6 no. 2 december 2022 93 value of 0.000 was obtained, indicating an effect of giving oketani massage and oxytocin massage on breastmilk production. in this case, the average milk production in the control group (only received oxytocin massage) on the first day was 10.76, with a standard deviation of 1.27. on the seventh day, the average milk production was 5.18, with a standard deviation of 0.179. based on the results of statistical tests, a p-value of 0.000 was obtained, indicating an effect of giving oxytocin massage on breast milk production. (see table 3) based on table 3 using the mann-whitney statistical test, the posttest comparison of the experimental and control groups obtained a p-value of 0.000, indicating a difference in the effect of giving oketani massage and oxytocin compared to the group receiving oxytocin massage without oketani massage. discussion frequency distribution of characteristics of postpartum mothers on day 1-7 the descriptive statistic results of the means and standard deviation of breastmilk adequacy between the measurements before (pre) and after the intervention of combined oketani and oxytocin massage showed a mean difference in the pretest and posttest of the intervention groups. the age of 20-35 is the age of healthy reproduction, the optimal time for women to conceive as their reproductive organs are ready and mature (liang et al., 2021). similarly, at these ages, women are psychologically ready for the growth and development of the fetus in the womb. the age of 35 is considered a high risk for congenital abnormalities and complications during pregnancy and childbirth (zhang et al., 2020). age above 35 is associated with reduced power resistance and various common diseases. in this case, studies have found that women of ama (advanced maternal age) have an increased risk for obstetric complications and adverse perinatal outcomes, including gestational diabetes mellitus (gdm), hypertensive disorders, preeclampsia, perinatal congenital disabilities, stillbirth and preterm birth (khalil et al., 2013). in addition, the maternal age of above 35 years old was also associated with a 65% increased risk of stillbirth, with a higher relative risk at 40 years old. this risk becomes most notable after 37 weeks of gestation (corea & yoon, 2020). in addition, the effect of reduced fertility also occurs after the age of 35 years old (ann carson & n kallen, 2021). many primipara mothers experience problems with milk production on days one to 7 due to several factors, such as stress, fatigue (çankaya & ratwisch, 2020), lack of sleep (lateef & akintubosun, 2020), and inhibition of the function of the thyroid gland in producing essential hormones in the body such as estrogen and progesterone (hannan et al., 2023). this hormone imbalance further causes the decreased production of breastmilk or even being absent altogether (gonzales & v.seeman, 2019). the researcher assumed that the productive age for giving birth is widely known. when a mother is psychologically comfortable and happy, the hormone oxytocin and prolactin increase, leading to adequate and smooth breast milk production (pal et al., 2019). the effect of oketani massage and oxytocin massage on the adequacy of breastmilk before and after the intervention in the experimental group on postpartum mothers on day 1-7 based on table 2, the results showed that there was an effect of giving oketani massage and oxytocin massage on milk production. the results of the current study suggested that oketani massage had positive effects on the mother’s breastfeeding success and could improve it in different respects, including readiness to feed, root, fix (latching on), and suck (jamzuri et al., 2019). in addition, since oketani massage is based on massaging all breast muscles base and the areola, it affects blood and lymph flows. it can also reduce milk stasis in the breast without any unwanted side effects. it can even reduce the pain of breast congestion and increase breastfeeding success by stimulating the oxytocin/milk ejection reflex (dehghani et al., 2017). oketani massage also stimulates the strength of the pectoralis muscle to produce milk, making the breasts softer and more elastic and making it easier for the baby to suckle at the breast (astari & machmudah, 2019). indonesian journal of nursing practices 94 the oketani massage causes no discomfort or pain to the mother. the mother will suddenly feel general relief and comfort, and the lactation is enhanced regardless of the size or shape of the mother's breasts and nipples. furthermore, deformities such as inversion, flattening, or cracking of the nipples are rectified, and nipple injuries and mastitis are prevented (romlah & rahmi, 2019). another study conducted by foda (2014) on nursing mothers revealed that breast massage therapy could improve the quality of breastmilk and breast massage. the results showed an increase in the average weight of newborns in the intervention group and a small portion in the control group. in this case, neonatal weight gain in the breast massage oketani group was significantly higher than in the control group (harefa et al., 2020). the results showed that related to postpartum mothers on day 1-7 who received oxytocin, there is a mean difference in the pretest and posttest of control groups. oxytocin massage is spinal massage starting from the 5-6th rib to the scapula, which will accelerate the work of the parasympathetic nerves to convey commands to the hindbrain so that oxytocin is released (sulistiana et al., 2021). oxytocin massage is intended to increase the hormone oxytocin, which can calm the mother so that the breast milk will automatically come out (dağli & çelik, 2022). the mechanism of the love hormone or oxytocin is the stimulation of pressure receptors under the skin, which calms the nervous system, including reducing the stress hormone cortisol and, in turn, increasing the oxytocin (field, 2020). furthermore, regarding the effect of oxytocin massage on the adequacy of breast milk before and after in the control group in postpartum mothers on day 1-7, the results showed that there was an effect of giving oxytocin massage on milk production. another non-pharmacological application that can be used to increase the milk release of mothers in the postpartum period is oxytocin massage. oxytocin massage, which is effective in stimulating oxytocin release, is administered to mothers during lactation to increase milk release (uvnasmoberg et al., 2020). this massage can increase milk production by 11.5 times by stimulating the spinal muscles and reducing cortisol levels by 28% (helina et al., 2020). neurotransmitters stimulate the medulla oblongata and send a message to the hypothalamus to secrete posterior pituitary oxytocin. applying massage to the spinal muscles reduces tension, relieves stress, and stimulates the milk and let-down reflex (fitriani et al., 2019). a previous study, the effect of acupressure, acupuncture, and massage techniques on the symptoms of breast engorgement and increased breast milk volume in lactating mothers a systematic review, revealed that a combination of acupressure or oxytocin massage could increase milk production (hajian et al., 2021). hence, apart from oxytocin and prolactin, other local factors may be responsible for increased milk secretion, requiring further research (kumar kraleti et al., 2018). the effect of the combined oketani and oxytocin massages (fitriani et al., 2019) on breast milk adequacy before and after the massage in the experiment group and control group in postpartum mothers table 4 shows a difference in adequacy before and after the combined oketani massage in postpartum mothers massage is one of the solutions to overcoming low breast milk supply (helina et al., 2020). one type of massage, oketani massage, is a management skill to address lactation problems such as low breast milk production and breast swelling (anderson et al., 2019). oketani massage causes breasts to be soft and supple. the areola, lactiferous ducts, and nipples become more elastic. quality breast milk is produced since the total solids content, the concentration of fat, and gross energy increase (dehghani et al., 2018). the outlines that increased protein levels are caused by increased activity of protease enzymes which are stimulated by massaging the mammary tissues and glands. increased protease enzyme activity can increase protein synthesis. oketani massage can also make the mammary glands mature and broader, so more milk glands are formed, and more breast milk is produced, decreasing lipoxygenase activity (lawrence, 2022). vol. 6 no. 2 december 2022 95 oketani breast massage is a special technique practiced by japanese midwives to improve breast milk secretion and quality (roy et al., 2019). the results of research entitled the effect of oketani breast massage on successful breastfeeding, mothers' breastfeeding support need, and breastfeeding self-ecacy: a clinical trial study demonstrated that oketani massage is beneficial for increasing milk production, shortening the breastfeeding time, and can be a recommendation for mothers who gave birth by cesarean section (shahri et al., 2020). oketani-massage, compared to routine care, quickly and more efficiently reduces the severity of breast engorgement after delivery (dehghani et al., 2017). oketani breast massage significantly increases total solids, lipids, and casein content, as well as the gross energy of breast milk; thus, it improves the overall quality (rahnemaie et al., 2019). prolactin and oxytocin reflexes are also generated from the combination of oketani massage, which aims to stimulate the nerves in the posterior pituitary gland so that the hormone oxytocin is released. it can cause myoepithelial cells around the alveoli to contract (shahri et al., 2020) and push milk into the ampulla (fatrin et al., 2022). apart from being influenced by the baby's sucking, the release of oxytocin is also influenced by receptors in the ducts (monks & palanisamy, 2021). conclusion the combination of oketani massage and oxytocin massage significantly affected breast milk adequacy for postpartum mothers on day 1-7 in the experiment group and control group. postpartum mothers and families are expected to seek other information sources on how to increase breast milk production, both complementary or herbal, to provide exclusive breastfeeding to the baby. acknowledgement in conducting this research, the author 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(2020). changes in maternal age and prevalence of congenital anomalies during the enactment of china’s universal two-child policy (2013– 2017) in zhejiang province, china: an observational study. plos medicine. 17(2): e1003047 https://doi.org/10.1371/journal.pmed.1003047 https://doi.org/10.3329/bmrcb.v45i3.44644 https://doi.org/10.21203/rs.3.rs-64870/v1 https://doi.org/10.18502/kls.v6i1.8742 https://doi.org/10.1186/s13006-022-00466-9 https://doi.org/10.1186/s13006-022-00466-9 https://doi.org/10.1111/mcn.13098 https://doi.org/10.1371/journal.pmed.1003047 vol. 6 no. 2 december 2022 99 table 1. frequency distribution of the characteristics of postpartum mothers day 1-7 age total percentage (%) 20-35 76 76% 36-40 24 24% parity primipara 42 42% multipara 58 58% total 100 100% table 2. the effect of oketani massage and oxytocin massage on the adequacy of breast milk at the pre and post-massage in the experimental group on postpartum mothers day 1-7 experiment group mean std. dev p-value n pretest 10.34 1.697 0.000 50 posttest 3.96 0.879 control group pretest 10.76 1.27 0.000 50 posttest 5.18 0.719 table 3. differences in the effect of oketani massage and oxytocin massage on the adequacy of breast milk after massage between the intervention group and the control group in postpartum mothers breast milk mean rank z p-value n control 67.97 6.312 0.000 50 experiment 33.03 50 vol. 6 no. 1 june 2022 18 ijnp (indonesian journal of nursing practices) vol 6 no 1 june 2022: 18-27 siti aminah tri susila estri1*, muhammad khotibudin2 1department of dermatology and venereology, faculty of medicine and health sciences, universitas muhammadiyah yogyakarta, indonesia 2department of family medicine and public health, faculty of medicine and health sciences, universitas muhammadiyah yogyakarta, indonesia corresponding author: siti aminah tri susila estri email: aminah.satse@gmail.com incidence and management of scabies in boarding school: perception from residents article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v6i1.13355 : 10 december 2021 : 31 may 2022 : 05 june 2022 abstract background: scabies is a sarcoptes scabei infection of the human epidermis. this disease is often found in patients who live in groups, such as in boarding schools. although the risk factors, knowledge, and treatment of scabies have been known, the incidence of scabies in islamic boarding schools is still high. there is a perception that scabies is a common disease among students. scabies can interfere with the quality of life or activities of sufferers. objective: therefore, it is necessary to study the perceptions of managers and residents of boarding schools regarding the management and incidence of scabies in islamic boarding schools. methods: this research was conducted in an islamic boarding school using a qualitative method. the information was obtained from 40 participants: school leaders or managers, teachers, non-educational staff, students, and parents of students in boarding schools. information was collected using a google form, then coded and grouped based on the item. this study has been declared ethically feasible by the research ethics committee. result: the result showed that participants considered scabies a skin disease that could interfere with daily activities. it could be transmitted through direct contact, using toiletries or clothes together. school leadership policies, based on good knowledge, followed by the appropriate behavior of all school residents, had an important role in the incidence of scabies in boarding schools. conclusion: the participants had explained similar perceptions about scabies and their management in their boarding school. participants agreed that scabies could be eliminated by jointly implementing healthy lifestyle behaviors based on islamic values. the researchers suggest continuing and improving activities and management of students with scabies so that the school can be free from scabies. second, further research can be carried out in schools with a high incidence of scabies so that it can be compared and find the basic problem about why there is still a high incidence of scabies in boarding schools in indonesia. keywords: scabies; boarding school; infection; perception; risk factor http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/13355 indonesian journal of nursing practices 19 introduction scabies is still widely found in indonesian society, especially in people who live in groups. scabies is an infectious disease of sarcoptes scabei on the skin of the human epidermis. it is a human-to-human disease through direct skin contact or contact with mites. scabies can affect all races, ages, and education levels worldwide1. it is easily transmitted, so the disease is commonly found in patients who live in groups, such as in boarding schools or orphanages (engelman et al., 2020). the prevalence of scabies in the general population is 18.5% in fuji and tends to be higher in children (43.6%) (romani et al., 2015). until now, the prevalence of scabies in certain boarding schools is still high, reaching 54.7% of 53 people (hilma & ghazali, 2014) and even 85% of 52 people (tresnasari et al., 2018). in other boarding schools, it has greatly decreased, like a study in kulon progo which found the prevalence of scabies in urban and rural boarding schools of 0% and 2% with a population of 30-40 people (aminjati & estri, 2014) and 5,3% in the boarding school of kendal (ratnaningrum & avidah, 2020). various factors that influence the case of scabies are different, namely knowledge, perceptions and healthy behavior (hidayati & akrom, 2006), occupants of room density, endurance, environmental sanitation, and closeness of physical contact (chandler & fuller, 2019). complaints of itching, especially at night, in scabies can interfere with either learning activities or rest, so it can be said that this disease can interfere with the quality of life. scabies caused moderate to severe quality of life in 61% of subjects (purwanto, 2016) and 79.1% of 105 patients in brazil, with an impressive rate of 0.72 (worth et al., 2012). the management of scabies has been widely researched, namely by controlling various risk factors and appropriately administering anti-rabies drugs. treatment of permethrin 5% as an antiscabies in an appropriate way is still the first choice and is effective (gunning et al., 2019; widaty et al., 2017). although the risk factors, knowledge and treatment of scabies have been known and identified, it turns out that the case of scabies is still quite high in the population and boarding schools. managers' perceptions may influence the management of scabies in boarding schools. there is a perception that scabies is a disease that occurs among students or a harmless disease, although scabies actively interferes with the sufferer's activities (setiawan, 2018). therefore, it is necessary to re-examine the perceptions of managers and residents of a boarding school regarding the management of scabies disease. method this study used a qualitative method to determine a phenomenon of human experience. the phenomenon in this study included the incidence of scabies in boarding schools. to understand the experience of managing scabies events, this study examined the experiences of subjects who were directly involved and relatively long in boarding schools to develop certain patterns and meaningful relationships (creswell, 2017). this study has been declared ethically feasible by the research ethics committee of the faculty of medicine and health science universitas muhammadiyah yogyakarta with ethical approval number 031/ep-fkikumy/iii/2020. this study was conducted at an islamic boarding school in yogyakarta from september to october 2020. to fully understand the phenomenon of scabies incidence, information was collected from participants from all people who lived or were involved in the school's activities. the participants of this study were residents of a boarding school located in the city of yogyakarta. this boarding school was selected since the information from several parents stated that the incidence of scabies in the boarding school was not much; thus, an overview of the management of scabies disease could be obtained. the school could ensure that none of the school residents experienced scabies. the participants involved in this study were: (a) school leaders or managers; (b) implementers of education, consisting of teachers, caregivers/ musyrif, supervisors for academic or extracurricular activities, health workers, cleaning service; (c) students at grades 8 and 9; (d) parents of students. questionnaires were sent to 5 groups of participants via whatsapp, including student and parent groups. vol. 6 no. 1 june 2022 20 to find out participants' experience in managing scabies events in schools, the researchers asked various questions via google form to school residents. researchers chose to use google forms as it is simple, safe, cheap, and accessible to many people. the questions given to participants were in the form of open-ended questions (table 1.) and were distributed or given to participants by the research coordinator at the school. participants in this study were members of the whatsapp group who filled out the questionnaire within the specified time limit, appropriate to consecutive sampling. the information described by the participants was stored automatically in the google form and documentation of research data information. the filling of the questionnaire or the determination of participants was closed after the study ended, and the answers of many participants were similar. (see table 1) data were collected through a questionnaire via google form. the questions were made in the form of open-ended questions so that subjects could explain according to their respective knowledge, understanding and expectations. the insufficient information was confirmed via whatsapp messages or telephone. the information collected from the google form was grouped based on the theme or category presented by the participants. information that had been grouped was squeezed into several sentences in the form of a certain pattern or relation of meaning as a result of the analysis of this research. the validity of the data in this study could be identified from the willingness of the subject to provide information. confirmation of the results to school leaders and teachers had also been carried out, and observations were done with subjects at the research location. result characteristics of the participant this study obtained information from 40 participants consisting of 6 males and 34 females, aged 13-51 years with an average age of 30. the subjects worked as part of school residents between 1-29 years old with a mean of 4.9 years old. students and parents were limited to students in grade 8 and above and lived in the dormitory. it is to ensure that the subjects had experienced or become residents of the school for at least 1 year. the status of these subjects consisted of various parties in boarding schools, as shown in table 2. (see table 2) the case of scabies in boarding schools was caused by various factors. the results of this study indicated that all components of school members played an important role in preventing the case of scabies in schools. this study also showed the role or participation that each component could play so that scabies or other infectious diseases could be prevented. information about the school environment was not only provided by the teacher but also based on direct observation. the dormitories in islamic boarding schools were grouped based on the gender of the students. female students occupied a dormitory built by the school, with a room measuring 10x10 m2 containing 12 students. rooms contained 30-50 cm apart wooden beds, wardrobes, windows, and adequate ventilation and light. male students occupied dormitories in the form of houses around the school rented by the school. each room was filled by 4-8 students depending on the room size. the room contained a wooden bedroom with a wardrobe and books made of wood. rooms had good ventilation and lighting; some rooms were equipped with a fan. the number of bathrooms in dormitories varied, with a ratio of 1 bathroom for 10 students. the bathroom in the female dormitory was equipped with a bucket to collect water, while in the male dormitory, the bathroom was equipped with a water tub. students were required to bring their own water spoon and toiletries. perception: disease awareness the subject's knowledge and understanding of scabies factors were not yet qualified as most subjects only explained that scabies was a skin disease characterized by itching and was contagious. however, as written below, most subjects did not understand that scabies is a disease caused by certain microorganisms, namely mites. in fact, some subjects explained that scabies was an allergic disease. indonesian journal of nursing practices 21 “scabies is a disease that occurs in the skin. in general, it causes itching.” (teacher or musyrif) “scabies is an infectious disease that usually happens in the fingers, caused by lack of hygiene.” (teacher or musyrif) “scabies is a disease on the skin surface. if you are exposed to the disease, spots appear on the skin surface, the skin feels itchy, and if you scratch it, it will hurt.” (students) however, some subjects were able to explain that scabies is caused by certain mites or germs, such as the following: “skin disease is caused by mites” (parents of students) “one of the skin diseases caused by the scabies germ which is quickly transmitted” (parents of students) “scabies is an itchy and rash on the skin caused by lice mange.” (students) perception: incidence of scabies the results showed that most participants did not see any scabies in their boarding schools, but 2 out of 9 students (22,2%) claimed to have experienced scabies during the 2019/2020 school year. several factors could prevent the number of scabies cases, namely a clean environment, consistent use of personal tools, or being able to maintain good personal hygiene, as in the following statement: question: has anyone ever been scabies in the past year, as far as you know? if there is, please explain the characteristics and why he could get scabies. if not, please explain why there was no scabies incident in this school. “nothing, because children are used to maintaining cleanliness and using personal equipment” (noneducation employees) ‘nothing, because the toilet itself keeps clean” (parents of students) “nothing, because my school keeps the environment clean and no one has scabies.” (students) “nothing, because our pesantren is relatively clean” (teacher or musyrif) “i don't know. but in my opinion, cleanliness in schools, especially dormitories, needs to be improved again because there are many cats pee found.” (students) “it's been a long time....no. thank god.” (school managers) meanwhile, participants who had seen students with scabies stated that the disease was related to personal hygiene behavior or unclean air. like the statement below: “i have experienced itching on the hands, specifically between the fingers. when i saw the doctor, the doctor said it was scabies. as far as i know, no friends or teachers have been affected besides me.” (students) “there is. in direct contact, the water is not clean.” (parents of students) “it seems someone has itching, maybe because of living in the same dormitory and sometimes lack of personal hygiene. usually, the treatment by school health unit (shu) officers is by giving ointment or medicine” (teacher or musyrif) perception: scabies transmission the subjects sufficiently understood information about the transmission of scabies and explained that scabies could be transmitted through interaction, touch, or physical contact. some subjects explained that behaviors that supported the transmission of scabies are sharing personal items, such as bedding, clothes, toiletries or towels and bath water. some subjects also stated that the factors that influenced the transmission of scabies included the lack of personal hygiene or through animals. the statement below is an example. “lack of personal hygiene” (students) “from one to another, that people do not maintain healthy behavior” (parents of students) “often interact, through touching, sharing items or bathrooms that many people use,” (teacher or musyrif) “usually because of using the same water and soap,” (teacher or musyrif) “because of contamination with bacteria through skin contact with sufferers, clothing, other personal tools and water used together.” (parents of students) “through physical contact and contaminated fluids.” (school managers) vol. 6 no. 1 june 2022 22 perception and practices: disease management this pesantren had a health management system with a school health unit (shu), with 1 general practitioner and 1 dentist, who came once a week and took medical practices. however, online health consultations with doctors could be done 24 hours. if students in the dormitory were sick and needed medical examination or treatment, they would be taken to a hospital 100 meters from the school. medicines were also available in each hostel. if students in the dormitory were sick, they would be checked or confirmed by the musyrif (dormitory caretaker), given medicine, or taken to the hospital. some students had also been given medicines according to their respective health conditions. the cleanliness of the dormitory was carried out by all students with a daily cleaning picket system, both inside and outside the dormitory yard, coordinated by musyrif. the hostel's cleanliness was supported by adequate room facilities and equipment. room facilities in the dormitory included wooden bunk beds with mattresses arranged separately at 30-50 cm, a wardrobe, lamp, and fan, although it was not always available in every room. not all rooms had windows. however, other means of ventilation were available. the following is a subject statement that explains the aspects mentioned above. “dormitory health management is good; medicine boxes are provided in each room, and students can deliver medicine boxes to shu to update the contents of the box every 2 weeks. there is shu for schools but no shu for dormitories, and school shus are only open during working hours and weekdays/study times, so it is a bit difficult if there are sick students. however, the musyrif is quite quick to respond if there are students who are sick.” (students) “it is good enough, there is a janitor team to help in cleaning, and there is a picket schedule for each dormitory” (teacher or musyrif) “yes, there is a shu, a prayer room to keep the daily activities and morals of the students in the dormitory.” (students) "it has been good. in the dormitory, there is a cleaning picket schedule, a hostel cleaning competition and each dormitory is equipped with a medicine box, and there is health counseling.” (teacher or musyrif) "air circulation is quite good, the distance between the beds is not too tight, the pillow sheets and bolsters are washed regularly." (parents of students) however, there was some information that the management of health, especially environmental health, was hardly good. it is evidenced by saying there was still garbage scattered everywhere, used mattresses, or an insufficient number of clotheslines. the subject statement is as follows: “not very good, we still tend to use personal medicine. in some places, there are still piles of garbage.” (parents of students) “not very good because when i moved to the dormitory. i used mattresses from other students whom i didn’t know the history of, also for clotheslines, too little space so wet clothes are close together.” (students) perception and attitude: promotion and scabies prevention the topic in this study required policies or rules in schools to maintain environmental health and clean and healthy behavior in accordance with islamic values, current management of ill students, and guidelines that provided information or health education. these aspects are indicated in the statement below: “always keep the school environment clean, especially for children, given instructions about the importance of maintaining cleanliness. keep telling them." (non-education employees) “applying islamic values properly” (parents of students)) “students' initial orientation on hygiene and health regular health education routine cleaning schedule health and fitness counseling provide medicines and shu officers.” (teacher or musyrif) “arranging picket schedule and socializing the importance of cleanliness together” (teacher or musyrif) “hygiene management must always be improved both at the school level (school environment) and the personal level of the children. because skin diseases usually arise from a person who does not know how to keep their body clean.” (school managers) indonesian journal of nursing practices 23 discussion the result showed that there were 2 out of 9 students claimed to have experienced scabies during the 2019/2020 school year. based on data from health centers throughout indonesia in 2008, the prevalence of scabies in indonesia was 5.612.95% (ministry of health of the republic of indonesia). at the same time, the prevalence in boarding schools or islamic boarding schools varied between 5,3% (ratnaningrum & avidah, 2020), 38% (ridwan et al., 2017), 52.33% (ibadurrahmi et al., 2016), to 84,8% (mayrona et al., 2018). this study also showed that scabies was considered a skin disease, and one participant stated that scabies was a disease that usually occurred in santri or boarding school students. it is different from the results of other studies, which found that most participants said that scabies was a common disease among santri, and some students who had lived in islamic boarding schools had experienced scabies. in addition, participants thought that scabies was harmless, but the disease was disturbing the patent’s activities (setiawan, 2018). similar results were shown by lopes, who found that 92% of participants had experienced scabies symptoms. participants assumed that scabies was not a serious disease and did not cause death (lopes et al., 2020). the other research showed that scabies interfered with patients' quality of life due to complaints of itching, disturbances in sleep, study and work activities. research that examined risk factors for scabies revealed that there were 2 groups of risk factors, namely the characteristics of the host or student and the student's environment, including school leadership policies. this research involved all groups of people or communities in a boarding school: school leaders, teachers, school officials, students and parents. by involving all of these components as participants, a good picture of the perception of the incidence of scabies in the boarding school environment would be obtained. furthermore, ibadurrahmi's research revealed that the characteristics of students with the greatest relationship strength to the incidence of scabies are attitudes, knowledge, and behavior (ibadurrahmi et al., 2017). this study showed that students had good knowledge about scabies by explaining that scabies was a contagious skin disease characterized by itching and infection. most of the participants were able to explain that mites caused scabies. some participants explained that scabies was a disease that often occurred in students. it is in line with the consensus that the clinical diagnosis of scabies could be made by finding lesions in the predilection area accompanied by itching and a history of contact with scabies patients (engelman et al., 2020). a good understanding of scabies in most participants is the basis for increasing awareness and ability of the boarding school community to behave in a healthy manner (pedoman penyelenggaraan pesantren sehat, 2019). the next individual factor related to the incidence of scabies is attitudes and behavior in maintaining individual hygiene and health. attitude and behavior factors with less risk are 2.4 times greater than those with sufficient and good attitudes and behavior (ibadurrahmi et al., 2017). this study showed that most participants had good attitudes and behaviors about scabies. it is shown from the participants' explanations about the mode of transmission of scabies, caused by direct and frequent touch, or indirectly, through the use of shared items or sleeping together. this participant's knowledge was followed by daily attitudes and behavior in the dormitory, such as using their own personal items, not lending personal items to other students, and changing bed linen, pillowcases or bolsters regularly. parents supported students' hygiene behavior at this school by providing bed linen and pillowcases so that students could change them weekly. the results of this study align with the lopes research, which revealed that individual health was less associated with the incidence of scabies by 96% based on interviews with respondents in bijago (lopes et al., 2020). furthermore, environmental factors that affect the incidence of scabies are residential density, air humidity, natural lighting, temperature and room ventilation (ibadurrahmi et al., 2017). research by ibadurrahmi et al. (2017) revealed that environmental factors had a greater role or relationship strength than student characteristics. environmental factors in this boarding school that supported the least incidence of scabies included vol. 6 no. 1 june 2022 24 each student sleeping on a mattress with wooden beds separated by 30-50 cm; there were wardrobes, lights, and fans, although they were not always in every room. not all rooms had windows, but there were other means of air ventilation. it is in line with the requirements for a healthy home set by the minister of health of the republic of indonesia (ri) in 1999. the bathroom environment in boarding schools was considered good as there were bathrooms with buckets and the use of individual toiletries and a clothesline, although there was a participant who believed that the available clotheslines were still lacking. to maintain the cleanliness of the dormitory environment, the school leadership required students to carry out picket cleaning of their respective rooms and dormitories by sweeping the rooms and the dormitory environment every day. the dormitory cleaning picket activities were carried out by the students who lived in the rooms or dormitories, each of which was monitored and coordinated by the musyrif of the dormitory. it similarly happened at the walisongo islamic boarding school, pontianak (setiawan, 2017). students in the class carry out cleanliness in the classroom by taking turns. meanwhile, to maintain the cleanliness of the school environment, the school leadership assigned janitors to sweep the school grounds every day. various activities were carried out to keep the environment clean, which was the policy of the school leadership to keep the school environment clean and healthy. school leaders held cleanliness competitions between rooms in one dormitory or between dormitories in schools to increase student motivation and musyrif in maintaining the cleanliness and health of the room and dormitory environment. it was a school leadership innovation activity. setiawan's research report (2017) explained that no cleaning competition activity had been like this. other efforts made by school leaders to maintain the health of school residents were by conducting counseling, providing information or socialization about health, and providing a school health business unit (shu). besides, health counseling was carried out when students entered school orientation, and health and hygiene information was also placed in a strategic school environment. in shu, there were doctors, nurses, provision of simple examination facilities, medicines and vitamins. provision of simple medicines and vitamins was also available in each dormitory. although, there were participants who complained that the school health unit opening hours were limited to working hours. if a student were seriously ill, the musyrif or the teacher would take the ill student to the hospital closest to the school. health checks were carried out regularly. school leaders built hand washing stations with liquid soap in various school environments. most of the student participants and their parents considered the management of ill students in this boarding school quite good. some participants thought and hoped that school leaders would teach and apply islamic values in maintaining the personal health of students and the school environment. many islamic values are related to cleanliness and health, as in the letter of al mudassir verse 4, which means “and clean your clothes”, and the hadith of the prophet muhammad, which means “cleanliness is part of faith”. in islam, daily activities intended as worship to allah almighty have a very meaningful reward value for muslims. school leaders, teachers or musyrif, school cleaners and students collaborated in various activities to maintain school cleanliness and students’ health. this activity was supported by parents who had facilitated their children by providing personal tools so that student participants used personal items well, not lending to each other. the collaboration formed in boarding schools is in line with the ministry of health to realize healthy islamic boarding schools, which requires the cooperation and involvement of all parties in boarding schools or islamic boarding schools by involving health workers in the school health unit, including student as health cadres, nurses, and doctors (pedoman penyelenggaraan pesantren sehat, 2019). hulaila’s research showed that the availability of a large number of health cadres who have strong motivation to be actively involved, good skills, and a background in the health sector is necessary for the successful implementation of the boarding school health unit (hulaila et al., 2021). many studies related to scabies had examined the incidence of scabies in students but had not seen the incidence of scabies in all residents or school members, such as school leaders or administrators, teachers or dormitory assistants, or noneducational officers. likewise, the role of school members or educational institutions has not been indonesian journal of nursing practices 25 widely studied; how big is their role in preventing scabies in boarding schools or islamic schools. this study showed that all school members had a role in health management, especially in infectious diseases such as scabies. conclusion participants included students, parents, teachers and musyrif, non-educational staff and school leaders. they had good knowledge and modes of transmission of scabies. participants had similar attitudes and behaviors toward keeping boarding schools clean and healthy, so the participants who experienced scabies would not exceed. various efforts had been made jointly by all participants. school leaders made various policies that students implemented with the support of parents and supervision of teachers and musyrif. noneducational staff involved in managing school health and hygiene also carried out their duties to maintain school hygiene and health. if all of these activities are based on islamic values, then maintaining personal hygiene and health and the room environment, dormitories and schools is worth worship. all these activities made the incidence of scabies at the boarding school decrease. acknowledgement we would like to thank lp3m umy for funding the research. references aminjati, h. w., & estri, s. a. t. s. 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(2017). faktor-faktor yang berpengaruh terhadap kejadian penyakit skabies pada santri di pondok pesantren qotrun nada cipayung depok februari tahun 2016. jurnal profesi medika : jurnal kedokteran dan kesehatan, 10(1). https://doi.org/10.33533/jpm.v10i1.12 lopes, m. j., teixeira da silva, e., ca, j., gonçalves, a., rodrigues, a., manjuba, c., nakutum, j., d’alessandro, u., achan, j., logan, j., bailey, r., last, a., walker, s., & marks, m. (2020). perceptions, attitudes and practices towards scabies in communities on the bijagós islands, guinea-bissau. transactions of the royal society of tropical medicine and hygiene, 114(1), 49–56. https://doi.org/10.1093/trstmh/trz102 mayrona, c. t., subchan, p., & widodo, a. (2018). pengaruh sanitasi lingkungan terhadap prevalensi terjadinya penyakit scabies di pondok pesantren matholiul huda al kautsar kabupaten pati. diponegoro medical journal, 7(1), 100–112. https://doi.org/10.14710/dmj.v7i1.19354 pedoman penyelenggaraan pesantren sehat. (2019). kementerian kesehatan ri. vol. 6 no. 1 june 2022 26 purwanto, n. f. (2016). hubungan antara penyakit skabies dengan tingkat kualitas hidup santri di pondok pesantren al muayyad surakarta. eprints ums. ratnaningrum, k., & avidah, a. (2020). the difference in incidence of scabies between conventional and modern boarding school. mutiara medika: jurnal kedokteran dan kesehatan, 20(1): 42-44. https://doi.org/10.18196/mm.200141 ridwan, a., sahrudin, & ibrahim, k. (2017). hubungan pengetahuan, personal hygiene, dan kepadatan hunian dengan gejala penyakit skabies pada santri di pondok pesantren darul muklisin kota kendari 2017. jurnal ilmiah mahasiswa kesehatan masyarakat, vol. 2/no.6. http://ojs.uho.ac.id/index.php/jimkesmas/a rticle/viewfile/2914/2173 romani, l., koroivueta, j., steer, a. c., kama, m., kaldor, j. m., wand, h., hamid, m., & whitfeld, m. j. (2015). scabies and impetigo prevalence and risk factors in fiji: a national survey. plos negl trop dis, 9(3). https://doi.org/10.1371/journal.pntd.0003452 setiawan, a. d. (2017). persepsi pengelola pondok pesantren walisongo kecamatan pontianak kota terhadap penanganan kasus skabies tahun 2017. 16. setiawan, a. d. (2018). persepsi pengelola pondok pesantren walisongo kecamatan pontianak kota terhadap penanganan kasus skabies tahun 2017. jurnal mahasiswa pspd fk universitas tanjungpura, 4(1). tresnasari, c., respati, t., maulida, m., triyani, y., tejasari, m., kharisma, y., & ismawati. (2018). understanding scabies in religious boarding school (pesantren). proceedings of the social and humaniora research symposium (sores 2018). https://doi.org/10.2991/sores18.2019.120 widaty, s., soebono, h., nilasari, h., listiawan, m. y., siswati, a. s., triwahyudi, d., rosita, c., hindritiani, r., yenny, s. w., & menaldi, s. l. (2017). panduan praktek klinis bagi dokter spesialis kulit dan kelamin indonesia. perdoski. worth, c., heukelbach, j., fengler, g., walter, b., liesenfeld, o., & feldmeier, h. (2012). impaired quality of life in adults and children with scabies from an impoverished community in brazil. int j dermatol, 51(3), 275–282. https://doi.org/10.1111/j.13654632.2011.05017.x indonesian journal of nursing practices 27 table 1. the question in the questionnaire no question 1. what is scabies disease? 2. how is scabies transmitted, or how can someone get scabies? 3. has anyone ever been scabies in the past year, as far as you know? if there is, please explain the characteristics and why he can get scabies. if not, please explain why there are no scabies incidents in this school. 4. is the school's management of boarding student’s health and environmental health good? please explain how the management is carried out. 5. what are the policies or regulations that (should) be implemented so that there will be no students with scabies in this school? table 2. participants’ characteristic no the subject’s status total 1. school managers 2 2. teacher or musyrif (dormitory teacher) 9 3. non-education employees 4 4. students 9 5. parents of students 16 total 40 vol. 6 no. 1 june 2022 38 ijnp (indonesian journal of nursing practices) vol 6 no 1 june 2022: 38-47 jose mari louis g. alforque college of nursing, cebu normal university, philippines corresponding author: jose mari louis g. alforque email: alforquej@cnu.edu.ph an axiomatic approach in the development of the theory of creative aging article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v6i1.13351 : 10 december 2021 : 16 may 2022 : 10 june 2022 abstract background: there are several ways in which the term ‘creativity; is defined. it may be considered an ‘act’ or an ‘expression’. at an earlier age, people do things in accordance with what is expected of them and moreover, do things from their perspective. in older adults, creativity is an innate characteristic developed to improve oneself, and on the other hand, an ‘expression’, a way of doing things in everyday life. objective: this study aimed to develop a substantive theory of creative aging among older adults. methods: the theory was developed using an axiomatic approach where six axioms were deduced into three emergent propositions. it is theorized that creativity is an innate ability of a person that does not stop upon reaching old age, and is motivated by factors that may limit or enhance creativity. result: the expression of creativity among older adults in the later years is dynamic and a continuous engagement in activities and life pursuits leads to a healthier and more productive state of aging. conclusion: providing opportunities and an avenue where older adults can express their creativity should be considered to better understand the life of older adults and how they continue to flourish in their later years. keywords: axioms; creativity; creative aging; older adults; propositions introduction there may be several terms in which one interprets the word “creativity. from the words of the renowned author of creative aging, gene cohen (2006), creativity is bringing something into existence that is valued. it is a way for one to give value to what he / she possesses and how others give value to one as well. but for many people, creativity is a way of expressing themselves in ways that are more vibrant and more versatile that give a sense of satisfaction to a person. creativity is a highly philosophical thought, with no concrete ways to measure it. but if we look around us, we can see and feel that creativity is not meant to be measured but is meant to be observed, understood, lived, and most of all be felt. this may not be among the many issues and concerns revolving around the lives of older adults, but this is a phenomenon that is existing and must also be given attention. the practical minds of the people nowadays focus on the concerns of older adults and the issues that are commonly being discussed in almost all media. however, we may tend to forget that like us, these older adults need to be understood from all dimensions, including how they express and enjoy their elderly years. initiating creativity has its own pace. some may start it young, while other people develop it in later years of their life. but it is not on the length of time but how one is able to perfect what he has started http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/13351 indonesian journal of nursing practices 39 to make; something that is of value to others and to himself as well. creativity is a multifaceted phenomenon that is existent since the start of life and is bound to be nurtured until the end. though there may be phases in which creativity is dormant but it tells us there is a time for everything. being old is a number, but never a matter of quality of work or productivity. therefore, since the beginning of time and even until we age, this creativity always resides within us. thus, the concept of creative aging shows that creativity continues to exist despite in the later years. understanding the concept of creativity among older adults gives them a sense of perspective of the kind of individuals they will be in their later years. it gives them a sense of anticipation of how they can enjoy life past their retirement years; where adjustment to life is being made and overcoming the onset of depression or any other older adult – related issues be made convenient because they are made to express themselves in ways which they did not have the opportunity in their younger and middle-age years. as one becomes an adult, people’s creativity becomes less, but not in the traditional way. their continued creative drop is more due to decreasing into a number of cognitive traps than the fading of old age. creativity slowly fades away when not used. as they say, ‘use it or lose it.’ one of the biggest culprits here is the simple pattern of human habit. once people start doing something one way, they get contented with it and then do not anything to change or vary it. everything is a phase; a process which one has to go through and eventually will be a part of the person that we will be. this study was made to pave way for a better understanding of how the elderly remains to be involved and engaged in society through ways that are made more convenient and more creative. a look at the creative side of aging helps healthcare professionals as well as the family to address the needs of these individuals and be able to understand how they keep themselves and get a grasp of reality despite their age. it is through creativity that one is able to express oneself, limiting his / her own potential; a point in which, despite age, there will be an opportunity for one to reconnect and to continue connecting with the creative side of them. furthermore, it is the intent of the researcher to explore the concept of creative aging from a perspective of how he will continue to flourish and nurture one’s creative capacities as one comes of age. this is an avenue in which health care professionals will better understand creativity among the older adults and better understand their full potential as creative older adults in the years to come. methods theory generation process the theory of creative aging among older adults was developed using an axiomatic approach. this study implored a deductive-axiomatic approach to develop a theory that explains and describes the occurrence of the phenomenon. this method is similar to logic, in that it starts with an existing theory that supports the phenomenon in issue and leads to a new hypothesis (streubert & carpenter 2011). deductive reasoning as noted by sternberg (2011) is a systematic and logical technique for arriving at a conclusion based on the agreement of several premises that are widely accepted to be true. using deductive reasoning as pointed out by creswell & clark (2007) by the researcher entails the researcher from working from the ‘top down’, beginning with a theory, hypotheses, and finally facts to support the or refute the theory. a comprehensive review of related literature and studies was done initially to provide related knowledge and bases for the formulation of relevant axioms and propositions in the study. using google search engines, google scholar, and proquest, the following words were put in and searched for, namely, creative aging, creativity in aging, aging and creativity, creativity in nursing, nursing and creativity which yielded more than a hundred thousand literatures and studies. these literatures were sifted though and were selected as to which is the most relevant to the phenomenon being explored for. alligood & tomey (2010) described the deductive process as the form in which specific assumptions are deduced from more general premises or assertions. reasoning proceeds from general statements to specific conclusions. a theory that is established deductively follows a process with a series of premises called axioms, that is, vol. 6 no. 1 june 2022 40 statements or propositions that are consequent from broader premises. the concluding statement is unknown which leads to the prediction of the theory and the formation of a hypothesis to be empirically tested. the consistency of the axioms is presupposed from the beginning of the axiomatization process. there are different ways to prove the consistency of the axioms of a theory. this is due to the fact that the choice of the axioms can be motivated in different ways. since truths and other non-falsities in a theory are all (intended to be) determined by the axioms, they have to be in the reaches of logical consequences drawn from the axioms. if the structures that are intended to be studied by axiomatizations do not exist and the axiom in question is not consistent, the whole process becomes nothing but a meaningful manipulation of figures. there are two ways of understanding consistency. first is where the axioms are presupposed to hold true in the structures they determine. second is where they are presupposed to be not false in the structures. in both ways, the ultimate presupposition of axiomatization is the existence of the structures and the objects involved. hence, consistency is presupposed in axiomatization from the very beginning. aristotle’s conception of the axiomatic method can be seen as deduction-oriented in the following way: according to aristotle, axioms speak about real entities which have cognitive dependencies with further truths. that is to say, the axioms are taken to be true as well. that is, their logical consequences belong to the same system of truths as the axioms. in such system, we have some given knowledge in terms of the axioms. starting from the axioms we seek further knowledge in terms by asking further questions. the cognitive meaning of the axioms (as well as of the terms they involve) is either obvious or definable by what is obvious. so that axioms require further proof. unlike the axioms, further truths are deducible from the axioms by syllogism. a deductive axiomatic system or theory is build using the deductive process. the essence of axiomatic approach, as employed in logic and mathematics, is that set of claims called propositions is obtained by applying deductive logic to a more fundamental set of statements known as axioms (padua, 2012). in a deductive system, axioms reflect the basis statements. the steps that the paper followed are reflective of the deductive axiomatic approach in generating the theory (padua, 2012), as illustrated in the figure 1. (see figure 1) result derivation of axioms gene cohen is a renowned personality in the concept of creative aging. relating to the work of famous psychoanalyst erik erikson, a teacher of cohen at harvard, cohen (2001) charted four phases in the second half of life, namely, (1) re-evaluation, (2) liberation, (3) summing-up, and (4) encore. the re-evaluation phase occurs in the age of 50s onwards when adults search for new ways to bring meaning to their life – the ‘midlife crisis’ from a positive perspective. liberation phase occurs in the 60s and 70s in which added freedom from work and family fuelled creative endeavors, reaching some comfort about who they are, asking themselves “if not now, when?”. the summing-up phase which is from the 70s onwards is where people more urgently seek the meaning in life by looking back, summing up and giving back, where activities such as autobiography, storytelling and philanthropy are common. lastly, the encore phase which is from age 80 and beyond are marked by a desire to further contribute, affirm life, to enjoy one’s place in family or community and take care of unfinished business. engaging in the different fields of arts influences the lives of older adults. mcquillan (2019) noted that the difference between those who experience a peak in creativity during their mid-twenties and those who are more likely to peak in their mid-50s is in the type of creativity involved. hull (2007) noted that older adults who take up painting, writing, music and other forms of art developed a greater sense of control, or ‘mastery’ over their lives. cohen (2001) added that these factors, namely, developing relationships and ‘social engagement’ improved older adults’ immune system responses. for quite a time remarkable accomplishment were seen in later life. many of these (achievements) are occurring not despite aging, but because of aging. reed (2005) pointed out that creativity and productivity are not equivalent and that creativity grows, changes, and indonesian journal of nursing practices 41 evolves along with life span development according to the current life span development model. creativity will always be part of a person’s life; the more one ages, the more experienced they get. the more experienced one is, the more that they have a better grasp of the environment they are situated in. developing a better understanding of the environment and relating it to the myriad experiences of a person leads to an improved level of creativity in a person’s lifetime as they age. thus, axiom 1 states that creativity is ageless; it transcends all ages. in the course of time, one realizes that the need for creativity is always a part of every person regardless of how old one is. it is etched in the hearts of every human experience the desire and ability to create, to express creativity in ways that fosters life satisfaction. it helps us adapt to new atmospheres, survive with what life hands us, and helps us to express ourselves as human beings. creativity is like a seed that is implanted in us the day we are born. as one progresses with life, the seed of creativity within them also grows. every experience a person encounters influences the level of creativity, as it may motivate or demotivate the person. with time, the creativity of one does not disappear because the longer the time there is, the deeper are its roots in a person. it may seem that as one grows old, the creative side starts to disappear. on the contrary, the creative spirit has a period of waning yet it takes another form and degree once one reaches old age. cooke (2006) noted that human creativity does not inevitably decline with age although it changes and matures. instead, creative impulses occasionally get stronger with age in fields such as the arts as older people find the time, resources, and inspiration to explore writing, sculpture, art, music, photography, and other satisfying pursuits. in other words, age is not a handicap nor a disability, and researchers say new talents often bloom even as frailties such as hearing loss and fading vision appear. older people have depths of experience to draw on as compared to the younger generation, they often already have many skills and they are not as determined by the need to prove themselves. thus, the above mentioned supports axiom 2 which states that creativity is innate: it knows no retirement age. like any other individual, the formation of one behavior and overall attitude is relative to the internal and external environment. the locale in which one is being settled will have an impact to how one adapts to the environment. creativity, like any other attribute of a person, is attributed to how the person is influenced by the people around him and the different components present in the outside environment. the experiences met by an individual as he goes on with life will have an impact on the level of creativity he has. the intrinsic experiences of one person influence his perspectives on how to deal with everyday life and the degree of these experiences affects the ability of a person to handle every situation that is at hand. furthermore, extrinsic experiences also affect a person’s way of carrying out activities and tasks, and how they deal with the people around them. creativity is a drive that is affected by intrinsic events and extrinsic components. gowans (2006) believes that the arts give us a good opportunity for a sense of mastery and control; the opportunity to produce something new and beautiful offers real fulfillment and empowerment. the mind has a dominant influence on the body. a powerful interaction between the nervous system and the immune system has an effect on behavior and health. positive emotions can also influence the immune system by boosting t cells, which act as a protective mechanism. thus, the importance of overall health is essential for one to be able to maximize his creativity, supporting axiom 3 which states that creativity is influenced by intrinsic and extrinsic factors. according to beal (2008), dean bette r. bonder, phd. of the cleveland state university said that “people are happiest and healthiest when they are engaged in activities that are gratifying and meaningful”, and in so many ways, those are or could be activities related to arts”. few people know about the good benefits that another kind of sustained exercise – participation in art programs that have participants stretching and bending their minds and “thinking outside the box” – seems to have on older adults. nor are they aware of how easy it is to keep things dynamic after they have taken the plunge. fitzgerald (2022) pointed out that creative thinking is a critical skill; not only for artists or musicians, but also for children and older adults alike as a way of thinking about – and being in – the world. it is through being creative that a person is able to get their senses, sensibility and spirit working together. thus, axiom 4 states that overall vol. 6 no. 1 june 2022 42 health is essential to be able to maximize one’s creativity. discussion creativity is something that is rare. needlessly, because of the way the mind works, it is rare in some individuals. it is rare in groups because of the groups’ way of respond to new ideas. but with the use of techniques to get around the mind's limitations and ground rules for responding to others' ideas, any group can increase its creativity dramatically. frugé (2012) pointed out that creativity is an innate process within all life, including each and every human being and to discover how to tap into this process and use it successfully in all aspects of living. getting creative (cohen, 2001) in your later years is a self-fueling engine. the more you do the more you can do. so far, cohen added, the studies of creative aging, also referred to as productive aging – have been completed with people (between 65 and 103) who participated in organized art programs, such as painting classes, poetry writing workshops, or choral singing classes. meier (2022) pointed out that creativity is the backbone of innovation; it helps one to achieve and be empowered, and being a creative individual allows one to live in freedom by thinking and acting with deep expression of one’s purpose and values in an authentic way. one is not going to innovate by thinking the same old though or doing the same safe things, or reinforcing the way things have always been done or blocking new ideas by limited or negative thinking that reinforces the status of quo and the way things have always been done. one innovates by thinking creatively and by challenging and exploring the art of the possible. thus, axiom 5 states that creativity is a matter of perspective: it is doing things your own way, when new or different way is done to old things. the aging brain (carson, 2015) has a resemblance with the creative brain in numerous ways. for instance, the aging brain is more distractible and somewhat more disinhibited than the younger brain (so is the creative brain). aging brains on tests of crystallized iq (and creative brains usually preserved knowledge to make novel and make original associations) score well. these changes in the aging brain may make it ideally suited to achieve work in a number of creative fields. so instead of encouraging retirement at age 65, perhaps we as a society should be promoting a shift at age 65: transition into a creative endeavor where our emergent resources of individuals with aging brains can preserve their wisdom in culturally-valued works of art, music, or writing. mcquillan (2019) pointed out that your most creative period is more a product of the type of creator you are and the nature of your work than of the particular field you are in – extend to other academic and scholarly disciplines as well. if one is a conceptual thinker, they are likely to be more creative when they are younger; if one is an experimental thinker, they are likely to do their most creative work when they are older, perhaps even past middle age. thus, axiom 6 states that some older adults reach creative heights later in life. (see figure 2) creativity is something inherent and at the same time a multifactorial phenomenon that affects how a person perceives things around him. as shown in the diagram, creativity transcends all ages, thus, it persists in a man’s lifetime. health as an essential aspect of creativity is a concern in an older adult. the manifestation of creativity in a person has its highs and lows, thus, the onset of creativity in an older adult is early or late, depending on the circumstances. the different axioms presented above thread through the concept of creative aging in older adults. development of propositions emergent from the identified axioms are the different propositions developed by merging two or more axioms. hence, the propositions are presented as follows: proposition 1. creativity does not decline with age, however, with physical disabilities, it limits the level of creativity. bradford (2002) noted that there is creativity every day, like solving sticky human struggles or figuring out how to work smarter and become more efficient. being persistent, resisting conformity, and willingness to take risks is a characteristic of creative people. creativity or in other ways, being creative, gives one a sense of control over the external world, conveying balance and order to modern life, which is increasingly manifested by uniformity, sameness, and an overemphasis on productivity. in everyday life, opportunities for creative pursuits prove to be very indonesian journal of nursing practices 43 advantageous and meaningful to people with sight impairment, hearing impairment, and other physical disabilities. to some, it even becomes a new life force, allowing them to course through difficult and challenging days with a greater sense of ease and a sense of purpose. gustafson (2014) emphasized that the beauty of aging is that there are opportunities for new perspectives based on reflection and greater appreciation for the importance of time. it is also a most humbling phase in life when we comprehend how little, if anything, we are able to achieve beyond the narrow horizon of our short presence. and yet, it is up to each person how their day, up to the last, continues to clarify. creative older adults who have outlets that they can indulge in are proven to be happier than other without. proposition 1 is deduced from axiom 1 (creativity is ageless; it transcends all ages), axiom 2 (creativity is innate; it knows no retirement age), and axiom 3 (creativity is influenced by intrinsic and extrinsic factors). proposition 2. creativity aids in promoting a healthy and productive state of aging; the more active and engaged, the better. health is a very important component as one grows old, and being happy and healthy as one grows old is another consideration. gustafson (2014) noted that persons endowed with certain abilities tend to fare well in other ways, both physically and mentally, as compared to those whose existence mainly consists of monotony and repetitions. the challenge of aging is coming into our own, and not just staying young but growing old as a whole. goldman (2009) pointed out that human destiny is interwoven in the process of aging with a challenge for other others to embrace the challenges and aridity of aging and figure out the person you are now and now what you have been. the importance of a creative activity poses manifold benefits which relieve and improves symptoms of anxiety and depression and help cope with a physical illness or disability. how one cultivates their talents and capabilities helps in handling everyday situations. these day-to-day experiences affect their perspective on things. the difficulties, the challenges, and the responsibilities that one has to undergo is everyday life becomes an ingredient for one to be able to go through with life. proposition 2 is deduced from axiom 3 (creativity is influenced by intrinsic and extrinsic factors), axiom 4 (overall health is essential to be able to maximize one’s creativity), and axiom 5 (creativity is a matter of perspective: it is doing things your own way, when new or different way is done to old things). proposition 3. creativity is influenced by intrinsic and extrinsic factors; these may enhance or limit creativity. as one grows old, the experiences become richer, and the understanding of reality becomes wider. the level of creativity takes another path making things seen from a different and meaningful perspective. being a creative older adult in the later years of life is not just about making something but how something creates a better impact in the lives of every individual and there are times the realization takes a certain amount of time. carson (2015) pointed out that the expectation of people toward older adults should be changed. instead of referring to them as a form of burden, we should consider the productivity of older adults throughout the course of their lifespan. each individual should take the challenge of becoming an older adult or a soon-to-be older adult: first, contemplate one life lesson that one should like to share with the younger generation, and secondly, one should decide upon an avenue of creativity wherein the lessons can be embedded – perhaps through writing a novel or a painting or a tune from a musical piece. how one performs a certain task of responsibility is highly influenced by internal and external factors, be it one’s own personality, attitude towards work, the workplace itself, the people around, the changing weather, and all other possibilities that occurs in a day. proposition 3 is deduced from axiom 3 (creativity is influenced by intrinsic and extrinsic factors), axiom 5 (creativity is a matter of perspective: it is doing things your own way, when new or different way is done to old things), and axiom 6 (some older adults reach creative heights later in life). conclusion creativity is the expression of transforming novel and abstract ideas into something that is real and concrete: a reality, characterized by being able to perceive and view the world and everything around in new and wonderful means, seeking for obscured patterns and connecting unrelated concepts, and to make general and relevant solutions. it is creativity that one thinks, and then produces a way for one to vol. 6 no. 1 june 2022 44 act on ideas that are being conceptualized in one’s mind. creativity is a way of life: as one continues to create, to do, to make, is a way of leading a productive and healthy life as it is a form of exercise. the theory of creative aging assumes that creativity is an innate ability or every person and it will not stop at old age and is motivated by factors that may limit or enhance creativity. the expression of creativity does not stop even if one reaches older years, and by creativity, it is a way of how one thinks, perceives, and expresses. the more one is able to be engaged in a creative pursuit leads to a healthier and more productive state of aging. creativity is innate, and we are born with it. with experience, an older adult’s creativity continues to flourish. it is thought that with any physical disability leads to the creativity being stopped. however, it is by nature of creative individuals to persist creating despite disability. the passion to create never stops, however, the ability to produce is diminished but never totally gone. there are intrinsic factors that directly and indirectly influences a person’s creativity, that may either enhance or limit one’s level of creativity. intrinsic factors such as passion, motivation, good health are the ones that fuels an individual to nurture and to mobilize his creative potential. extrinsic factors such as rewards, praise and appreciation, social support, and environment are the ones that gears an individual to express his creative potentials. these factors in creativity enhance an individual’s capacity to become more creative and be able to express in manners which is accordance to his perspective. thus, when creativity reaches a turning point, the process is being continued as the knowledge and principles are being passed on to younger generations. acknowledgement i would like to acknowledge dr. marylou b. ong, my dissertation adviser and dr. jezyl c. cutamora, my research mentor who helped me and supported me in formulating this paper and guided me all throughout the process of making this paper a realization. references alligood, m. r. & a. m. tomey. 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(2014). why creative people age better. the hufftington post. retrieved at: http://www.huffingtonpost.ca/timigustafson/creative-peopleaging_b_5622062.html hull, v. (2007). expert: aging enhances creativity. sarasota herald tribune. retrieved at: http://search.proquest.com/docview/27080 4113?accountid=141440 isfahani, s. s., hosseini, m.a., khoshknab, m.f., peyrovi, h. & khanke. h.r. (2015). iranian red crescent medical journal. 17(2): e20895. https://doi.org/10.5812/ircmj.20895 jenson, j. (2002). is art good for us: beliefs about high culture on american life. lanham, md: rowman & littlefield meier, j. d. (2022). how to be creative at any age? jd meier: high performance and innovation coach. retrieved at: https://jdmeier.com/how-to-be-creative-atany-age/ mcquillan, s. (2019). at what age does creativity peak? psychology today. retrieved at: https://www.psychologytoday.com/us/blog/ cravings/201911/what-age-does-creativitypeak padua, r. (2012). teaching theory development. training presentation from cebu normal university reed, i. c. (2005). creativity: self-perceptions over time. international journal of aging and human development, 60(1), 1-18 https://doi.org/10.2190/wm5y-fhem-cxqtuexw sternberg, r.j. (2011). the theory of successful intelligence. in r.j. sternberg & s.b. kaufman (eds.). the cambridge handbook of intelligence. pp. 504 – 627. cambridge university press. https://doi.org/10.1017/cbo9780511977244 .026 streubert, h. j & carpenter, d. r. (2011). qualitative research in nursing: advancing the humanistic imperative. 5th ed. philadephia, pa: lippincott william and wilkins vaartio-rajalin, h., santamaki-fischer, r., jokisal, p. & fagerstrom, l. (2021). art making and expressive art therapy in adult health and nursing care: a scoping review. 8(1), 102-119. https://doi.org/10.1016/j.ijnss.2020.09.011 vol. 6 no. 1 june 2022 46 steps in theory development figure 1. deductive axiomatic approach in theory development (adapted from padua, 2012) choosing the phenomenon of interest (20%) reading the literature (20%) brainstorming (40%) formulating the axioms and propositions (10%) formulating the axioms and propositions (10%) indonesian journal of nursing practices 47 figure 2. the axiomatic approach in developing the theory of creative aging proposition 1. creativity does not decline with age, however, with physical disabilities, it limits the level of creativity proposition 2. creativity aids in promoting a healthy and productive state of aging; the more active and engaged, the better. proposition 3. creativity is influenced by intrinsic and extrinsic factors; these may enhance or limit creativity theory of creative aging creativity is an innate ability of a person that does not stop upon reaching old age, and is motivated by factors that may limit or enhance creativity. axiom 1. creativity is ageless; it transcends all ages axiom 2. creativity is innate; it knows no retirement age axiom 3. creativity is influenced by intrinsic and extrinsic axiom 4. overall health is essential to be able to maximize one’s creativity axiom 5. creativity is a matter of perspective: it is doing things your own way, when new or different way is done to old things axiom 6. some older adults reach creative heights later in life indonesian journal of nursing practices 28 ijnp (indonesian journal of nursing practices) vol 4 no june 1, 2020 : 28-36 agustina arundina triharja tejoyuwono1 1universitas tanjungpura corresponding author: agustina arundina triharja tejoyuwono email: ina.tejo@gmail.com health lecturers and students views’ about healthcare workers’ as healthy lifestye role models: a qualitative study article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.41105 abstract background: health education institutions as producers of healthcare workers have a duty to demonstrate healthy lifestyles to the students as the future healthy role models. objective: this research aimed to describe the views of health lecturers and students about their role and the effect of healthcare workers’ behavior as healthy lifestye role models. method: an exploratory qualitative study with in-depth interviews was conducted in 2017. six lecturers and five studentss were chosen as key informants, who were selected from the medicine, nursing, and health nutrition departments. we analyzed the data manually, by identifying categories then created into themes. result: healthcare workers were judged as a representative figure to demonstrate healthy lifestyles. unhealthy lifestyle practice by healthcare workers was considered a violation of their responsibility. furthermore, it will decrease the image and respect of healthcare workers which will cause people to trust less in the treatment process and health counseling, and finally, the society will imitate unhealthy lifestyles. furthermore, in medical education, this influences lecturers’ self-efficacy in health counseling, causing guilty feelings and shame for not implementing a healthy lifestyle although they had already learned health science. moreover, the students sometimes feel sadness and disappointment, since not all lecturers can become healthy lifestyle role models. conclusion: healthcare workers are role models of healthy lifestyles in society and expected to be in any setting. therefore, they should appropriately respond to becoming someone who qualifies to be imitated and be a good example of a healthy lifestyle in society. keywords: health lecturer; health student; healthcare worker; healthy lifestyle; role model introduction a healthy lifestyle has been believed for a long time to be the main strategy for prevention of disease and the indicators are maintaining dietary habits by increasing the consumption of fruits and vegetables, doing physical activity, and avoiding smoking (alateeq & alarawi, 2014; özçakar, kartal, mert, & güldal, 2015). unfortunately, some healthcare workers have an unhealthy behavior, eighty-two percent of healthcare workers have a very low physical activity, and only 13% of doctors do physical activity >30 minutes 5 times a week (barros, lucas, & ferrari, 2012; borgan, jassim, marhoon, & ibrahim, 2015). furthermore, only 26.2% consume fruits and vegetables >5 portions per day and maintain healthy habits significantly related to physical activity (florindo et al., 2015). in indonesia, 32% of health office workers of south sulawesi have low physical activity and 62% have low fruit and vegetable intake (nadimin, 2011). other research http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/6971 vol. 4 no. 1 june 2020 29 showed 38% of doctors do physical activity once per week and mostly consume only two portions of fruits and vegetables daily (31.6%) (prabandari, 2013). being a healthy role model is an unwritten contract between patients and healthcare workers so that implementing a healthy lifestyle is a personal commitment and responsibility of healthcare workers toward their patients (hoare, mills, & francis, 2013). research shows becoming a positive role model in the society will increase trust in medical practice (birden et al., 2014), compliance of treatment plan and satisfaction of the service (mold & forbes, 2013). oppositely, unhealthy lifestyle practices by healthcare workers will affect society’s judgment toward them, making people uncomfortable if they consult with healthcare workers who have similar unhealthy behavior with them. as a result, they will consider healthcare workers have no right to give healthy lifestyle suggestions to them (pistikou et al., 2014). moreover, this negative perception will affect healthcare workers’ self-confidence and desire to give counseling about physical activity or healthy lifestyle to society (bleich, bennett, gudzune, & cooper, 2012; florindo et al., 2015; zhu, norman, & while, 2013). medical education institutions have a role in developing professionalism, professional identity, career path, and students’ ethical character as a role model (benbassat, 2014; passi & johnson, 2015). teachers have become the first-seen image of healthcare workers, therefore students give a deep attention, judging and imitating their teachers’ behavior, and this role modeling also applies to the educational staff (haider, snead, & bari, 2016). eventually, it will affect the students’ self-image and professional perceptions in the future (felstead, 2013). however, the lecturers and educational staff often ignore their responsibility to be positive role models (jochemsen-van der leeuw, van dijk, van etten-jamaludin, & wieringa-de waard, 2013; vinales, 2015), although many actually understand they should become healthy role models (passi & johnson, 2016). unfortunately, the practice of lecturers as healthy lifestyle role models in the health education institutions is still uncommon, and as a result, the impact on the students and their perceptions of becoming healthy role models are not well understood yet. this study aimed to determine the perceptions and experiences from the perspectives of the lecturers and health students about the role of healthcare workers as healthy lifestyle role models. method the exploratory qualitative methods with in-depth interviews was conducted from may until june 2017. the interviewer served as the principal investigator, in addition to a lecturer in the faculty of medicine, tanjungpura university and an alumnus from the department of nutrition science health polytechnic of pontianak. the informants were lecturers and students from an undergraduate program of medicine and nursing, faculty of medicine, tanjungpura university, and diploma program of nutrition science, health polytechnic of pontianak. at the beginning of the study, we selected informants by a personal approach, explaining the aim of the study, and asking about their willingness to participate in the research. criterion sampling method was used to choose the informants, where the chosen lecturers had working period for more than three years because of his/her experience and closeness to the students, and students were year-end students (sixth semester) who also had longer exposure to their lecturers and were soon to start their clinical rotation in various communities. there were 6 lecturers and 10 students who agreed to participate, however for the data analysis we only selected some of the informants as subjects from each study program and finally had 11 key informants. selection of key informants was completed after conducting all interviews and rereading the transcripts from all 16 informants. eventualy, 6 lecturers (3 doctors, 2 nurses and 1 nutritionist) and 5 students (3 medical students and one student each from nursing and nutrition department). the number of informants was not picked from the beginning, but determined by the amount of information given by the informants and saturations (malterud, siersma, & guassora, 2016). each interview was conducted at an agreed time and location between the informants and investigator, so we could not ideally set the interview room. the informant sat beside the interviewer so to maintain eye contact and have clear voice during the interview. before starting, the informants had indonesian journal of nursing practices 30 already received a clear explanation of the interview process, which involved using a voice recorder and taking notes. each informant’s privacy was maintained and their identity kept anonymous and all knew they had the rights to not answer any question or refuse to continue to participate in the study. each interview ran for 45 minutes and started with an opening question: ‘what do you understand about the concept of a role model?'. there were 2 main questions as response triggers: ‘from your opinion, is it necessary for healthcare workers to become healthy lifestyle role models?’ and ‘from your opinion, what is the influence of healthcare workers’ behavior as a healthy lifestyle role model?’ we inserted probing questions to collect additional data and also clarify the meaning of informant’s answer. the interviewer did not limit the informants from answering with relevant experiences about healthy lifestyles and role models. replaying the voice recording was done after interviewing and reading the transcript were completed, to ensure all questions were answered, clarified, and written down. we conducted manual descriptive analysis by reading the transcripts line by line and then organizing the data manually. data categorization was performed by giving highlights in a unique sentence or giving a categorical meaning from informants’ answers. that process was done two times until the investigators clearly understood the meaning of the answers and the categories were also already appropriately saturated, i.e. no new codes were emerging. in the next step, we categorized similar categories into several subthemes and from sub-themes into an organizational framework. there were some categories that needed to be separated because they had no similarity with other categories and did not provide themes but were not deleted, since they will enrich the content of the study. after completing the process, all investigators re-read the categories and themes to better establish the correct themes that match with the study aims and finally applied simple coding to designate data sources (sutton & austin, 2015). member-checking with one qualitative expert was conducted to ensure the trustworthiness. we gave the code to each of the informants who were lecturers (l1-l6) and students (s1-s5). this study was approved by the medical and health research ethics committee faculty of medicine, public health and nursing, universitas gadjah mada, number ke/fk/0528/ec/2017. results informants characteristic informants with a variety of ages was chosen, which for lecturers were between 30-53 years old and for the students were between 19-20 years old. according to sex, lecturer informants were predominately males (4 from 6) while there were more female student informants (4 from 5). we selected only qualified informants, where one of the informants was a former head of a study program and another was currently head of a study program. we selected year-end students, who were currently doing their final thesis, and the background of their participation in an organization was also a consideration, where one of them was the head of the students’ organization. what is a healthy role model? healthcare workers are considered as ‘vanguard’ people, since their behavior is seen as a role model, even if it is a ‘bad one’. from the view of society, the healthcare workers must be a ‘representative’ as a healthy person, since they are seen as ‘a leader’, so being healthy is a must, especially for a doctor. becoming a healthy role model is not a compulsory act, but it is a ‘mindset’ that all healthcare workers must have. one informant explained the following: “from my opinion, a role model is a reference or an example ... we as a doctor act to serve the society, it means we become a role model or reference for the society in daily life, especially in health. if we are a lecturer, it means we become references for the students in attitude, something like that” (l1) the previous statement explained that a role model in healthcare workers was someone who is being ‘an example to others’, while others stated it as someone who ‘exemplifys’ healthy lifestyle. on the other hand, some informants emphasized a role model was someone who is ‘eligible’ to be followed from the scientific and ethics-norm viewpoints. the society also described healthy healthcare workers from their ‘appearance’ and ‘healthy lifestyle’. most vol. 4 no. 1 june 2020 31 highlighted the ‘bad’ lifestyle was the ‘smoking’ habit in healthcare workers. ‘no action talk only’ healthcare workers as an unhealthy role model healthcare workers who do not implement healthy lifestyle are considered as someone who only knows the theory or ‘no action talk only’. they can only ‘advise’ other people to implement a healthy lifestyle but they do not do that, and are considered as ‘irresponsible’ and ‘opposite’ from the ideal that should be performed by healthcare workers. this unhealthy behavior will reduce the important ‘image’ and ‘respect’ of healthcare workers as a competent person in health matters. in addition, all informants stated that it will negatively affect the ‘trust’ of patients so they will ‘refuse’ to do healthy lifestyles because they reflect on the lack of an appropriate role model in healthcare workers’ behavior. the informants stated that society will ‘question’ the result of the given treatment and not ‘trust’ in him/herself to practice a healthy lifestyle. moreover, unhealthy behavior conducted by healthcare workers will be ‘followed’. in the end, it will severely affect the health promotion programs in society: “...healthcare workers conduct unhealthy behavior... so we (society) also followed them (healthcare workers)... if it is contradictive, they won’t follow us anymore... they do not want to follow what we advise to them” (l3). one of the adverse effects of the unhealthy behavior conducted by healthcare workers in him/herself is the lack of ‘self-confidence’ of giving consultation for patients. they will self-reflect while doing education, feeling what they said is not yet done and that they had not enough ‘experience’ in giving education about healthy lifestyle. they felt they ‘lied to’ the patients and the patients felt ‘cheated’ if the healthcare workers giving the instruction about health recommendations that had never been conducted by him/her. the worst impact may create the image of the healthcare workers as a ‘contagious patient’ and the real patient feels worried if he/she got infected by some disease while they get treatment. one informant stated that: “...the doctor is prone to catch a disease... it would shape people’s mind that if doctor or paramedics often ill ‘how could they treat sick people, if they often got sick too” (l4). other informant stated: “we told them, ‘please watch your diet, ma’am’ meanwhile i am obese’.... thus, patient will respond with ‘heh’ [cynical face while looking at me from head to toe].... yes, negative look from patient like she wants to tell me, ‘ah you’re just like me doc’ that’s what i felt’... “oh doctor also got the flu”, oh yeah right. so, we are afraid of bringing our children which have no flu before, will catch the flu after visiting doctor” (l1). feel guilty as a professional healthcare worker as someone who receives higher education in the health field, it is a must for a healthcare worker to apply healthy lifestyle behavior. it is a responsibility of healthcare workers towards themselves and the community as stated by one student: “... healthcare workers act as people who know more about health, people who understand about health have the responsibility to give model ... we could not order other people to do healthy lifestyle if we do not start it ourselves” (s4). healthcare workers who do not apply healthy lifestyle according to what it is said by the people in the communities would be presumed guilty due to the assumption of being irresponsible towards their obtained knowledge and health messages about what they said to their patient. this ‘guilty’ feeling is felt by healthcare workers appearing either from themselves or direct reprimands from community. some informants stated that: “... we did not avoid those so there is a feeling of talking only and not accompanied by actions, this triggers a guilty feeling of doing nothing but still lecturing about the topic.” (l1). “...we educate something which is not done by ourselves, sometimes it hits us ... you have not done that but why you are still brave enough to tell people to do so’, it becomes a reflection for us.” (s4). furthermore, it is stated that healthcare workers are “part of the community” so that the practice of indonesian journal of nursing practices 32 healthy lifestyle behavior is a form of social responsibility by being amidst a community. considering the role as part of the community might sometimes raise the issue that the practice of healthy lifestyle behavior is caused by ‘shame’ feelings due to not showing and practicing a healthy lifestyle. what comes up as interesting is that the feeling of shame is caused by not yet obtaining the ideal ‘physical appearance’. obtaining good physical appearance is presumed as proper body image for healthcare workers in the community’s view and success in applying a healthy lifestyle is assessed from clothing size. “ .... smoking, like it or not, is due to habit... would feel ashamed if seen by people, trying to change little by little.’ ... we try to keep our weight in the ideal state, would be a disgrace if healthcare workers are fat.” (l6). besides, there is a ‘demand’ from communities that healthcare workers demonstrate a healthy lifestyle, since if there is unhealthy behavior acted by even one healthcare worker, it will reflect on all healthcare workers and health messages. as a result, sometimes behavior which is not shown by healthcare workers would be as a boomerang to them. eventually, negative lifestyle behavior done by healthcare workers would affect community behavior. “just said by proverb ‘a speck of indigo would damage the entire milk’ (nila setitik rusak susu sebelanga) ... even though others try perfectly, yet if there is even one who does wrong, sometimes people would defend themselves that they want to smoke (be unhealthy)” (s4). one of the lecturers stated that practicing a healthy lifestyle is part of applying religious teaching, believing that: “god would be angry if we talk something that we do not do ourselves” (l3). while the healthy lifestyle is a ‘fortress’ towards healthcare workers’ behavior so that they are in accordance to obtain knowledge, and ‘awareness’ as role models of practicing healthy lifestyle which has been known by healthcare workers as their: ”morale and personal responsibility towards knowledge, god, and themselves” (l2). although they understood this, some of the informants stated that being a role model is a ‘personal entitlement’ and depends on ‘awareness’. ‘ironic’lecturers as students’ bad role models in health education institutions students see lecturers as their role models. lecturers are viewed as ‘health educators’ so that they are presumed to perform the ‘ideal’ behavior as a model, which students will later imitate during their study period. therefore, becoming a role model is a joint responsibility, not only by lecturers as healthcare workers but also all of the people who exist in the campus environment and relate to the college image as a field of health education. lecturers who do not perform healthy lifestyle behavior lead students to be ‘confused’ because they are considered to practice improper behavior that is not in accordance with their knowledge as a health educator. besides, other feelings were expressed by students such as ‘sadness’ and ‘disappointment’, since lecturers are considered ‘useless’ as healthcare workers. also, it is ‘unfortunate’ regarding the obtained knowledge because of being unable to perform healthy lifestyle behavior for themselves, and eventually it is considered as ‘ironic’. “hmm.. maybe only disappointment in the community, he/she should be able to perform what he/she has known, it feels like ‘unfortunate’, his/her knowledge becomes useless” (s3). other supporting statement: “yes, become role model, because they teach about health, would be an irony if healthcare workers teach about health yet still smoking, do not obtain the culture of a healthy lifestyle, eating without hand washing, still love to stay up all night, etc... so, it would be an irony, even less as a lecturer (we) should be a role model too” (l3). vol. 4 no. 1 june 2020 33 teaching about the application of healthy lifestyle behavior should be done as early as possible even though not all of the healthcare workers could be a role model of a healthy lifestyle. making someone into a role model needs ‘acquaintanceship’ (s1) and a ‘learning process’ (l2,l3) over a long time period, and this statement also was affirmed by the lecturers. the behavior shown by lecturers inside or outside campus becomes an ‘attention-getter’ for students. one of the students said that: “there are some lecturers bringing unhealthy lifestyle to campus who want to transmit their behavior to students” (l1). students would see, and assess the behavior even to the extreme state to seek for lecturers’ behavior outside the campus. students clearly consider the goodness and badness shown by lecturers such as healthy lifestyle behavior habits including smoking habit, sports habit, hand washing, and selection of food. responsibility as a role model of healthy lifestyle behavior for students is actually very important. for example, there was a lecturer teaching about obesity who received reprimands from students for being obese: “sir...why is it fat, sir? the student reprimanded me.....so we are ashamed basically if the healthcare workers are fat, it’s a shamed” (l6). although based on some students’ statements (s2,s3), the practice of healthy lifestyle does not have to be applied to lecturer due to their position as an indirect healthcare worker in the communities. there is sometimes a contradiction in knowledge between what has been taught and lecturer’s appearance, such as in the experience where the lecturer was reprimanded by a patient due to having an obese appearance, so that the patient disbelieved the solicitation of doing healthy lifestyle behavior (l1) and was doubting the behavior was also done by healthcare workers (l5). interestingly, those reprimands also were felt by students (s1,s3), where the status of being health science students forms the image that students have practiced healthy lifestyle behavior so that they are appropriate enough to be role models for the community. this fact represents the learning community’s perspective that being role models of a healthy lifestyle should be performed since becoming a student. healthcare workers are also human although performing healthy lifestyle behavior is an obligation for healthcare workers towards the community and themselves, there are several constraints faced. as a worker assigned to working hours, constraints appear from time limitations to do physical activities since they have to divide their time for family and work. another interesting reason to justify not being healthy is frequent ‘meetings’ serving unhealthy meals. even though they have the status as a healthcare worker, selection of food still depends on indulgence so that healthcare workers’ behavior is similar to the patient. obstacles in applying healthy lifestyle in daily life are presumed part of being human, thus if healthcare workers could not perform healthy lifestyle behavior or become ill, those outcomes are considered reasonable. “i could say sometimes i do it, other times i do not, yet i frequently do it. because i know the effect so i still do it anyway, but as a human, we may feel tired, bored, so sometimes we just forget and seek for other eating patterns” (l5). until recently, all of the lecturer informants stated that they have done changes in lifestyle behavior, while some informants changed due to gaining negative impacts of unhealthy lifestyle behavior such as increasing weights, hypercholesterol, feeling unproductive while working and feeling ashamed about their overweight bodies. other factors that served as backgrounds were getting older, afraid of the risk of degenerative diseases and feeling older than they should be. this state is inversely proportional to the students, where all of the student informants have not performed healthy lifestyle behavior yet, and this is due to time limitations. the density of campus activities caused all of the students to not have more time to do physical activities, and besides, they are also involved in organizational activities, and thus the rest of the time is used for resting. another reason for not applying healthy eating lifestyle is ‘economic limitations’, because the limited amount of money affected their desire and the daily needs indonesian journal of nursing practices 34 for buying and eating fruits and vegetables are seldom fulfilled. therefore, they feel that: “being role models for performing healthy lifestyle is very strenuous” (s2,s5) . discussion in this study, we analyzed perspectives from lecturers and students about the role of healthcare workers as healthy lifestyle behavior role models, whereas most of the studies about role models are usually related to the medical education field, and as a consequence, there is a lack of sources of information concerning this discussion. however, as healthcare workers who also obtain the role of medical educator, it may be felt that the discussion of healthcare workers’ role as an educator would be similar to a clinical practitioner in the community. as a person being imitated and serving as a model about health to the community, healthcare workers are urged to be role models for good healthy lifestyle behavior. according to kelly, wills, jester, and speller (2016), several factors influence the eagerness from healthcare workers to be role models of a healthy lifestyle including credibility, responsibility, the impact of health behavior, professional duties and social norms. compared to the result of the study, that statement is especially true because unhealthy lifestyle behaviors which are done by healthcare workers are presumed irresponsible according to the point of view of the community, thus it would give impact on patients’ trust toward healthcare workers. furthermore, it would influence healthcare workers’ confidence to give counseling about health and their health condition would eventually lead to the community perspective that healthcare workers have lied and are not to be trusted if they are not modeling the healthy lifestyle. teaching methods by role modeling is judged to be strongly effective for teaching and achieving changes in students (jochemsen-van der leeuw, van dijk, van etten-jamaludin, & wieringa-de waard, 2013). students can more easily form selfidentity by seeing, analyzing and imitating actions, skills, and behaviors from their lecturers (haider, snead, & bari, 2016). the role modeling process could happen unconsciously, inadvertently, dynamically and continuously during the learning process (benbassat, 2014; nouri, ebadi, alhani, & rejeh, 2015). research has showed that there is a unique relation between modeling and the image of the role model, where being a model is not always something that can be taught and obtained through education. character qualities such as being enthusiastic, compassionate, open-minded, and having integrity and good relations with a patient should be known consciously by medical educators because their behavior would serve as an example for students beyond the learning process in the class (paice, 2002). according to this research, health education lecturers are sometimes not representing appropriate behavior towards health in a campus environment. this problem could be caused by a lack of attention toward the important aspects of being role models to shape the identity of students or community views toward their profession, although they are aware and understand about the responsibility of being a healthy role model (passi & johnson, 2016). being a negative role model would have a poor effect on students, causing confusion toward the difference between correct clinical management and actions showed by role models, which eventually might lead to students’ desperation in finding the truth between theory and practice. as a consequence, they would be constrained by ashamed feelings of not having enough experience and afraid of questioning lecturers (mileder, schmidt, & dimai, 2014). therefore, students’ identity formation through role modeling should be taught correctly by lecturers, by encourage the self-awareness to practice healthy behavior and self-confidence to be a good role model. on the other side, the health education institution also need to provide the health facilities for support healthy behavior. conclusion role model in healthcare workers is defined as a person who is recognized by society for exemplifying healthy lifestyle, so their behavior is considered worthy to be followed. this study shows only lecturers’ and students’ perspectives toward the role of healthcare workers as role models in the healthy lifestyle, therefore further studies are still vol. 4 no. 1 june 2020 35 needed to compare the perceptions of service users toward the role of healthcare workers mainly in the profession of lecturers as healthy role models. these future studies are aimed to increase awareness of all health professions in any field to perform healthy behaviors. acknowledgements the authors would like to thank the ministry of research, technology and higher education republic of indonesia (kemenristek dikti) as a scholar funder, staff of klinik bahasa faculty of medicine, public health and nursing universitas gadjah mada and all informants who participated in this research. references alateeq, m. a., & alarawi, s. m. 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(2015). the mentor as a role model and the importance of belongingness. br j nurs, 24(10), 532-535. https://doi.org/10.12968/bjon.2015.24.10.532 zhu, d. q., norman, i. j., & while, a. e. (2013). nurses’ self-efficacy and practices relating to weight management of adult patients: a path analysis. int j behav nutr phys act, 10(art. 131), 1-11. https://doi.org/10.1186/1479-5868-10131 vol. 5 no. 1 june 2021 51 ijnp (indonesian journal of nursing practices) vol 5 no 1 june 2021: 51-59 lailil fatkuriyah1, chae sun-mi2 1stikes dr. soebandi jember, indonesia 2college of nursing and the research institute of nursing science seoul national university, south korea corresponding author: lailil fatkuriyah email: lailil.fatkuriyah88@gmail.com the relationship among parenting style, self-regulation, and smartphone addiction proneness in indonesian junior high school students article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v5i1.11186 : 20 february 2021 : 23 march 2021 : 24 march 2021 abstract background: smartphone addiction leads to physical, psychological, and social consequences for users, particularly for adolescent users, as psychological development is still in the process of maturation. individual and family characteristics are shown to contribute to shaping adolescent’s behavior related to smartphone usage. specifically, perceived parenting style and selfregulation have been reported as significant factors influencing smartphone addiction among adolescents. objective: this study aims to identify the relationship among parenting style, self-regulation, and smartphone addiction proneness in indonesian junior high school students. method: this study used a cross-sectional, descriptive study design. data collection took place in five public junior high schools in jember from the 7th of january to the 8th of february, 2019. the total sample of this study was 158, purposively asked to fill out three questionnaires: parental authority questionnaire, self-regulation questionnaire, and smartphone addiction proneness scale. chi-square test and pearson’s correlation coefficients were used to test the relationship between two variables. result: the differences in smartphone addiction proneness between the risk group and non-risk group were significant depending on gender (p=0.004), daily smartphone usage time (p=0.025), and purpose of smartphone usage (p=0.001). a significant negative correlation was found between self-regulation and smartphone addiction proneness (r= -0.448, p=0.001). conclusion: the current study found that 11.4% of junior high school students in jember-indonesia were categorized into risk groups for smartphone addiction. gender, daily smartphone usage time, and purpose of smartphone usage showed significant differences between the risk group and the non-risk group. however, there was no difference in the parenting style of the mother between the two groups. selfregulation showed a significant association with smartphone addiction. keywords: indonesia, junior high school students, parenting style, self-regulation, smartphone addiction proneness http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/11186 indonesian journal of nursing practices 52 introduction smartphones have become an indispensable device for all groups of people, especially adolescents, due to their multipurpose and attractive features. based on the study by husni and fatulloh (2016), involving 1,551 elementary and middle school students in bandung-indonesia, approximately 67.4% of participants spent 1-4 hours per day using smartphones. the study showed that 18.6% and 7.7% of students spent 4-8 hours and 8-12 hours per day, respectively. meanwhile, approximately 6.3% of participants spent more than 12 hours per day. although smartphones have countless benefits, many harmful effects are also at stake when they are overused. furthermore, smartphone usage's increasing frequency and duration are positively linked to a higher risk of smartphone addiction (cha & seo, 2018; haug et al., 2015). several studies have reported that smartphone addiction can result in several physical, psychological, and social problems (cha & seo, 2018; lee et al., 2017). several studies found that family environmental factors have an important role in predicting smartphone addiction. specifically, a positive parenting style characterized by affection, rational explanation, and parents’ supervision could reduce smartphone addiction (bae, 2015). meanwhile, a negative parenting style characterized by parental rejection and restriction could increase the level of adolescents’ reliance on smartphones (bae, 2015; lian et al., 2016). individual characteristics have been considered an essential factor in human development. thus, adolescents’ characteristics should be factored in when determining the extent to which adolescents are affected by their environments (bronfenbrenner, 1979). nowadays, adolescents’ use of online space is strongly related to fulfilling their psychosocial development tasks, such as selfidentity, self-esteem, and social connection improvement (shapiro & margolin, 2014). haug et al. (2015) also reported that adolescents tended to utilize their smartphone features suited to their preferences as a way to manage their friendship and academic-related stress. these adolescents’ characteristics regarding technological utilization push adolescents to become firmly attached to their smartphones. in addition, the failure of self-regulation could increase media usage, which will develop into media addiction (osatuyi & turel, 2018). van deursen et al. (2015) showed that a low level of self-regulation increased the risk of smartphone addiction. the combination of the immature self-regulation of adolescents and the above characteristics of adolescents drives smartphone addiction more compared to the other age groups. adolescents face the troubling impacts of smartphone addiction, deteriorating their future as the nation’s next generation. however, studies investigating the correlation of parenting style, self-regulation, and smartphone addiction proneness among adolescents in indonesia remain limited. therefore, a study of the relationship among parenting style, self-regulation, and addiction proneness among junior high school students in indonesia becomes very important. methods this study was a quantitative study with a crosssectional approach. the study was conducted from the 7th of january to the 8th of february 2019 in five public junior high schools. purposive sampling was used to recruit participants for this study. the inclusion criteria in this study were as follows: student in grades 7-9 of junior high school in jember, smartphone user, living with both parents, and willing to participate in the study. students who lived with one parent, either mother or father, only, were excluded from the study. this study utilized the g-power software program version 3.1 to calculate the minimum sample size with a statistical correlation test. this study's significance levels, effect size, and power are 0.05, 0.25, and 0.8, respectively. this study's significance and power levels were based on a previous similar study by lee, chae, bang, and choi (2015). by counting for missing values and withdrawal, a missing rate of 20% was set. a total of 158 eligible junior high school students participated in this study. vol. 5 no. 1 june 2021 53 data were collected using three questionnaires. the first questionnaire was the smartphone addiction proneness scale (saps), consisting of 15 items ranging from 1 (strongly disagree) to 4 (strongly agree). smartphone addiction proneness is classified as follows: high-risk group (total score ≥45), potential-risk group (total score=42-44), and non-risk group (total score ≤41). only two categorizations of smartphone addiction proneness were used in the study, including non-risk and risk groups (kim et al., 2014). since there is no reliable and valid instrument for measuring smartphone addiction proneness in bahasa indonesia, the translation and content validity process were conducted using five stages of cross-cultural adaptation of self-report measurement guideline (beaton et al., 2000). the saps-indonesian version was reviewed by three experts to assess the content validity. content validity index (cvi) was calculated for item-level cvi (i-cvi) and scale-level cvi (s-cvi). in this study, all of the items of the saps-indonesian version produced an i-cvi of 1.00, indicating an excellent value. the scvi was 1.00, reflecting an excellent validity of the overall scale. the reliability test of saps was conducted as well, following the process of crosscultural adaptation. the reliability test of the sapsindonesian version involving 158 participants was verified with an overall cronbach’s alpha value of 79, indicating an acceptable internal consistency. parental authority questionnaire (paq) was used to measure adolescents’ perceived parenting style. the parental authority questionnaire (paq) indonesian version developed by tamami (2011) included father and mother versions. only the paq of the mother-indonesian version was used in this study. it consisted of 27 items, where each item was scored on a 4-point likert-type scale ranging from 1 (strongly disagree) to 4 (strongly agree). the items were categorized into three subscales, including authoritative, authoritarian, and permissive parenting styles. cronbach’s alpha coefficient of the paq of the mother version in this study was 86. each parenting style was later classified into three categories based on the mean score and standard deviation. self-regulation was measured using the selfregulation questionnaire (srq) indonesian version developed by restuti (2016). the srq indonesian version consisted of 23 items, and each item was scored on a 4-point likert-type scale ranging from 1 (strongly disagree) to 4 (strongly agree) for favorable items. unfavorable items were scored in reverse. cronbach’s alpha coefficient of the srqindonesian version in this study was 83. a higher total score of the srq indicated higher selfregulation ability. this study has passed the ethical clearance from the universitas muhammadiyah yogyakarta (umy) with ethical number 622/ep-fkik-umy/xii/2018. this study has also obtained research permits from the national political and society protection board (badan kesatuan bangsa dan politik/bakesbang) and the office of education of jember region. as the age of the participants was less than 18 years, the students who agreed to participate in the study received two informed consent forms, including student assent and parents’ consent forms. since the researcher did not meet the parents directly, the parents’ consent forms were enveloped and sealed. the students were then asked to deliver that form to their parents. the students and their parents had a week to read and sign the consent forms. only those who submitted both the participant’s assent form and parental informed consent form were included in the study. results as presented in table 1, out of the 158 participants, 88.6% (n=140) were identified as a non-risk group for smartphone addiction, and 11.4% (n=18) were classified as a risk group. among 18 participants in the risk group, five participants were classified into the high-risk group, while 13 participants were classified as a potential-risk group. to identify the differences in smartphone addiction proneness according to individual and family characteristics of participants between the non-risk group and the risk groups, the chi-square test and fisher’s exact test were performed. as evidenced from table 2, smartphone addiction proneness was significantly different based on some individual characteristics of participants, including gender (p=0.004), daily smartphone usage time (p=0.025), and purpose of smartphone usage (p=0.001). a pearson’s correlation coefficient was performed to identify the relationship between self-regulation indonesian journal of nursing practices 54 and smartphone addiction proneness. a negative correlation was found between self-regulation and smartphone addiction proneness (r=-0.448, p<0.001). it indicated that the higher the selfregulation is, the lower the participant's risk of becoming addicted to a smartphone will be. conversely, the lower the self-regulation is, the higher the participant's risk of becoming addicted to smartphones will be. discussion the prevalence of smartphone addiction proneness in this study was 11.4%. there is no survey nationally representing smartphone addiction in indonesia. thus, comparing this finding to the current situation in indonesia becomes quite challenging. however, this finding should be considered an important issue that needs more serious attention from relevant institutions to establish strategies to overcome these phenomena. individual characteristics of adolescents, including gender, daily smartphone usage time, and purpose of smartphone usage, showed significant differences between the risk group and the non-risk group. most participants in the risk group were female, whereas most participants in the non-risk group were male. in supporting the current study's finding, previous studies showed that smartphone addiction had been more prevalent among female adolescents (lee et al., 2017). another study reported that females exhibited 2.7 times more risk of smartphone addiction than males (lee et al., 2017). it might be because female adolescents were more disposed to use smartphones for social purposes, such as maintaining a social relationship with their valued people, prompting greater utilization of various communication services of the smartphone, such as chatting, texting, and accessing social networking sites (snss) (chiu et al., 2013). meanwhile, playing online games was the main predictor of smartphone addiction among males (chen et al., 2017). this finding implied that prevention and intervention strategies to overcome and reduce smartphone addiction among adolescents should be implemented by considering the gender perspective on smartphone use. daily smartphone usage time is found to be significantly different between the two groups. most participants in the risk group spent more than four hours on smartphone use, while most participants in the non-risk group spent less than four hours. some previous studies supported this finding. according to haug et al. (2015), aljomaa et al. (2016), and hussain et al. (2017), longer duration on smartphone use strongly predicted smartphone addiction, whereas shorter smartphone usage time negatively affected smartphone addiction (cha & seo, 2018). as junior high school students are still dependent on their parents and interact with their parents mostly in daily life, this finding emphasized a need of supporting parents in providing clear rules and time limits on daily smartphone use to their children. among other smartphone content, including music, online games, and streaming video, social networking sites (snss) were frequently used among adolescents. sns was revealed to have a more significant effect on smartphone addiction than the effect of game use (jeong et al., 2016). the first reason why sns exhibits the most substantial effect on addiction is that, once people access sns, they can also access various entertainment applications, such as online games, videos, and music (kuss & griffiths, 2017). second, sns enables people to either maintain relationships or create new connections with others from different areas across the world, something that cannot be done with other content on a smartphone (frehat & abushanab, 2014). third, people nowadays tend to use sns applications to send messages or make online calls rather than making conventional phone calls and messages, which require additional costs (salehan & negahban, 2013). these aforementioned benefits of sns pull more adolescents to become engaged in sns application, contributing to excessive smartphone use. as a result, the more frequently adolescents use sns is, the longer time they spent on smartphone use will be. it later increases the vulnerability to smartphone addiction. this finding, hence, proved that educational programs on good practices for using smartphones and sns are necessary with the goals that adolescents will be able to develop a healthy utilization of such communication tools. the two groups showed a significant difference regarding the purpose of smartphone use. getting vol. 5 no. 1 june 2021 55 new information and communicating with people were the two most essential motives in using smartphones in the non-risk group. meanwhile, participants in the risk group mostly used their smartphones for seeking fun and regulating mood. these findings were in line with a previous study in which students who showed minor addiction to smartphones were more likely to use their smartphones for communication and informationseeking. meanwhile, students who were dominantly using their smartphones to seek enjoyment and regulate their mood showed more significant addiction to smartphones (zhang et al., 2014). it might be because behaviors that produce feelings of fun and enjoyment are more likely to raise our motivation to keep doing the same behaviors (song et al., 2004). therefore, when smartphone users experience a better feeling and obtain pleasure when using smartphones, they are more likely to get addicted to smartphones. this result can be used to develop health education programs related to healthy smartphone use for the risk group by including fun and attractive activities such as gamebased learning, quizzes, and competition to improve the engagement of adolescents in the programs. both groups showed no difference in smartphone addiction proneness depending on perceived family socioeconomic status. regarding the parents’ education level, either the father’s or the mother’s education level appeared to not be statistically different between the two groups. akin to this study, cha and seo (2018) found that family income and parents’ education were not significantly related to smartphone addiction proneness among korean middle school students. similarly, kumcagiz and gunduz (2016) showed no significant difference in the mean scores of smartphone addiction among university students based on family economic background. furthermore, cha and seo (2018) argued that, since a smartphone provides various content tailored to the individual’s needs and interests, individuals from any level of socioeconomic status would easily find content in which they were interested or satisfy their needs. this finding demonstrated that, due to smartphones' convenient and multifarious functions, adolescents from families with different levels of socioeconomic status might have a similar risk of smartphone addiction. another variable reflecting the family characteristic of participants in this study was the mother’s parenting style. in this study, there was no difference in smartphone addiction based on mothers' parenting styles between the two groups. on the other hand, bae (2015) and yoo and kim (2015) reported that authoritarian and permissive parenting styles were significantly associated with smartphone addiction among adolescents. this finding may suggest using another measurement tool that can identify the parenting style of indonesian mothers more accurately. self-regulation showed a significant negative correlation with smartphone addiction proneness among indonesian junior high school students. this finding was in line with some recent studies which revealed that self-regulation was an essential factor in smartphone addiction. ching and tak (2017) stated that people having higher self-regulation skills became more aware of the rationale and the desired outcome of certain behaviors and had more worthwhile life goals. as a result, they were less likely to use smartphones uncontrollably. kim et al. (2016) also stated that the level of self-regulation ability could also reflect an individual’s capacity to delay satisfaction. individuals with a high sense of self-regulation would demonstrate higher selfdiscipline, a higher focus on long-term goals, and a greater capability to delay short-term gratification. therefore, those people showed a low tendency to attain the temporary satisfaction which smartphones can provide (ching & tak, 2017). ching and tak (2017) and gökçearslan et al., (2016) reported that students with lower self-regulation abilities were more likely to exhibit an addictive use of smartphones. it may be because individuals with poor self-regulation showed a low capability to avoid distractors and could not focus on their works (ramzi & saed, 2019). therefore, it seems necessary to facilitate adolescents in developing a higher selfregulation ability related to smartphone use. even though this study provides some contributions regarding smartphone use patterns and smartphone addiction proneness in indonesian adolescents, it has a limitation that should be considered. this study only involved 158 junior high school students from one city in indonesia. the number of students who participated in this study was very few compared to the total adolescents in indonesia. indonesian journal of nursing practices 56 conclusion individual characteristics of adolescents, including gender, daily smartphone usage time, and purpose of smartphone usage, showed significant differences between the risk group and the non-risk group. family socioeconomic and parent education level, which reflected the family characteristics in this study, had no differences in the two groups. the result of the bivariate analysis showed a significant association between self-regulation and smartphone addiction proneness. this present study provides meaningful information about the prevalence of smartphone addiction proneness in indonesia and the individual factors contributing to smartphone addiction proneness. this study can initiate other research in indonesia focusing on similar issues, which could subsequently discover an effective nursing intervention in reducing smartphone addiction among children and adolescents. this study also suggests that the indonesian government should establish a national prevention program related to smartphone addiction integrated into the school curriculum. acknowledgments we acknowledge the support received from the indonesian endowment fund for education (lpdp), ministry of finance, for providing research funding for this study. author contribution first author: designing the study, carrying out the data collection, performing a statistical test, and writing the manuscript second author: providing advice and guidance for conducting appropriate research, monitoring and supervising the progress of the study conflict of interest no existing or potential conflict of interest relevant to this article was reported references aljomaa, s, s., al.qudah, m, f., albursan, i, s., bakhiet, s, f., & abduljabbar, a, s. 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(2014). understanding the role of motives in smartphone addiction. paper presented at the proceedings pacific asia conference on information systems, pacis 2014, retrieved from https://www.scopus.com/record/displa y.uri?eid=2-s2.084928645102&origin=recordpage https://doi.org/10.1016/j.chb.2018.03.037 https://doi.org/10.1016/j.chb.2018.03.037 https://doi.org/10.19080/pbsij.2019.13.555863 https://doi.org/10.19080/pbsij.2019.13.555863 https://doi.org/10.1016/j.chb.2013.07.003 https://doi.org/10.1016/j.chb.2013.07.003 https://doi.org/10.1089/cpb.2004.7.384 https://doi.org/10.1089/cpb.2004.7.384 https://doi.org/10.1007/s10567-013-0135-1 https://doi.org/10.1007/s10567-013-0135-1 https://doi.org/10.1016/j.chb.2014.12.039 https://doi.org/10.1016/j.chb.2014.12.039 http://dx.doi.org/10.12934/jkpmhn.2015.24.2.127 http://dx.doi.org/10.12934/jkpmhn.2015.24.2.127 https://www.scopus.com/record/display.uri?eid=2-s2.0-84928645102&origin=recordpage https://www.scopus.com/record/display.uri?eid=2-s2.0-84928645102&origin=recordpage https://www.scopus.com/record/display.uri?eid=2-s2.0-84928645102&origin=recordpage vol. 5 no. 1 june 2021 59 table 1. smartphone addiction proneness of junior high school students (n=158) risk group (n=18) non-risk group (n=140) total (n=158) risk group high-risk group potential-risk group total score m (sd) 18 (11.4%) 5 (3.2%) 13 (8.2%) 44.17 (2.89) 140 (88.6%) 33.42 (4.82) 34.65 (5.76) table 2. differences in smartphone addiction proneness by individual and family characteristics (n=158) personal and family characteristics category non-risk group (n=140) risk group (n=18) x2 p n (%) n (%) age (years) 12-13 14-15 >15 59 (89.4) 75 (87.2) 6 (100.0) 7 (10.6) 11 (12.8) 0 (0.0) 0.978 0.613 gender male female 67 (97.1) 73 (82.0) 2 (2.9) 16 (18.0) 0.004† grade 7 8 9 48 (90.6) 55 (91.7) 37 (82.2) 5 (9.4) 5 (8.3) 8 (17.8) 2.575 0.276 smartphone ownership personal shared 134 (88.2) 6 (100) 18 (11.8) 0 (0.0) 1.000† daily smartphone usage time (hours) ≤4 >4 78 (94.0) 62 (82.7) 5 (6.0) 13 (17.3) 4.992 0.025 purpose of smartphone usage getting new information and communicating with people seeking fun and regulating mood 90 (95.7) 50 (78.1) 4 (4.3) 14 (21.9) 0.001† most frequently used content of smartphone social network sites (sns) others (music, online game, streaming video) 96 (86.5) 44 (93.6) 15 (13.5) 3 (6.4) 0.276† family’s socioeconomic status low moderate high 6 (100.0) 126 (87.5) 8 (100.0) 0 (0.0) 18 (12.5) 0 (0.0) 1.975 0.373 father’s education level elementary school high school university or higher 13 (100.0) 74 (89.2) 53 (85.5) 0 (0.0) 9 (10.8) 9 (14.5) 2.296 0.317 mother’s education level elementary school high school university or higher 14 (100.0) 72 (85.7) 54 (90.0) 0 (0.0) 12 (14.3) 6 (10.0) 2.612 0.271 permissive parenting style low medium high 20 (100.0) 98 (85.2) 22 (95.7) 0 (0.0) 17 (14.8) 1 (4.3) 5.012 0.082 authoritarian parenting style low medium high 25 (86.2) 94 (89.5) 21 (87.5) 4 (13.8) 11 (10.5) 3 (12.5) 0.282 0.868 authoritative parenting style low medium high 21 (95.5) 98 (87.5) 21 (87.5) 1 (4.5) 14 (12.5) 3 (12.5) 1.187 0.552 6. 11186 -lailil fatkuriyah; bookmark_clean.pdf 6. 11186 -lailil fatkuriyah-lampiran_clean.pdf vol. 5 no. 2 december 2021 76 ijnp (indonesian journal of nursing practices) vol 5 no 2 december 2021: 76-86 falasifah ani yuniarti1, djauhar ismail2, yayi suryo prabandari3, sri werdati4 1universitas muhammadiyah yogyakarta, indonesia 2,3,4universitas gadjah mada yogyakarta, indonesia corresponding author: falasifah ani yuniarti email: falasifah.ani@umy.ac.id placing priority on faith in providing a foundation for children to face puberty article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v5i1.12350 : 19 july 2021 : 01 august 2021 : 27 september 2021 abstract background: children will experience puberty at the age of 915 years, influenced by several factors. various changes require children to be ready to face them. teachers carry out preparations, especially those who teach in elementary schools. objective: this research is qualitative research that aims to explore the preparation made by teachers in preparing for puberty. a total of nine islamic-based school teachers were interviewed at their schools. methods: in-depth interviews were conducted using structured open questions. the analysis employed van manen’s method. result: this study raised three themes: the teacher's perception of student development, how the teacher prepares for puberty, and the problems faced in educating children to face puberty. conclusion: it is necessary to develop a model that can prepare children to enter puberty. keywords: menarche; pra puberty; puberty preparation in elementary school; sex education for school-age children introduction some children experience puberty at school age (612 years), mostly at 10-12 years old (chomaria, 2012; risman et al., 2016). according to havighurst (years), the developmental task theory of middle childhood states that children need to build healthy habits, learn the roles of men and women, build conscience, morality and values (manning, 2002). therefore, children of this age need attention, guidance and direction from adults such as their parents to develop properly and correctly (santrock, 2011; upton, 2012). islam has provided a detailed explanation of the issue of sexuality. islam has regulated what is accepted and not accepted in sexual behavior. in addition, decency and indecency are instincts that allah created to regulate all aspects of life with the type and other aspects of life behavior such as dressing, eating and so on (halstead & reiss, 2004; hastuti et al., 2016). muslims in indonesia are expected to implement sexual education for muslim children based on religious rules and norms in islam. it needs to be taught and emphasized to children to avoid violence, including sexual problems. sexual education is important, and the role of parents, teachers and the environment is essential. each has a role and it complements each other (akers et al., 2011; hastuti et al., 2016; jackson et al., 2012; lee et al., 2015; leerlooijer et al., 2014; protogerou & johnson, 2014). several obstacles were encountered in the implementation of sexual education for school-age children, namely inadequate parental knowledge, the assumption that sexual problems are taboo and dirty or sinful to talk about, and ignorance of how to http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/9558 indonesian journal of nursing practices 77 convey, and discrimination as a teenager accessing sexual health services (grossman & charmaraman, 2016; kamaljit et al., 2012; khubchandani et al., 2014; purwati & anjarwati, 2014; tabatabaie, 2015; weatherley et al., 2012). inadequate parental knowledge occurs due to differences in knowledge, experience, cultural, religious and educational background (allen et al., 2011). those reasons prevent older people from providing inadequate information as children do not get enough information about sexual education. consequently, children seek information from easily accessible sources or with their friends. they easily get information through their electronic devices. friends can influence children positively or negatively. children easily imitate what they see without realizing whether it is good. the aspects that stimulate sexual reactions such as sex films, soap operas, books and magazines with sexy pictures, temptations and stimulation from men and women, as well as direct observation of sexual behavior, will result in peaking or increasing sexual reactions and sexual maturity faster in children (fathunaja, 2015; rahmawati, 2015; widanarti & nashori, 2015; yusuf, 2015; zahara & karyani, 2018). on the other hand, parents cannot completely filter out these negative influences. therefore, active mediation is needed to build self-awareness and help children sort out whether the content is good or bad (catherine et al., 2017). in addition, information obtained regarding reproductive health is also limited. children who are not directed are likely to get the wrong information; thus, they form wrong perceptions. according to the data and information center of the indonesian ministry of health (infodatin) regarding the adolescent reproductive health situation in 2013, data showed the percentage of pre-marital sex for adolescents aged 10-14 years increased from 2007 to 2012; in males, it increased from 3.7% to 4.5% while in females aged 15-19 years, pre-marital sexual activity decreased from 1.3% to 0.8%. (pusat data dan informasi kementrian kesehatan ri, 2015). efforts to raise children’s awareness about sexuality issues can be carried out. berman, snyder, kozier dan erb (2008) suggested that health promotion is a habit motivated to enhance good standing and actualize potential health (berman et al., 2008). schools are one of the places where health promotion programs are implemented. children spend years in school, and programs created in schools can be more focused and cost-effective (berman et al., 2008). some interventions related to sexual education have been carried out in primary school students in several studies (references). winarti and colleagues (years) conducted a study in the fifth grade on providing health education with elementary school students' anxiety in facing menarche. the results showed a significant effect of providing health education on students' anxiety who faced menarche (winarti et al., 2017). however, some children have experienced menstruation in the fourth grade of elementary school. the result from a private secondary islamic school study triggered a question of elementary school children’s knowledge of sexual health where puberty school children are more likely to occur (lukmana & yuniarti, 2018). thus, it is necessary to prepare beforehand to prepare children better when entering puberty. this study aims to explore the experiences of islamic base elementary school teachers in preparing children for puberty. methods to explore the experiences of islamic base elementary school teachers in preparing their students, the researcher employed a qualitative study. qualitative descriptive research explores the phenomena (polite & beck, 2008). a semistructured interview method was used, and an interview guide included questions about their perception of puberty on children nowadays. the preparation needs to be made for children who are facing puberty, what they have done to prepare their children for puberty, what the students need to know in preparing themselves for puberty in accordance with islamic teachings, how preparation for puberty is related to curriculum, and what should be given to children and how it will be given to prepare children to puberty. interviews were conducted with nine teachers currently teaching upper grades in three muhammadiyah elementary schools in yogyakarta. the teachers were homeroom teachers, science, religion, and sports teachers. the school was chosen with permission from majelis pendidikan dasar dan menengah (primary and secondary education board) of muhammadiyah yogyakarta; each school vol. 5 no. 2 december 2021 78 has two groups of level four and five. the head of the school sent the name of the teachers. firstly, the researcher sent a bundle of information about the research to the potential participant, and then the researcher obtained the informed consent from the participants in two days. the researcher conducted interviews with prospective participants who were willing to become research participants. data collection was carried out by in-depth interviews with 9 (nine) teachers for about an hour face to face in the sitting room of the schools. two research assistants helped the researcher take notes and documentation during the interviews. all interviews were recorded using a sony ic recorder. after conducting the interview, the research assistant transferred the interview recordings into a conversational transcript form, using the otranscribe application. after the transcript was made, the researcher double-checked by listening to the conversation and reading the transcript. it was done to minimize the possibility of a loss of information. the researcher only allowed the research assistant to transcribe the recorded interview and save the recordings files to protect participant identity. furthermore, this study was analyzed by van manen's method. it consisted of three methods: a holistic approach, selective approach, and detailed approach. firstly, the researcher read the text in the holistic approach and captured its meaning. secondly, in the selective approach, the researcher highlighted or pulled out statements or phrases that seemed essential to the experience under study. finally, the researcher analyzed every sentence (polite & beck, 2008). this research had received ethical approval from the ethics committee of the faculty of medicine and health sciences, university of muhammadiyah yogyakarta number 001/epfkik-umy/i/2020. result after the researchers read the interview transcripts and analyzed the data using van manen’s method, the researchers set three emerging themes. these themes included the teacher's perception of student development, how the teacher prepared for puberty, and the problems faced in educating children to face puberty. (see figure 1) figure 1 shows two sub-themes, namely physical development and social development. teachers observed that their students developed faster than their time. girls obtained their period earlier, even in fourth grade. meanwhile, boys grew taller quickly. there were cases where children who were exposed to pornography had different views. “…when streaming, sometimes cartoons appear… but when the boy and girl are close together, the two children have a different way of looking at them from their friends, who incidentally see the children as children. the child knows it from his eyes, he can see it, oh his eyes are eyes that…” (participant 2) two themes can be raised from the social side: friendship with the opposite gender and gadgets. regarding socializing with the opposite gender, the participant perceived that students were already embarrassed to play with the opposite gender, especially girls who have experienced menstruation. those who got used to playing with their friends began to limit themselves after puberty. some children have started to be attracted to the opposite gender; some claimed to have a boyfriend, as stated by one participant. “there are some fifth graders who already have girlfriends…the emotion is that now there is such thing as dating. in my past, there was no such thing; for example, we were in the same class sitting with the boy, there was no one who made fun of it by saying 'hiiii hiiii', now, ihi ihi… wow”. (participant 3) as for gadgets, some children already have cellphones. teachers ask parents to postpone giving children gadgets as they are still not ready to be morally responsible for using them. however, parents have already given it. as a result, they do not freely control the use of gadgets. "due to cellphones, children sometimes are against their parents; they argue and can continue to be against them in the form of disobedience, and i see more or less the news spread outside has a negative impact.” (participant 1) regarding the use of gadgets, children exposed to pornography have a different perspective, as one of the participants stated. indonesian journal of nursing practices 79 "the child's behavior is more... what is it... from the way they look, for example, from the first glance they stare at each other, then the other students see, that is the way they think, na.." (participant 6)] how teachers prepare children for puberty figure 2 shows the subtheme arising under the theme of how teachers prepare children for puberty. those aspects included method, media and subject matter. teachers used various methods to deliver material related to the preparation of puberty, for example, through the advice given at the beginning of the lesson or inserted during the lesson or using a certain moment. the teacher also held a girls' class on fridays when the boys performed friday prayers. teachers prepared their students for puberty in various ways. according to one participant, teachers alternated roles in interacting with students, sometimes as teachers, parents, friends, police, or judges. it is done so that students captured the value presented. teachers frequently paid attention to their students and advised them through roles based on the circumstances. (see figure 2) the teacher prioritized lessons about faith in allah swt, supervision from allah, a description of the grave, and accountability for all actions on the last day. one participant stated, “… i have not focused on material changes to his body or anything else, i pay attention to aspects of the mindset, so what is it, that there is a god who watches over you, maybe that is the best, so it is more divine if i do not waste it” (participant 2) “…for me, the first is faith. i emphasize faith… well, when we have faith, we will talk about puberty and its dangers.. it will be better.” (participant 5) in addition, in terms of faith lessons, the teacher also conveys lessons about the association between men and women and physical changes during puberty “…it seems that there is a lesson, but i was more concerned about the separation, so i was more careful. covering the aurat of course, then the association between men and women is also carried out, yes, some knowledge about maturity, related to being an adult and how to behave, has been conveyed, especially for women.” (participant 1) these materials are implemented on various occasions and in several ways. for example, there are cases outside of school that are interesting to discuss during lessons and girls' classes. meanwhile, the methods used are, for example, by showing related programs from youtube, giving a kind of trauma to children, and scolding children for violating principles. the trauma in question provides an experience difficult for children to forget. some of the lessons are contained in the curriculum, for example, physical changes during puberty, which are given in sixth grade, about respecting others, attitudes towards the opposite gender, body parts that may and may not be touched and problems with taharah (cleanliness), tayammum and water are given since students are in the first grade. “…from grade one to grade six, i also taught students about body parts, basically about body parts that should not be touched...” (participant 5) “…yes, first grade, second grade, because we introduce ablution, tayamum, and najis including moderate and heavy level. furthermore, in terms of the taharah level and purification, there is a level of using water, which started in first grade. there is…” (participant 1) in addition to the students, a meeting was also held with parents. the meeting is held during academic report distribution day or regular meetings filled with parenting lessons. on that occasion, the teacher again equalizes the perception of parents' responsibility for children's education, where the parents will bear the child's sins if the child is not well-educated according to god's command. "... here every month there is a recitation on sunday morning, after that, a consultation is held with the student's guardian ..." (participant 4) problems encountered in educating children to face puberty there are at least three issues of educating children to face puberty, as shown in figure 3. the issues vol. 5 no. 2 december 2021 80 come from the internal and external parties. the problems include an unclear explanation about puberty, parents who lack synergy with the school, unclear materials, and a less supportive environment and friends. the unclear authority in providing material about puberty may be due to the lack of teacher coordination in this issue. thus, the material is given based on the initiative of the teacher. (see figure 3) sometimes, some parents are not in line with the teacher in educating their children. parents do not carry out what has been conveyed in the teacher and parent meetings. the teacher knows this issue from the student's confession, like the problem of cell phones, which according to the teacher, is not yet time for students to have since they do not have the responsibility to use them. some parents give it as a gift, and that the ownership is in the hands of the child, and parents will find it difficult to control. "...how to use sanitary napkins or something like that, you know, it has never been taught, so i do not know whose authority it is, teacher's authority i think, and sports teachers or maybe parents should tell me how to use sanitary napkins properly" (participant 8) “…as i am a religious teacher, i have to give this because it is related to purification, about menstruation, what to do after menstruation, etc. if the curriculum does not exist and the teacher does not explain it themselves, they will be surprised in grade 6 about what menstruation is, so they do not know what it was like…” (participant 1) furthermore, other influences come from friends and the environment. of course, the scope of teacher supervision cannot extend to the environment outside the school and children's playmates outside of school. bad influences often occur due to friends outside this school. discussion based on the results as shown in figure 1, 2 and 3, three themes emerged from this study: teachers' perception of student development, teachers’ preparation for students’ puberty, and the problems encountered in educating children to face puberty. two sub-themes were raised regarding the development of children observed by the teacher, namely physical and social development. the teacher stated that girls experienced earlier menarche and boys experienced faster height gain. puberty for boys and girls in developed countries has decreased since the 1800s. the age difference of puberty is about three years from the 2000s. it occurs due to changes in social structure, improved nutrition and increased health standards. furthermore, life stress also plays a role in aging (bellis et al., 2006). this decrease is not related to gestational age at birth. menarche in children born prematurely occurs later than in those born normally (hui et al., 2012). however, social puberty is not as accelerated as physical puberty. the age of social maturity of children does not correlate with physical maturity. thus, various problems can arise, such as physical problems, academic problems, difficulties in communicating with friends, parents and family, high-risk behavior, early pregnancy, and so on (mostofi et al., 2018). meanwhile, in terms of the problem of height, indonesia has experienced stunting for a long time. this stunting condition causes childrens’ low height in their age. stunting probably occurred after the forced cultivation program carried out by the dutch colonial. the land they cultivated for family needs was reduced in size, which also impacted the health of family members. it leads to a more serious problem during japanese colonialism. after indonesia's independence, stunting remains a major problem in children health under five. during the new order regime, health management was more organized. meanwhile, during the administration of president susilo bambang yudhoyono, the stunting problem was brought back for improvement. during the administration of president jokowi, stunting was still a priority in the health sector, resulting in a decline of up to 30% (siswanto, 2019). thus, it is possible that the government program in the health sector prioritizes stunting, improvements in the economy, and increasingly fulfilled nutrition, causing children's height to increase faster. the teachers’ statement about the social development of their students was that there was an interest in the opposite gender, that the students hesitate to play with the opposite gender and possession of gadgets. in school-age, children are already familiar with the world outside the family. children have been hanging out with other children indonesian journal of nursing practices 81 and interacting with the opposite gender. some children have started to be interested in each other; some even have a boyfriend. according to sullivan, having a romantic relationship is an important developmental stage in a child's life and a change that a child will experience (chomaria, 2012; ivanova & veenstra, 2012; risman et al., 2016). however, islam teaches that attraction feeling towards the opposite gender is controlled by lowering the gaze, controlling hesitancy, teaching what is allowed and not allowed, avoiding mixing of men and women, etc. therefore, it is natural for children to feel hesitant when hanging out with the opposite gender. this trait will keep them from transgressing as they feel that allah is always watching over them (chomaria, 2012). the last thing the teacher stated was gadgets, especially smartphones. children easily access the information only in a safe hand. the problem is that the accessible information is random, regardless of the appropriateness (chomaria, 2012; shin et al., 2019). therefore, children need to be equipped with limiting views and curiosity and saying "no" to pornographic things. the teachers prepare their students to face puberty in various ways, namely by giving advice, doing various roles, and carrying out girlhood classes. at the same time, the media frequently used is video. what is conveyed to children concerns faith in allah, the relationship between men and women and physical changes. the teacher’s experience in interaction with the students makes them understand their students and influences their ways of promoting sexual health and preparing them for puberty. ulwan (2017) mentioned that advice given to children at the right time would hit and be easier for children to understand. teachers use occasions to advise their students, such as caring for the children when they have problems, one-on-one communication, and discussing problem-solving. there was an incident when the students did not memorize the prayer spell given by the teacher weeks before. it made the teacher unpleasant. the teacher used this chance to admonish and advise them about the importance of memorizing the prayers spellings, which directly affected the students. since then, the students have been able to memorize the spell. abdullah nashih ulwan already mentioned the advice method. he stated that sincere and influential advice would significantly impact if delivered with a clean heart and wise mind. these pieces of advice can be conveyed in several methods, namely: telling stories, dialogues and asking questions, starting with an oath in the name of allah, inserting jokes in conveying advice, arranging advice to avoid boredom, giving examples with hand demonstrations, with the media of images, with practice and take advantage of the momentum, diverting to the important things and showing what is forbidden (ulwan, 2017). teachers employed only some methods, such as telling stories, telling jokes, giving examples, taking momentum, and showing what needs to do and not to do. meanwhile, the material taught emphasizes faith in god, the interaction of men and women and physical changes. teachers mentioned that faith in god is a basic thing emphasized to children. if the child already has a strong faith in allah, it will be easier to follow what is ordered and prohibited. this statement was also mentioned by ulwan (2017) that teachers and parents should prioritize the education of faith in allah swt. the cultivation of faith in allah swt is carried out by contemplating and thinking about the creation of the heavens and the earth, which is carried out from sensing rational things, from small parts to whole things, and from simple to complex ones. it makes children have a strong foundation of faith based on evidence and satisfactory arguments (ulwan, 2017). signs in a relationship need to be given to children as they will experience feelings of attraction and ripple when close to the opposite gender. these signs are given to understand the relationship in a healthy manner (chomaria, 2012; madani, 2003). however, some problems arise both from internal and external parties of the school. the internal problems include the lack of coordination between teachers and the material hardly understood by students. meanwhile, external problems include parents, friends and the environment. the children are the responsibility of the teacher during school time. however, when they return home, the responsibility goes back to their parents. furthermore, when children go outside, they will get vol. 5 no. 2 december 2021 82 a bad influence from their friends or environment if they do not have strong provisions. therefore, children need to be given a foundation that can counteract the negative impacts of the environment. this provision can be instilled by parents and teachers. thus, it is necessary to have good communication and relationships between parents and teachers in this case. what is taught in school can be applied at home and vice versa. moreover, if there is a problem with the child, both can work together to solve it, not blaming each other (chatib, 2016). it was revealed in interviews through the teacher’s statement that sometimes parents were not in tune with school education which caused children to behave inappropriately. teachers need coordination in providing material to students about who teaches and what needs to be taught. there is nothing wrong with repetition as it will strengthen students' understanding. in terms of external problems, the teacher cannot control them. in arabian states, except for tunisia and iran, there are very few programs addressing young people's sexual and reproductive health. curricula about the topics were rare. if there were few, the teachers frequently skipped over it (dejong et al., 2005). meanwhile, in malaysia, the problem was almost similar in arabic states. sex and reproductive education were prepared inadequately by teachers, such as instruction and teaching materials and a lack of school and community support (kamrani & yahya, 2016). it is likely that sex and reproductive education are still challenging to teach in many countries. therefore, the program is needed to prepare their puberty, especially for school-age children. the model contains guidance on sex education based on child development, relationships with others, including etiquette (adab), and faith to allah swt. this study was conducted in three elementary schools with islamic backgrounds. it only conducted interviews with nine teachers. however, the study results can be used to determine the next steps. the results of this study indicated that the coordination between teachers was still limited; thus, the authority of each teacher in providing the material was unclear. in addition, it is necessary to involve parents in preparing children for puberty and that a harmonious relationship between teachers and parents is developed. furthermore, the researcher proposes a guidebook on preparation for puberty that teachers, parents and children can use to facilitate the delivery of material and as learning material for students. conclusion teachers prepared students for puberty with various methods, media, and materials. coordination and cooperation between parents and teachers were needed to prepare children to enter puberty. further researchers can develop media that can be used as references for teachers, parents, and children. besides, further research is also suggested to carry out by using quantitative and qualitative research methods with larger and wider samples or participants to generalize this research. acknowledgement this article was presented at iconurs 2020 in icosi of universitas muhammadiyah yogyakarta. this research was conducted with financial assistance from bppdn, lp3m umy, and the faculty of medicine and health sciences umy. the authors would like to thank the education council for the muhammadiyah regional management of yogyakarta city, the school administrators, teachers, and students where the research was conducted, and the assistants in this research. references akers, a. y., holland, c. l., & bost, j. 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https://ejournal.almaata.ac.id/index.php/jnki/article/view/360 https://eprints.ums.ac.id/59799/1/naskah%20publikasi.pdf https://eprints.ums.ac.id/59799/1/naskah%20publikasi.pdf indonesian journal of nursing practices 85 perception of teachers on the development of students figure 1. children's development observed by teachers figure 1. teachers’ preparation to face puberty vol. 5 no. 2 december 2021 86 figure 2. the problems encountered by teachers jurnal mjn vol. 3 no. 1 juni 2016.indd 43 muhammadiyah journal of nursing errick endra cita1, tri wulandari 2, yuni permatasai istanti 3 1mahasiswa program studi magister keperawatan universitas muhammadiyah yogyakarta, 2dosen fakultas kedokteran universitas muhammadiyah yogyakarta, 3ketua program studi magister keperawatan universitas muhammadiyah yogyakarta korespondensi : universitas muhammadiyah yogyakarta, indonesia. email: endracitta@gmail.com terapi islamic self healing terhadap quality of life pada klien gagal ginjal kronis dengan terapi hemodialisa abstrak latar belakang. pengukuran terhadap kesehatan yang berkaitan dengan quality of life penting dilakukan untuk mengetahui bagaimana pengaruh penyaktit terhadap kehidupan. upaya dalam pengobatan nonfarmakologi telah dilakukan untuk meningkatkan quality of life pada klien dengan gagal ginjal kronik. terapi islamic self healing adalah terapi nonfarmakologi yang didalamnya terdapat aspek tausiah, doa, dzikir dan meminum air zam-zam. tujuan dari penelitan ini adalah membuktikan efektifi tas terapi islamic self healing dalam meningkatkan quality of life. metodologi. penelitian ini bersifat kualitatif dengan menggunakan desain action research. jumlah partisipan pada penelian ini sebanyak 5 partisipan, metode pengambilan sampel dengan purposive sampling. pengumpulan data pada penelitian ini dengan semi struktur wawancara, observasi dan dokumentasi untuk mengeksplorasi quality of life dan efektifi tas dari terapi islamic self healing. analisa data dilakukan dengan manual sampai tema-tema ditemukan. hasil. analisa secara tematik telah didapatkan. empat tema telah teridentifi kasi pada qualty of life sebagai dampak dari penyakit gagal ginjal kronik : gangguan terhadap status fi sik, terhadap status psikologi, dan terhadap status hubungan sosial dan lingkungan. tiga tema telah teridentifi kasi sebagai dampak positif terapi islamic self healing terhadap quality of life pada pasien dengan gagal ginjal kronik yaitu dampak positif terhadap fi sik, dampak positif terhadap hubungan sosial dan dampak positif terhadap status psikologi . kesimpulan.berdasarkan analisis terhadap hasil wawancara dari seluruh partisipan gagal ginjal kronik dengan terapi hemodialsia terhadap quality of life didapatkan hasil bahwa terapi islamic self healing dapat meningkatkan quality of life terutama pada domain psikologi. key word :gagal ginjal kronik, islamic self healing, quality of life. abstract background. the measurement of health that related to quality of life is necessary to fi nd out the impact of the illness to the life. non pharmacology therapy is being used to enhance patients with chronic renal failure quality of life. islamic self healing therapy is non pharmacology therapy that includes counseling aspect, prayer, dzikir and drinking zam-zam water. the purpose of this research is to prove the eff ectiveness of islamic self healing therapy in improving quality of life. methodology. this study design is qualitative using action research, with 5 participants and purposive sampling. collecting data in this study with semistructured interviews, observation and documentation to explore the quality of life and the eff ectiveness of islamic self healing therapy. manual data analysis is used to fi nd the theme out. results. thematic analysis has been obtained. four themes have been identifi ed in qualty of life of patients with chronic renal failure: the disruption of the status of the physical, the psychological status, and the status of social relationships and environment. impact of self healing islamic therapy to quality of life in patients with chronic renal failure have identifi ed three themes, includes the positive impact on the physical, social and psychological status. conclusion. based on an analysis of interviews of all participants with chronic renal failure therapy hemodialsia showed that islamic self healing therapy can improve the quality of life, especially in the domain of psychology. key word: chronic renal failure, islamic self healing, quality of life. 44 muhammadiyah journal of nursing pendahuluan insidensi gagal ginjal kronik di indonesia diduga sebesar 100-150 tiap 1 juta penduduk per tahun pada tahun 2000 terdapat sebanyak 2.617 pasien dengan hemodialisa dengan beban biaya yang ditanggung oleh askes sebesar rp 32,4 milyar dan pada tahun 2004 menjadi 6.314 kasus dengan biaya rp 67,2 milyar [1]. di indonesia, yaitu berdasarkan data survei yang dilakukan pernefri baru-baru ini mencapai 30,7 juta penduduk. menurut data pt askes, ada sekitar 14,3 juta orang penderita penyakit ginjal tingkat akhir (pgta) yang saat ini menjalani pengobatan yaitu dengan prevalensi 433 perjumlah penduduk menurut ketua perhimpunan nefrologi indonesia (pernefri) dr. dharmeizar [2]. insiden dan prevalensi modalitas untuk hemodialisa, peritoneal dialisa, dan transplantasi ginjal pada tahun 2010 per satu juta penduduk yang menjalani hemodialisa sejumlah 316, peritoneal dialisa 23,3, transplantasi 7,9[3]. mayoritas terapi dialisa yang dijalani pasien crf adalah terapi hemodialisa[4]. dampak secara fi sik menimbulkan gejala-gejala seperti enselopati, cegukan, perikarditis, mual, muntah, pruritus, malaise, impotensi, gangguan menstruasi, dan neuropati (campuran motorik dan sensorik) (kowalak, 2011). pada penelitian yang dilakukan oleh chen (2010) [7] pada 200 pasien dengan hemodialisa didapatkan 35% mengalami depresi, kecemasan sebesar 21%, dan bulan sebelumnya dengan ide bunuh diri sebesar 21,5%, tingkat depresi lebih tinggi daripada kelelahan dan terjadi penurunan quality of life. pengukuran terhadap kesehatan yang berkaitan dengan quality of life (domain fi sik, psikologis, hubungan sosial dan lingkungan) penting dilakukan untuk mengetahui bagaimana pengaruh penyaktit terhadap kehidupan [7]. untuk mengatasi gangguan psikologi/mental pada pasien dengan hemodialisa telah dilakukan, baik pengobatan farmakologi dan nonfarmakologi. upaya dalam pengobatan nonfarmakologi salah satunya adalah cognitive behavior teraphy (cbt) [8]. , intradialytic exercis, humor, yoga, meditasi, imageri, music terapi dan doa yang dapat meningkatkan kondisi psikologis dari individu[10]. pengobatan islamic self healing merupakan pengobatan nonfarmakologi yang mempunyai dasar pemikiran dari pengobatan islam yang diadalamnya terdapat aspek hikmah faidahf a i d a h a d a n ya p e n ya k i t , d o a , d z i k i r d a n herbal (pengobatan dengan air zam-zam) yang bertujuan untuk mendatangkan keridhaan allah, menguatkan hati dan badan. mengikuti jejak rosulullah muhammad saw, merupakan suatu sunnah bagi umat islam, termasuk mewarisi metodologi pengobatan. allah berfi rman: ”hai manusia, sesungguhnya telah datang kepadamu pelajaran dari tuhanmu dan penyembuh-penyembuh bagi penyakitpenyakit (yang berada) dalam dada dan petunjuk dan rahmat bagi orang-orangnya yang beriman” (qs:yunus 57). sampai saat ini belum banyak penelitian di bidang keperawatan untuk mengkaji terapiterapi modalitas secara islami pada pasien dengan gagal ginjal kronik deangan terapi hemodialisa. fenomena pada latar belakang diatas menjadi motivasi tersendiri bagi peneliti untuk melakukan penelitian tentang terapi islamic self healing terhadap quality of life pada klien gagal ginjal kronis dengan terapi hemodialisa. tu j u a n u m u m p e n e l i t i a n i n i a d a l a h “ m e n i n g k a t k a n q u a l i t y o f l i f e d e n g a n implementasi islamic self healing pada penderita gagal ginjal kronis dengan terapi hemodialisa dan untuk mengetahui efektifi tas dari terapi islamic self healing. hasil penelitian ini diharapkan m e m p e r k a ya k h a s a n a i l m u k e p e r a wa t a n khususnya keperawatan nefrologi terkait dengan terapi modalitas keperawatan. metode 1. partisipan sampel dalam penelitian ini dipilih dengan pertimbangan dan tujuan tertentu, dengan 45 muhammadiyah journal of nursing teknik pengambilan sampel yaitu purposive sampling[21]. partisipan yang digunakan sejumlah 5 partisipan gagal ginjal kronik dan 2 orang profesi. besar sampel dalam penelitian ini ditentukan oleh pertimbangan informasi dimana penentuan unit sampel dianggap telah sampai pada taraf “redundancy” [5] [22]. adapun kriteria inklusi partisipan dalam penelitian ini adalah: a) diagnosis gagal ginjal kronik b) dapat berkomunikasi dengan orang lain c) memiliki pendengaran yang baik d) klien belum pernah mendapatkan islamic self healing sebelumnya. e) beragama islam f) mendapat terapi hemodialisa dua kali dalam satu minggu. g) umur ≥18 tahun tabel 1 karakteristik partisipan dan profesi karakteristik partisipan jumlah n % dari partisipan pasien jenis kelamin laki-laki 4 5 80 perempuan 1 20 status kawin 3 5 60 belum kawin 2 40 umur 20-29 tahun 1 5 20 30-39 tahun 3 60 40-49 tahun 0 0 50-59 tahun 1 20 pekerjaan bekerja 2 5 40 tidak bekerja 3 60 pendidikan sd 1 5 20 smp 1 20 sma 3 60 lama hemodialisa ≤ 1tahun 2 5 40 karakteristik partisipan jumlah n % dari partisipan > 1 tahun ≤ 5 tahun 2 40 > 5 tahun 1 20 profesi umur jk pendidikan ahli spiritual 40 lakilaki s2 perawat 43 lakilaki s1 profesi 2. metodologi/cara penelitian penelitian ini bersifat kualitatif dengan m e n g g u n a k a n d e s a i n a c t i o n r e s e a r c h , d e n g a n p r o s e d u r p e n e l i t a n m e n u r u t kemmis dan mctaggart [11] . prosedur itu membentuk siklus seperti spiral yang terdiri dari perencanaan, tindakan, observasi, dan refl eksi. pada penelitian ini tahap plan yaitu menerencankan implementasi islamic self healing. pada tahap action yaitu pelaksanaan islamic self healing. pada tahap observation yaitu melakukan observasi pada pelaksanaan tahap action. tahap refl ection yaitu menulis refletif, manganalisis dan mengintepretasi data dari partisipan berupa pengalaman hidup partisipan terhadap terhadap penyakitnya, dampak terapi islamic self healing terhadap kualitas hidupnya dan pendapat partisipan terhadap terapi islamic self healing. gambar 1: alur penelitian tindakan (kemmis & mctaggart’s, 2007) 46 muhammadiyah journal of nursing alat/instrumen yang digunakan untuk pengambilan data dalam penelitian ini adalah guide terapi islamic self healing yang sebelumnya telah disusun oleh peneliti dengan dasar pemikiran dari al-quran dan alhadist, panduan wawancara, alat perekam dan instrumen quality of life kuesioner whoqolbref. wawancara dengan cara berhadap-hadapan, peneliti melakukan wawancara perorangan, untuk mendapatkan kesan bebas dan wajar peneliti menggunakan wawancara tidak terstruktur yang dilakukan secara individu. pertanyaan-pertanyaan yang diberikan sifatnya spontanitas dan tergantung dari pewancara sendiri. pertanyaan yang dilontarkan untuk menggali data, informasi dan pengalaman partisipan adalah pengalaman hidup pasien dengan gagal ginjal kronik, ekspolrasi kondisi psikologi, spiritual dan emosional sebagai dampak dari penyakit dan perawatan hemodilaisa, pertanyaan terbuka berkaitan dengan proses pelaksanaan implementasi islamic self healing dan dampaknya. seluruh partisipan diberikan inform consent sebelum dilakukan wawancara dan terapi islamic self healing. analisa terhadap hasil wawancara secara tematik dilakukan secara manual dengan proses mengumpulkan data-data mentah (transkripsi, data lapangan), mengolah dan mempersiapkan data untuk dianalisis, membaca keseluruhan data, menkoding data (manual), menentukan sub kateori tema-tema, membuat deskripsi dan tema-tama, dan mentintepretasikan tema-tema [5] [22]. untuk melakukan uji kredibilitas data, penelitian ini menggunakan cara triangulasi data dan member check. hasil pelaksanaan terapi selama tiga minggu dengan frekuensi terapi dua kali dalam satu minggu didapatkan hasil yaitu terdapat peningkatan quality of life dengan skor sebelum diberikan terapi dengan total skor 81 dan terjadi peningkatan dengan skor 99 setelah pemerian terapi isalmic self healing dalam hal menikmati hidup, keberartian dari arti hidup, penerimaan terhadap diri, perasaan negatif yaitu berupa feeling blue’(kesepian), putus asa, cemas dan depresi, dan kepuasan hidupnya. gambaran kondisi status psikologis pasien dapat dilihat pada gambar 2. dibawah ini: gambar 2: gambaran skor kondisi psikologis partisipan terhadap terapi islamic self healing dengan menggunakan evaluasi kuisioner who-breef pada domain psikologi analisis wawancara dengan partisipan teridentifi kasi beberapa tema dibawah ini yaitu : a. dampak penyakit dan pengobatan terhadap status fi sik, psikologis, hubungan sosial dan lingkungan b. dampak terapi islamic self healing. terhadap status fi sik, psikologis, hubungan sosial. c. hasil refleksi partisipan dan ahli spiritual terhadap terapi islamic self healing terhadap aturan dalam pelaksanaannya. tujuan utama dari peneltian ini adalah untuk mengeksplorasi dampak gagal ginjal kronis dan dampak islamic self healing terhadap qualty of life partisipan dengan menggunakan temuan secara kontekstual kualitatif, whoqol breef digunakan sebagai kerangka untuk menganalisi data. domain dan aspek untuk mengukur qualty 47 muhammadiyah journal of nursing of life sebagai dampak dari penyakit gagal ginjal dan dampak dari terapi islamic self healing yang ditunjukkan pada tabel 2. aspek yang dicetak tebal adah gambaran tema/sub kategori tema dari analisis data secara kualitatif. tabel 2: asesmen whoqol domain dan aspek quality of life pada partisipan dengna gagal ginjal kronik dan dampak terapi islamic self healing terhadap quality of life[25]. dampak gagal ginjal kronik terhadap qol dampak terapi islamic self healing terhadap qol domain aspek domain aspek fisik nyeri fisik nyeri energi energi tidur tidur mobilitas mobilitas aktivitas aktivitas pengobatan pengobatan kerja kerja psikologis perasaan positif psikologis perasaan positif berfi kir berfi kir harga diri harga diri gambaran diri gambaran diri perasaan negatif perasaan negatif spiritualitas spiritualitas hubungan sosial hubungan hubungan sosial hubungan dukungan dukungan seks seks lingkungan keselamatan lingkungan keselamatan rumah rumah keuangan keuangan pelayanan pelayanan informasi informasi waktu luang waktu luang lingkungan lingkungan transportasi transportasi dari tabel diatas menggambarkan hubungan secara alamiah dengan domain pada whoqol breef dan bagaimana data-data dari penelitian masuk kedalam domain dan aspek-aspek pada quality of life. 1. dampak gagal ginjal kronik terhadap status fi sik. a) adanya ketidakseimbangan energi kelemahan dan tingkat penurunan energi berdampak pada kehidupan partisipan digambarkan partisipan mengungkapkan adanya perubahan dari kualitas bekerja, penurunan kemampuan dalam bekerja ini disebabkan oleh penurunanan energi atau perasaan lemah pada fisik untuk mengerjakan aktivitas yang lebih berat, sehingga semua partisipan hanya bekerja sesuai dengan kemampuannya saja “gak kerja mas gak kuat, badannya itu lemes, mau apa-apa males gak da tenaga”. (p4, w1, 83-84, 91) “lemas mas…sebelum ini kan saya sering tranfusi turun mas hb nya rendah terus dibawah 8, sering drop”. (p3,w1,61-64) “la dulu saya tu mau jalan sendiri aja susah lemes, harus dituntun bawaanya lemas gitu mas…”(p4, w1, 34-35) “bawaannya cuman tidur itu, sampe setengah tahunan itu, cuma bisa mah tidur, makan, kadang yo dede opo yo istilahe dede hoho…”(p2,w1, 132-135) b) adannya gangguaan aktivitas tidur. gangguan dalam akativitas tidur sebagai akibat dari kondisi fisik seperti sesak nafas dan kondisi dari fungsi tubuh yang berkurang. gangguan dalam aktivitas tidur partisipan mengungkapkan dapat berupa mimpi buruk, bangun tidur pada malam hari dan terbangun sampai pagi hari. “kalau tidur miringnya kiri…. e kadangkadang tidur gak nyaman…terus mimpinya itu yang buruk-buruk, yang jelek-jelek” (p1, w1, 107,109, 219-220) 48 muhammadiyah journal of nursing “kalo tidurnya itu kalo tidur di rumah itu paling miring…miring itu kadang nyesek mas…kanan kiri, pokoknya ga bisa nyenyak lah tidurnya…nanti kalo udah nyenyak setelah miring sana…kayanya panas gitu loh sininya.. (menunujuk sisi dada samping).. airnya kaya disini semua gitu loh mas”(p5,w1,74-83) c) adanya penurunan pemenuhan aktivitas kesulitan dalam berkativitas seharihari yang disebabkan oleh keterbatasan fisik karena penurunan fungsi yang disebabkan oleh lemahnya otot dan tulang, perasaan tidak ada adanya energy, dan merasa kesulitan dalam memakai pakain. partisipan juga mengungkapkan aktivitas sehari-hari sebatas duduk, makan dan tidur. “bawaannya cuman tidur itu, sampe setengah tahunan itu, cuma bisa mah tidur, makan, kadang yo dede opo yo istilahe dede hoho…”(p2,w1, 132-135) “ s a ya j a l a n n ya p a k e t o n g k a t u n t u k menopang tulangnya….kalo awal sakit sih masih bisa kemana-mana…kalo sekarang cuma duduk sebentar udah capek banget pinggulnya….sekarang waktunya cepet gitu loh mas, ga enggak kuat gitu loh. pake baju aja susah yah mas, jalan berapa langkah udah ngos nogosan”(p5,w5, 3646, 55-57) d) adanya ketidaknyaman fi sik. p a r t i s i p a n m e n g u n g k a p k a n ketidaknyamanan nyeri dan mual yang lama dijalani dan terapi hemodialisa dilakukan dua kali dalam satu minggu, setiap minggu harus datang untuk terapi hemodialisa dan harus mengalmai tusukan pada tangan atau pada paha, tidak boleh bergerak selama proses hemodialisa dan ini menyakiktan “ini pas ditusuknya ini mas sakit apa lagi pada awal diadaerah paha ini sakit mas, tapi sekarang lebih mendingan nusuknya ditangan ini mas sudah dipasang av shunt.”(p3, w1, 100-102) “apa ya, yang bikin gak nyaman itukan gak boleh bergerak ituloh. hehe gak boleh kemana-mana terus berjam-jam. harus tinggal di, hehe gak boleh ngapangapain.”(p1,w1, 295-301) “….bawaannya badan lemes terus, mual dan muntah,… kalau dirumah paling sih cuma makan tidur. hehe…”(p1, w1, 98,102) e) adanya penurunan menejemen kesehatan diri pengobatan gagal ginjal kronik sebagai salah satu cara yang diartikan oleh partisapan adalah hanya untuk memperpanjang hidup tetapi tidak menyembuhkan. partisipan juga mengungkpakan kejenuhanannya terhadap pengobatan hemodilialisa. “ya bosen lah namanya manusia ada toh. tiap hari jadwalnya rabu sabtu, coblos teruss haha.. ya ada bosennya, tapi ya gimana lagi obatnya.”(p2,w1, 145-147) “saya agak bosen, tapi kan harus . nunggu lama tapi gimana lagi…kan harus cuci darah cuci darah terus mas.”(p3,w1, 66-67) 2. dampak gagal ginjal kronik dengan terapi hemodialisa terhadap status psikologis. a. adanya gangguan konsep diri pa r t i s i p a n m e n g u n g k a p k a n a d a n ya keputusasaan terahadap terapi hemodialisa yang sudah berlangsung lama tetapi hasilnya belum ada, timbul berbagai pandangan terhadap pengobatan hemodialisa oleh partisipan diantarnya bahwa hemodilisa 49 muhammadiyah journal of nursing hanya untuk memperpanjang hidup yang lama kelamaan kondiisi tubuh akan semakin memburuk dan kemudian akan terjadi kematian. “…yang membuat berhenti cuci darah ini tidak ada, kalau sudah lama kan membuat badannya jadi rusak, diatas 10 tahun ada yang tulangnya rusak tulangnya kropos… ”(p3, w1, 216-218) “sudah banyak yang mati mas temanteman yang cuci darah disini, kayaknya cuci darah bukan obat hanya alat mbuang air darah nyaring saja… ”(p4, w1, 45-52) “…hampir satu tahun ini terus begini kok gak sembuh-sembuh… (menangis)”(p4, w1, 95-99) b. adanya resiko cedera fi sik p a r t i s i p a n j u g a m e n g u n g k a p k a n pengalaman dirinya tentang adanya stress depresi dan keinginan dan pasrah akan kematian, adanya ketidakstabilan emosi dan kemarahan, adanya perasaan kecemasan terahdap penyakit dan pengobatan dengan jangka waktu yang lama. “yo.. pernah mati gituu haha… mati “yowis ngono kui.. pernah dulu.. awal awalnya, stress-stressnya haha… dulu pernah sempat depresi… terus ngamuk, ya, awalnya ya emosi lah”(p2,w1,155-169) “ya sering mas, rasanya mau mati saja, sering muncul mas lebih baik mati saja apalagi pas keadaan sakit lemes, kan pas hb rendah perasaannya lemas gak mau makan, rasanya gak enak sakit, sudah kan perasaanya sudah sakit tambah saktit lagi tambah sakit gini ya ngedrop pula.”(p3, w1, 196-198) c. adanya perubahan respon koping ke maladaptif timbulnya mekanisme koping yang maladaptif, partisipan mengungkapkan kesedihan, kecemasan dan ketidakstabilan emosi terhadap situasi yang membuat mereka menjadi marah dan ngamuk meskipun pemicu sesuatu hal yang kecil. pelampiasan kemarahan mereka ada yang ditujukan kepada anggota keluarga dirumah, membunyikan musik dengan keras dan bermain musik yang tidak jelas. “yo ngamuk itu tadi… ra mari yo wiss.. p e l a m p i a s n n ya y o c u m a n n g a m u k 2 wong umah kae loh,.. marah-marah sama orang rumah…kadang yo opo emosi kaya nyetel music gitu loh mas, terusss keras, gitaran berak berok haha gitarnya gitar elek.”(p2,w1, 250-256) “emosinya tidak stabil tensinya selalu kan tinggi, bawaannya pengin marah biasanya hal apa saja mas yang memicu marah wah gimana ya apa ya hal-hal kecil bisa bikin marah.”(p3, w1, 112-114) d. a d a n ya p e n u r u n a n h a r g a d i r i d a n gambaran diri parsipan juga mengungkapkan adanya penuruan harga diri/perasaan tidak berguna. partisipan mengungkapkan ketidakbergunaan pada dirinya karena tidak mampu dalam melakukan bentuk aktivitas kerja dalam kehidupan sehari-hari sebagai dampak dari kurangnya energy, kelemahan fi sik dan kergantung dari mesin hemodialisa. “…hidup kok bergantung mesin. kayak apa ya. terus mau kerja itu agak repot. di rumah cuma klentrak klentruk. gak bisa manfaat, hihi. kata orang gitulah. biasanya bekerja, se-enggak enggaknya di rumah sendiri gitu kan, cuma sekarang ini sudah 50 muhammadiyah journal of nursing tidak kuat. yaa gitulah hehe….”(p1,w1, 155-162) “iya, yo cuman ya ini sakit ini, koyone iki ga loro.. ya agak minderlah...”(p2,w1,186-187) “merasa diri kurang tidak berguna…sejak awal penyakit ini dan kurang lebih delapan bulan ini…apa lagi saya harus cuci darah seumur hidup.”(p3,w3, 72-76) “bingung masa depannya sedih banget, diem, jarang keluar rumah, hampir gak pernah keluar rumah”(p3, w1, 147-152) e. adanya gangguan kognitif hasil analisis dari partisipan didapatkan gangguan kognitif berupa lompatan kesimpulan dalam hal ini klien sudah mempunyai keyakinan bahwa sakitnya kemungkinan tidak dapat disembuhkan dan merupakan suatu kepastian dengan melihat rekan penderita yang sama yang telah meninggal. paritisipan juga mengalami penalaran emosinal dimana perasaan negatife mencerminkan realita yang ada. “pikirannya? yo cuma mari atau enggak mari atau engga…”(p2,w1, 196) “ga ada, kayanya engga engga, ya udah ga bisa sembuh, kalo tetep sembuh prediksinya tetep ga bisa sembuh gitu, tapi gapapa, ga sembuh gapapa yg penting sehat, maksudnya bisa berjalan saya udah bersyukur gitu.”(p5, w1, 265-267) 3. dampak gagal ginjal kronik dengan terapi hemodialisa terhadap status hubungan sosial adanya perubahan dalam performa peran. hasil penelitian menunjukkan bahwa partisipan mengalami gangguan dalam hubungan sosial, partisipan mengalami penurunan interaksi sosial dan adanya perpisahan dengan anggota keluarga. “saya kan kadang ada bau mulut amoniak, jadi mesake mas nya bau yang gak enak, sekarang kan baru amoniak tapi udah minder banget… takut ngeganggu gitu loh haha…cuma kurag percaya dirinya santai aja mas, maksudnya ga terlalu ….nanti malah ga.. gimana yah?? mesake gitu loh mas.”(p5, w1, 157-162,167,168) “terasanya kayak gak ada teman, gak ada pacaar, jarang jalan-jalan keluar kalau malam badannya gak kuat…”(p3, w1, 157-159) “emm gimana ya, istri saya tinggal sama orang tuanya dan anak saya, gak tau lah mas mungkin sakit saya ini penyebabnya istri saya pergi. ”(p2,w1,170-180) 4. dampak terapi islamic self healing terhadap qualty of life terhadap status fisik pada partisipan dengan gagal ginjal kronik dengan terapi hemodialisa. a. adanya peningkatan keseimbangan energi partisipan merasa lebih badan lebih ringan , penurunan dari tekanan darah dan nafsu makan meningkat. percakapan partisipan dibawah ini mengilustrasikan dampak terapi islamic self healing terhadap status fisik partisipan berupa bertambahnya energi atau tenaga. “anu ringan enteng badannya, kaya orang gak sakit”.(p2,w3,18) “nafsu makan bertambah”.(p5,w4,11) “lebih nyaman, seneng sekarang ada kemaujuan sekarang tensinya sudah mulai turun yang dulunya sampai 190 sampai 200 sempat takut juga. alhamdulillah… sekarang lebih berkurang”.(p3,w4,16-19) b. adanya peningkatan aktivitas tidur partisipan juga mengungkapkan manfaat yang dirasakan setelah melakukan terapi 51 muhammadiyah journal of nursing islamic self healing adalah membaiknya kualitas tidur yaitu tidur lebih mudah, mimpi buruk berkurang, lebih nyenyak dan lebih mudah mengawali tidur. percakapan partisipan dibawah ini mengilustrasikan dampak terapi islamic self healing terhadap status fisik partisipan berupa membaiknya aktivitas tidur. “setelah doa ini lebih nyaman, tidurnya juga lebih enak nyenyak, biasyanya mau tidur itu sulit, sekarang lebih cepat dalam tidurnya”.(p3,w3,22-25) “tidur lebih nyenyak, biasanya sering mimpi buruk sekarang sudah berkurang mas”.(p1,w4,10-11) c. adanya peningkatan dalam aktivitas manfaat lain yang dirasakan partisipan setelah dilakukannya terapi islamic self healing adalah lebih bersemangatnya dalam beraktivitas, kondisi fisik lebih bertenaga untuk beraktivitas. dibawah ini adalah pengungkapan partisipan yang berkaitan dengan aktivitas setelah melakukan terapi. “kayakanya ada kemajuan, lebih sehat gak klentrak klentruk gak loyo, kayaknya sehat…sekarang sudah bisa ngambil air untuk minum walaupun naik motor, nimba itu mas gak pakai sanyo hee nimba di sumur kadang ya ngrumput untuk kambing itu , ya marmut he eh….tenaganya tambah (p2,w3,20-25) “gimana ya mas, lebih optimis semangat, lebih semangat gitu lah…terus pinginnya bersih-bersih, menata-nata yang dulu sukanya gak mau bersih-bersih, terus menata-nata biar tampak indah”.(p5,w4,5254). 5. dampak terapi islamic self healing terhadap quality of life pada klien dengan gagal ginjal kronik dengan terapi hemodialisa pada status hubungan sosial. adanya peningkatan interaksi sosial analisis verbatim berdasarkan hasil transkrip wawancara teridentifikasi atau ditemukan bahwa terdapat dampak terapi islamic self healing terhadap kondisi status hubungan partisipan adanya peningkatan interaksi sosial. percakapan partisipan dibawah ini mengilustrasikan dampak terapi islamic self healing terhadap status hubungan sosial partisipan partisipan. “sekarang sudah mulai keluar rumah mas, ke tetangga ya cuma ngobrol-ngobrol saja”. (p1,w3,27-28) “lebih semangat itu mas, yang biasnya lebih suka dirumah, sekarang mau main, kemarin saya bermain sepak bola, dengan anak-anak sekitar rumah, kemudian mau mengantar ibu, ke sawah gitu mas tapi juga lihat lihat kondisi mas kalau pas ngerasa badan akan ngedrop ya dirumah saja”.(p3,w3,41-45) “lebih cerah, mau melakukan kegiatan itu lebih berani lebih semangat, sebelumnya kan cuma apa dirumah jarang mau keluar, sekarang udah agak sering keluar gitu…lebih merasa aman dan semangat bertambah yang dulunya mau keluar takut kenapa-napa sekarang sudah keluar kesawah, kadang monceng ibu kesawah ngater itu mas….yah sekarang lebih sabar mas, insyaalllah sembuh”.(p3,w4,34-42) 6. dampak terapi islamic self healing terhadap quality of life pada klien dengan gagal ginjal kronik dengan terapi hemodialisa pada status psikololgis. a. adanya peningkatan perasaan positif analisis verbatim berdasarkan hasil transkrip wawancara teridentifi kasi atau 52 muhammadiyah journal of nursing ditemukan bahwa terdapat dampak terapi islamic self healing terhadap kondisi psikologis seluruh partisipan diantarnya a d a n ya p e r a s a a n k e n ya m a n a n d a n ketenangan, dapat terilustrasikan pada percakapan seluruh partisipan berikut ini: “persaan lebih tenang, tenang dari rasa kwatir, biasanya kan sering gelisah”.(p3, w2, 19-20) “ya kalau habis doa terasa tenang hatinya, terasa tidak sakit saja ada perasaan tidak takut, jadi mau pergi kemana perasaannya tenang”.(p4,w3,9-10) “hati lebih tenaang, lebih tentraaam, semakin enak gitu lo…gimana ya ada peningkatan gitu, saya merasa nyaman he…hati lebih hidup gitu mas, biasanya pikirannya grambyang kemana-kemana gitu, pokoknya hati lebih hidup lebih nyaman”(p5,w4,4-9) b. adanya penurunan perasaan negative parstisipan juga mengungkapkan danya penurunan perasaan prasangka negatif, gelisah dan kawatir setelah melakukan terapi islamic self healing “gelisah dah berkurang, biasanya hati was was gitu mas, rasangkanya jelek terus, dah mulai berkurang”.(p5,w2,12-13) “perasaanya kayaknya ayem, tidak ada kwatir lagi.. kan selalu berdoa to jadi ayem rasanya”.(p2,w3,26-27) “persaan lebih tenang, tenang dari rasa kwatir….rasa sedih juga semkin berkurang tidak gelisah biasanya gelisah tiap malam”. (p3,w3, 22, 28-28) “perasaan kwatir jarang minggu minggu ini gak pernah aku sekarang, dulu kan sering kwatir , dulu ada tapi sekarang tidak pernah, ya intinya percaya sembuh, kan ada yang bilang gak bakal mari to, tapi aku takut minder itu gak, kuat tetepan pasti sembuh, kalau aku terus yakin, ada yang bilang gak bakal -gak bakal mari lah, mereka kan gak tau to”.(p2,w4,25-29) c. adanya perubahan respon koping kearah positif partisipan dalam wawancara setelah pelaksanaan terapi dalam mengahadapi permasalah mengalami perubahan yaitu dengan cara baru yaitu menyerahkan segala sesuatunya kepada allah dengan cara berdzikir, dengan kesabaran, mengutarakan masalah , ketika menghadapi sesuatu yang tidak menyenangkan sehingga berdampak pada berkurangnya persaan marah, dalam arti bahwa partisipan mempunyai pola fi kir/koping kearah positif. seperti yang ditunjukan percakapan partisipan dibawah ini: “fikiran itu positif, gak gampang mikir yang jelek-jelek sabar kadang perasaan lebih senang”.(p1,w4,6-7) “dulu yang fi kirannya berat, alhamdulillah sekarang lebih tenang fikirannya, saya dulu sering dipendem terus fi kiriannya, sekarang sudah di lepas…ya seperti curhat gitu ketika doa misalkan masalah-masalah yang ada dirumah”.(p3,w4,16-25) “lebih banyak berfikir positif ya saya sekarng ini ya…mungkin seumpaama orang menggunjing saya, padahal mereka gak menggunjing saya, persaannya lebih enak yang dulu bawaannya curiga itu jangan mereka begini-begini pokoknya berubah positif mas, kadang orang tua bikin emosi, dan saya sekarang lebih bisa sabar”.(p5,w4,17-25) 53 muhammadiyah journal of nursing d. adanya penerimaan terhadap kondisi diri sebagian partisipan mengungkapkan p e n e r i m a a n t e r h a d a p k o n d i s i ya n g dialaminya setelah dilaksanakan terapi. partisipan menerima kondisi fisik dan sesuatu yang ada pada dirinya dengan pasrah kepada ketentuan allah dan memandang stressor dari lingkungan m i s a l k a n p e r k a t a a n y a n g t i d a k menyenangkan diterima dengan baik. “rasa kwatir, malu, putus asa kalau itu sudah berkurang, biarlah orang menilai apa, wis manur pasrah ngoten yang terjadi biarlah terjadi, emangnya yang saya takuti apa hanya allah saja tapi allah masih menutupi kejelekan saya bersyukur banget padahal dulu saya menghianati allah”. (p5,w3,39-42 e. adanya peningkatan kualitas keyakinan dan spiritualitas. selama proses pemberian terapi dari minggu pertama sampai dengan minggu ke tiga terjadi peningkatan darai kualitas keyakian atau spiritualitas yang dimiliki oleh partisipan. partisipan mengungkapkan peningkatan kedekatannya dengan allah, peningktaan aktivitas ibadah, timbulnya perasaan tenang tentram dan terdapat perasaan dosa-dosa telah terampuni. “tambah yakin pada allah bahwa allah itu ada, tambah semangat ibadahnya mas… setelah berdoa lebih yakin gitu”.(p5,w2,910, 25) “perasaan lebih dekat, koyok tentrem dari pada dulu… perasaannya kaya burog… ya kayak gak tau allah, gak percaya kalau allah itu ada saya tu dablek, semua larangan-larangannya dilanggar, minumanminuman ya diminum sekarang ya tidak… sudah ditinggalkan, ya gak kayak dulu orangnya kan ugal-ugalan, semrawut gak pernah sholat, sekarang lebih kayak apa itu allah sudah memberikan ampunan dosadosaku”.(p2,w3, 32-46) “keyakinan bertambah, persaannya semakin tenang, yang tadinya gelisah sekarang semakin tenang…apa ya gelisah dengan penyakitnya takut kalau tiba-tiba meninggal gitu…sekarang lebih tenang yakin bisa sembuh”.(p3,w4,14-19) 7. terapi islamic self healing s u a t u t i n d a k a n ya n g b e r t u j u a n u n t u k memberikan efek terapi secara islami yaitu p e n g o b a t a n d e n g a n m e m p e r k u a t h a t i serta bersandar dan tawakal kepada allah, mencari perlindungan, bersikap rendah hati dan memperlihatkan kelembutan hati di hadapannya, memohon kepadanya, dan berdoa kepada allah untuk memperoleh kesembuhan yang dilakukan dengan cara mendemonstrasikan dan memandu pasien dalam pelaksanaan terapi, berisikan aspek hikmah dan faidah adanya sakit, doa, dzikir kesembuhan dan meminum air zam-zam yang dilakukan kurang lebih selama 25-30 menit. posisi pada terapi islamic self healing ini dengan posisi bisa duduk dan berbaring sesuai kemampuan klien dengan tangan diletakkan diatas area yang sakit. setelah itu pasien diberikan modul mengenai terapi islamic self healing. penelitian pada guide islamic self healing dengan metode action research selama 3 siklus didapatkan penyempurnaan terhadap prosedur pelaksanaan terapi ini dan dari segi isi tidak mengalami perubahan. hasil prosedur terapi islamic self healing merupakan refl eksi dari pengguna terapi yaitu partisipan dengan gagal ginjal kronik dan refl eksi dari ahli spiritual. beberapa pengungkapan pernyataan partisipan terhadap terapi islamic self healing sebagai berikut. 54 muhammadiyah journal of nursing “kalau bisa terapi ini di lanjut terus, dibutuhkan sekali unutk menumbuhkan keyakinan dan biar semangat sebenarnya pada pasien pasien seperti ini meraka semaangat nya turun dan patas semangat, biar tidak patah semangat dan lebih sehat”.(p3,w4,27-31) “ya itu belum hafal doanya jadi saya baca, lebih enak kalau dipandu kaya seperti ni mas, kadang dirumah bapak saya yang suruh bacain”.(p1, w2, 17-19) h a s i l r e f l e k s i d a r i wa wa n c a r a d e n g a n partisipan dan ahli spiritual terhadap prosedur islamic self healing dapat dilihat pada tabel 3. tabel 3: aturan pelaksanaan terapi islamic self healing sebagai hasil dari hasil wawancara dengan ahli spiritual dan partisipan aturan pelaksanaan 1. dalam pelaksasaan terapi dapat dilkukan dengan membaca buku panduan 2. dalam pelaksaanaan terapi dapat dipandu oleh orang lain berdasarkan dari buku panduan buku terapi 3. dalam pelaksanaan terapi posisi tubuh menyesuaikan kemampuan pasien bisa duduk dan berbaring, tetap tangan diatas ginjal pasien dengan boleh bergantian 4. tausiyah dapat dilakukan dengan membaca buku panduan atau dijelaskan oleh orang lain berdasarkan buku panduan sampai pasien dapat mandiri 5. pelaksanaan doa-doa dalam buku panduan tidak harus dilakukan secara berurutan tetapi bisa dimulai dari doa mana saja yang ada dibuku panduan pembahasan individu dengan hemodialisis jangka panjang sering merasa khawatir akan kondisi sakitnya yang tidak dapat diramalkan dan gangguan d a l a m k e h i d u p a n n y a . m e r e k a b i a s a n y a menghadapi masalah fi nansial, kesulitan dalam mempertahankan pekerjaan, dorongan seksual yang menghilang serta impotensi, depresi akibat kondisi yang kronis, dan ketakutan terhadap kematian [4]. gejala secara fi sik dirasakan seperti cegukan, mual, muntah, pruritus, malaise, impotensi, gangguan menstruasi, dan neuropati (campuran m o t o r i k d a n s e n s o r i k ) t e r j a d i n ya u r e m i a menyebabkan anoreksia [24]. lebih dari 50 % pasien dengan gagal ginjal kronik dengan hemodialisi mengalami gangguan tidur [15], dapat berupa kesulitan mengawali dan menajaga tidur, masalah dengan kurangnya istirahat, kelemahan pada kaki, perasaan kantuk disiang hari. kebanyakan dari pasien dengan hemodialisis dapat tidur dengan bantuan dari obat [22]. dua penelitian kualitatif juga mengindikasikan bahwa kelemahan atau penurunan energy berdampak pada fungsi fi sik dan mental. partisipan mengungkapkan bahwa kelemahan fi sik sebagai efek samping dari hemodialisa dan penurunan fungsi dari ginjal [23]. kelemahan fi sik semakin memburuk pada hari demi hari dalam proses hemodialisa [14] dan berdampak pada partisipan dalam mengelola dalam kegiatas aktifi tas sehariharinya [23] dan kemampuan aktifitas lainnya [14]. partisipan menggambarkan berkurangnya kekuatan fi sik dan energy yang membuat mereka merasa tidak berguna, lemah, dan merasa terbuang [21]. pada penelitian yang dilakukan oleh chen (2010) pada 200 pasien dengan hemodialisa didapatkan 35% mengalami depresi, kecemasan sebesar 21%, dan bulan sebelumnya dengan ide bunuh diri sebesar 21,5%, tingkat depresi lebih tinggi daripada kelelahan dan terjadi penurunan quality of life [4]. pembatasan gaya hidup ini secara signifi kan berdampak pada fungsi sosial dengan pasien melakukan tindakan penyeimbangan untuk menjamin pemeliharaan kadar vitamin, zat besi, dan protein. pembatasan tersebut dapat berdampak pada pasien keyakinan sakit, rasa kontrol pribadi yang mengarah ke kecemasan dan depresi, menghambat koping, dan penyesuaian [13]. 55 muhammadiyah journal of nursing menurut wolcott et al. (1988) terdapat hubungan peningkatan quality of life dengan harga diri yang lebih tinggi dan penurunan gangguan mood. penelitan yang dilakukan oleh finnegan john (2012) bahwa hubungan personal juga dipengaruhi oleh adanya tanda dan gejala dari gagal ginjal kronik. perubahan persepsi juga sebagai dasar adanya perubahan hubungan personal. terapi islamic self healing merupakan suatu tindakan yang bertujuan untuk memberikan efek terapi secara islami yaitu pengobatan dengan memperkuat hati serta bersandar dan tawakal kepada allah, mencari perlindungan, bersikap rendah hati dan memperlihatkan kelembutan hati di hadapannya, memohon kepadanya, dan berdoa kepada allah untuk memperoleh kesembuhan yang dilakukan dengan cara mendemonstrasikan dan memandu pasien dalam pelaksanaan terapi yang berisikan aspek hikmah dan faidah adanya sakit, doa, dzikir kesembuhan dan meminum air zam-zam. manusia adalah makhluk fi trah (berketuhanan) dan kerenanya memerlukan pemenuhan kebutuhan dasar spiritual (basic spiritual needs). seseorang yang beragama hendaknya jangan hanya sekedar formalitas belaka, tetapi yang lebih utama lebih menghayati dan mengamalkan keyakinannya agamanya itu, sehingga ia memperoleh ketenangan dan kekuatan dari padanya. berbagai penelitian membuktikan bahwa tingkat keimanan seseorang erat hubungannya dengan imunitas atau kekebalan baik fi sik maupun mental [17]. do’a akan menimbulkan rasa percaya diri, rasa optimisme, mendatangkan ketenangan, damai dan merasakan kehadiran tuhan yang maha esa sehingga dengan mengingatnya maka keimanan seseorang semakain bertambah dan adanya rasa ketenagan, ketentraman dalam jiwa dengan jiwa yang tenang mengakibatkan rangsangan ke hipotalamus untuk menurunkan produksi crf (cortictropin releasing factor). crf ini selanjutnya akan merangsang kelenjar pituitary anterior untuk menurunkan produksi acth (adreno cortico tropin hormon). hormon ini yang akan merangsang kortek adrenal untuk menurunkan sekresi kortisol. kortisol ini yang akan menekan sistem imun tubuh sehingga mengurangi tingkat kecemasan [18]. dewasa ini perkembangan ilmu keperawatan sudah berkembang kearah pendekatan keagamaan (psikoreligius). dari berbagai penelitian yang telah dilakukan ternyata tingkat keimananan seseorang erat hubungannya dengan kekebalan dan daya tahan dalam menghadapi berbagai problem kehidupan yang merupakan stresor psikososial. bagi seseorang yang beragama (islam) stresor psikososial yang berdampak pada stres, kecemasan, depresi dan penyakit dapat dianggap sebagai musibah, cobaan, peringatan, ataupun ujian keimanan seseorang. oleh karenanya ia harus bersabar dan tidak boleh berputus asa serta melakukan mawas diri, berusaha berobat dan senantiasa tidak lupa berdoa dan ber dzikir [17]. who, (1984) telah menetapkan unsur spiritual (agama) sebagai salah satu dari 4 unsur kesehatan. keempat unsur tersebut adalah sehat fi sik, sehat psikis, sehat sosial dan sehat spiritual. pendekatan baru ini telah diadopsi oleh psikiater amerika serikat (the american psychiatric association/ apa. 1992) yang dikenal dengan pendekatan “bio-psycho-socio-spiritual”. lindenthal s, (1971) melakukan studi epidemologik yang hasilnya bahwa penduduk yang religius resiko untuk mengalami stres lebih kecil dari pada mereka yang tidak religius dalam kehidupan sehari-harinya [17]. sebagaimana juga di dalam al-qur’an alloh subhanahu wata’ala berfi rman sebagai berikut: artinya :“(tidak demikian) bahkan barang siapa yang menyerahkan diri kepada allah, sedangkan ia berbuat kebajikan, maka baginya pahala pada sisi tuhannya dan tidak ada kekhawatiran terhadap mereka dan tidak (pula) mereka bersedih hati”. (al-qur’an surat, al-baqarah ayat : 112) ayat diatas dapat diamalkan sebagai doa bagi mereka yang sedang mengalami kecemasan 56 muhammadiyah journal of nursing atau penyakit fi sik lainnya. tidak diragukan lagi bahwa semua musibah adalah ketentuan yang telah digariskan oleh allah subhanahu wata’ala [19]. penelitian dilakukan oleh nia et. al. (2009) yaitu efek doa terhadap kesehatan mental pada pasien dengan hemodialisa. penelitian ini adalah eksperimental dilakukan pada 88 orang di bawah perawatan hemodialisa, didapatkan hasil bahwa terapi doa adalah terapi yang sesuai atau cocok untuk penyakit gagal ginjal kronis karena tidak hanya menurunkan tingkat stress juga dapat meningkatkan status spiritual [20]. kesimpulan 1. berdasarkan analisis terhadap wawancara dari seluruh partisipan dengan gagal ginjal kronik dengan terapi hemodialisa terhadap quality of life didapatkan hasil bahwa terapi islamic self healing dapat meningkatkan quality of life pada status fisik, status hubungan sosial dan status psikologi (adanyan perasaan kenyamanan dan ketenangan, penurunan kegelisahan dan rasa khawatir, koping individu kearah positif, peningkatan kualitas keyakinan dan penerimaan terhadap kondisi diri partisipan. 2. terbukti bahwa terapi efektif islamic self healing dalam meningkatkan quality of life pada domain psikologi. saran penelitian dapat dijadikan data awal sekaligus motivasi untuk melakukan penelitian lebih lanjut dilingkungan keperawatan medikal bedah, baik dinstitusi pelayanan maupun. peneliti selajutnya dapat mengembangkan penelitian yang tidak hanya berfokus pada domain psikologi saja, tetapi dapat dilakukan peneltian lanjut berupa dampak terapi islamic self healing terhadap status fi sik yang lebih obyektif dengan menggunakan jenis peneltian quasy exsperiment desain peneltian time series untuk mengevaluasi kefektifan terapi islamic self healing secara kuantitatif. daftar pustaka bakri, s., 2005. deteksi dini dan upaya-upaya pencegahan progresifi tas penyaki gagal ginjal kronik, jurnal medika nusantara, 26(3):36-39). chen, c.k., tsai, y.c., hsu, h.j., wu, i.w., sun, c.y., chou, c.c., et al. 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(2012) annual data report: atlas of chronic kidney disease and end-stage renal disease in the united states, national institutes of health, national institute of diabetes and digestive and kidney diseases, bethesda, md diakses 11 juni 2013 dari htt p://www. usrds.org/atlas.aspx. walker s, fine a, kryger mh. sleep complaints are common in a dialysis unit. am j kidney dis 1995; 26(5): 751±756. world health organisation (2004), measuring quality of life, htt p://www.who.int/ mental_health/media.pdf. jurnal mjn vol. 2 no. 2 desember 2015.indd 135 muhammadiyah journal of nursing the factors that infl uence the implementation of smoke free campus policy in universitas muhammadiyah yogyakarta faktor-faktor yang mempengaruhi pelaksanaan kebijakan kampus bebas asap rokok di universitas muhammadiyah yogyakarta absctract smoking is one of the problems in society today that diffi cult to resolve. there are 6 million deaths each year are caused by smoking. the number of smokers in indonesia continues to grow, which is dominated by the age of 15 years and above. to overcome these problems the government issued a policy banning smoking in the learning process. universitas muhammadiyah yogyakarta (umy ) was one of the places that already have implemented smoke-free campus since 2011, but until now there is smoke in campus. this study was to determine the factors that aff ect the implementation kawasan bersih bebas asap rokok (kbbr) in umy.this study was a qualitative research with phenomenological approach. the data were taken using the method discussion focus groups, depth interviews and observation. participants in this study were determined by purposive sampling counted 20 participants consisting of students and campus employees in umy. the validity of the data in this study was done by using triangulation, triangulation methods and peer debriefi ng. data analysis was performed with the help of software open code version 4.2. these results indicate that the factors that aff ect the implementation kbbr in umy was knowledge of kbbr, attitudes toward kbbr, lack of socialization and prohibition signs of kbbr, the absence of strict sanctions against violators kbbr and environmental infl uences. this shows that umy needs to improve socialization and give strict punishment for violation of kbbr. keywords: factors, kbbr, umy ema waliyanti1, yudan harry sandika2 program studi ilmu keperawatan fkik umy email : emawaliyanti@umy.ac.id telepon : 085729259152 intisari merokok merupakan salah satu masalah di masyarakat yang sampai saat ini sulit untuk diselesaikan. enam juta kematian tiap tahunnya disebabkan oleh kebiasaan merokok. jumlah perokok di indonesia terus bertambah yang didominasi oleh usia 15 tahun keatas. untuk mengatasi masalah tersebut pemerintah mengeluarkan kebijakan larangan merokok di tempat proses belajar mengajar. umy adalah salah satu tempat yang sudah menerapkan kebijakan kampus bebas asap rokok sejak tahun 2011, namun sampai saat ini masih ada yang merokok di dalam kampus.tujuan penelitian ini adalah untuk mengetahui faktor-faktor yang mempengaruhi pelaksanaan kbbr di umy. penelitian ini merupakan penelitian kualitatif dengan pendekatan fenomenologi. data diambil menggunakan metode focus group disccusion, wawancara mendalam dan observasi. partisipan dalam penelitian ini ditentukan dengan purposive sampling sebanyak 20 orang partisipan yang terdiri dari mahasiswa dan karyawan kampus umy. keabsahan data dalam penelitian ini dilakukan dengan teknik triangulasi sumber, triangulasi metode dan peer debriefi ng. analisis data dilakukan dengan bantuan soft ware open code versi 4.2. hasil penelitian ini menunjukan bahwa faktor-faktor yang mempengaruhi pelaksanaan kbbr di umy adalah pengetahuan tentang kbbr, sikap terhadap kbbr, kurangnya sosialisasi dan tanda larangan kbbr, tidak adanya sanksi tegas terhadap pelanggar kbbr dan pengaruh lingkungan. hal ini menunjukan bahwa umy perlu meningkatkan sosialisasi tenrang kbbr dan memberikan sanksi tegas terhadap pelanggaran kbbr. kata kunci : faktor-faktor, kbbr, umy 136 muhammadiyah journal of nursing pendahuluan merokok merupakan salah satu masalah di masyarakat yang sampai saat ini sulit untuk diselesaikan. kebiasaan merokok merupakan salah satu perubahan gaya hidup yang disebabkan oleh efek globalisasi dan mempengaruhi kesehatan manusia mengkonsumsi rokok dapat menimbulkan banyak kerugian dan menimbulkan berbagai masalah kesehatan, bahkan kematian1. menurut data who (world health organization) tahun 2011, menyatakan bahwa 6 juta kematian tiap tahunnya disebabkan oleh kebiasaan merokok, termasuk di dalamnya yaitu perokok pasif. kemenkes ri (2013) melaporkan pada tahun 2007 jumlah perokok usia 15-19 tahun mencapai 18,8%, angka ini menunjukan peningkatan dari tahun 2001 sebanyak 12,7%2. hal ini dikarenakan usia tersebut termasuk dalam kategori usia remaja dimana pada fase ini terjadi peralihan dari kanakkanak ke dewasa. fase ini merupakan masa pencarian jati diri melalui mencoba hal-hal baru dan perilaku beresiko3. negara indonesia telah melakukan pengendalian asap rokok melalui undang – undang republik indonesia nomor 36 tahun 2009 dan peraturan gubernur daerah istimewa yogyakarta nomor 42 tahun 2009. peraturan ini mengamanatkan pentingnya pengembangan kawasan tanpa rokok. pada pasal 115 undang – undang republik indonesia menjelaskan kawasan tanpa rokok yaitu meliputi fasilitas pelayanan kesehatan, tempat proses belajar mengajar, tempat anak bermain, tempat ibadah, angkutan umum, tempat kerja, dan tempat umum dan tempat lain yang ditetapkan. universitas muhammadiyah yogyakarta termasuk tempat proses belajar mengajar yang telah menerbitkan surat keputusan rektor nomor: 164/sk-umy/xii/2011 tentang implementasi program kampus universitas muhammadiyah yogyakarta bersih dan bebas asap rokok (kbbr). kbbr adalah kebijakan tentang larangan merokok di seluruh area kampus universitas muhammadiyah yogyakarta (umy) baik indoor maupun outdoor bagi semua pegawai edukatif, pegawai administratif, mahasiswa dan semua stakeholder umy yang lainya. kebijakan kampus bebas asap rokok yang telah ada sejak tahun 2011 namun belum dapat menghilangkan perilaku merokok di lingkungan kampus umy. berdasarkan hasil observasi masih terdapat mahasiswa universitas muhammadiyah yogyakarta yang merokok di dalam kampus. berdasarkan latar belakang di atas, peneliti tertarik untuk mengetahui faktor-faktor yang mempengaruhi pelaksanaan kbbr di umy. metode penelitian ini merupakan penelitian kualitatif dengan pendekatan fenomenologi. partisipan dalam penelitian ini adalah civitas akademika umy yang terdiri dari mahasiswa dan karyawan sebanyak 20 partisipan. pengambilan sampel dalam penelitian ini menggunakan purposive samping dengan kriteria mahasiswa aktif yang dapat menunjukan kartu mahasiswa dan bersedia menjadi partisipan, kriteria inklusi untuk partisipan karyawan adalah karyawan yang telah bekerja di umy selama minimal 1 tahun dan bersedia menjadi partisipan. pengambilan data dilakukan dengan metode focus group disccusion (fgd,) wawancara mendalam dan observasi yang dilaksanakan pada bulani maret-juni 2016. instrumen yang digunakan dalam penelitian ini adalah panduan fgd, panduan wawancara mendalam dan ceklist observasi. dalam pelaksanaan pengambilan data dibantu menggunakan alat perekam, kamera, dan alat tulis untuk membuat catatan lapangan. keabsahan data dalam penelitian ini dilakukan dengan teknik triangulasi sumber, triangulasi metode dan peer debriefi ng. analisis data secara tematik dengan bantuan soft ware open code versi 4.2. 137 muhammadiyah journal of nursing hasil penelitian 1. karakteristik partisipan tabel. karakteristik partisipan karakteristik responden frekuensi (f) persentase (%) jenis kelamin laki-laki perempuan total 13 7 20 65 35 100,00 usia 20-30 31-40 40-50 total status akademik mahasiswa karyawan total 17 2 1 20 16 4 20 85 10 5 100,00 80 20 100,00 status merokok merokok tidak merokok 12 8 60 40 total 20 100,00 dari tabel diatas menunjukan bahwa partisipan paling banyak adalah laki-laki sebanyak 13 orang (65%) dengan usia paling banyak adalah sebayak 20-30 tahun (85%). status akademik terbanyak adalah mahasiswa sebanyak 16 orang (80%) dan status merokok partisipan terbanyak adalah merokok sebanyak 12 orang (60%). 2. faktor-faktor yang mempengaruhi pelaksanaan kbbr di umy hasil penelitian ini menunjukan bahwa faktor-faktor yang mempengaruhi pelaksanaan kbbr di umy adalah pengetahuan tentang kbbr, sikap terhadap kbbr, kurangnya sosialisasi dan tanda larangan kbbr, tidak adanya sanksi tegas terhadap pelanggar kbbr dan pengaruh lingkungan. hal ini dapat dilihat dalam gambar di bawah ini: gambar. faktor-faktor yang mempengaruhi pelaksanaan kbbr di umy a. pengetahuan tentang kbbr partisipan mengatakan tahu bahwa umy menerapkan kbbr, namun pengetahuan partisipan bervariasi. ada yang hanya mengetahui saja dan ada yang benar-benar memahami bahwa kbbr melarang semua masyarakat umy untuk tidak merokok di dalam kampus. berikut adalah ungkapan dari partisipan: “kalau setau saya sih paling cuma ya mahasiswa sama mungkin staff sama dosendosen gitu, tapi kalau kaya pekerja bangunan, sekarang kan lagi dibangun kan disitu kan kenapa enggak diterapin ke pekerjanya itu ….”. (laki-laki perokok, fgd 1) namun ada sebagian partisipan yang tidak tau bahwa umy menerapkan kebijakan larangan merokok di dalam kampus. hal ini dapat dilihat dalam pernyataan: “ndak tau pak, belum pernah dengar” (lakilaki perokok, wawancara mendalam) 138 muhammadiyah journal of nursing b. sikap terhadap kbbr sikap partisipan terhadap kbbr bervariasi, ada mahasiswa yang setuju terhadap pelaksanaan kbbr, ada pula yang tidak setuju terhadap pelaksanaanya. mahasiswa yang setuju terhadap kbbr ada yang melaksanakan peraturan tersebut dan ada yang melanggar dengan masih merokok di dalam kampus. hal ini dapat dilihat dalam pernyataan partisipan berikut ini. “setuju sih, karena kan biar nggak ngerugiin semuanya”. (perempuan perokok, wawancara mendalam) “kalau di kampus enggak merokok (perempuan perokok, wawancara mendalam) “… mungkin kalau enggak boleh merokok ini misalkan di dalam ruangan ya, tapi setelah di luar ruangan boleh lah” (laki-laki perokok, fgd 1) “ya kalau aku sih setuju aja, tapi kan kalau cuma staff sama mahasiswanya aja kan kaya nggak gimana gitu kaya nggak fair, tapi yang lainya bisa merokok bebas” (laki-laki perokok, fgd 1) partisipan yang tidak setuju terhadap adanya kbbr tidak mendukung penerapan kbbr, mereka masih tetap merokok di dalam kampus dengan alasan tidak adanya tempat khusus untuk merokok di kampus. selain itu mereka hanya mengetahui bahwa larangan merokok berlaku di dalam ruangan saja. “….kalau tujuanya untuk mengurangi pengkonsumsi rokok kurang setuju juga. justru kebanyakan dikita orang itu semakin ditekan semakin melanggar. itu fakta..” (lakilaki perokok, wawancara mendalam) “…. kalau udah ngasih kebijakan gini setidaknya kasih lah satu area yang bebas asap rokok khusus buat perokok, jadi kan kaya perokok aktif kalau nggak ada tempat mesti nyuri-nyuri tempat…”. (laki-laki perokok, fgd 1) c. kurangnya sosialisasi kbbr dan tanda larangan kbbr sebagian besar partisipan mengaku belum pernah mendapatkan sosialisasi tentang kbbr dari kampus. partisipan mengungkapan bahwa mereka mengetahui kampus menerapkan larangan merokok hanya dari poster, spanduk, maupun dari sesama mahasiswa. hal ini dapat dilihat pada pernyataan di bawah ini: pewawancara : “ apakah bapak tahu tentang kbbr?” partisipan : “nda tahu pak, nggak tau” pewawancara : “apakah dari kampus sebelumnya pernah memberikan sosialisasi kepada bapak?” partisipan : ”belum, tidak tau” (laki-laki perokok, wawancara mendalam) “sosialisasi secara langsung belum pernah, paling sih mulut ke mulut”. (laki-laki perokok, wawancara mendalam) selain kurangnya sosialisasi tentang kbbr, partisipan merasa poster larangan merokok di dalam kampus umy masih kurang. partisipan mengaku belum pernah melihat ada poster terpasang di loby, kemudian poster yang sudah tertempel kurang menarik. partisipan juga mengungkapkan sejauh ini tempelan larangan merokok cuma ada di dalam gedung. adapun ungkapan partisipan sebagai berikut: “… disudut loby belum pernah melihat ada poster terpasang” (laki-laki tidak merokok, wawancara mendalam) 139 muhammadiyah journal of nursing “… kalau kaya gini kurang tanda-tanda dilarang merokok, terus kecil, kadang-kadang ngumpet, publikasinya menurut saya masih kurang” (laki-laki tidak merokok, wawancara mendalam) d. tidak adanya sanksi tegas terhadap pelanggar kbbr partisipan menyatakan ketika sedang merokok dirinya pernah mendapatkan terguran dari dosen baik secara langsung m a u p u n t i n d a k a n l a n g s u n g b e r u p a pengambilan rokok. namun sanksi tersebut hanya berupa teguran saja tidak ada sanksi yang lebih tegas, sehingga mereka mengaku tidak jera dan hanya mematikan rokok sesaat ketika ada dosen kemudian melanjutkan aktivitas merokoknya di tempat lain, seperti yang diungkapkan sebagai berikut: “kalau buat aku sih enggak ya, nggak jera. soalnya walaupun udah dikasih sanksi (teguran) tetep aja ngelakuin lagi. misalkan kaya disindir, orang-orang pada tau, emang kebanyakan orang-orang udah tau kalau aku ngerokok. udah biasa”. (laki-laki perokok, fgd 1) “pernah di loby hi, lagi ngerokok gitu ada dosen datang, “mas rokoknya dimatiin”. dari hasil observasi, peneliti menemukan tanda-tanda larangan merokok baru ada di beberapa area saja belum di seluruh area kampus. sebagian tanda larangan merokok juga kurang dapat telihat dengan jelas. no indikator cek ket 1 mahasiswa merokok di area kampus v masih terdapat mahasiswa yang merokok di area kampus universitas muhammadiyah yogyakarta 2 ada tanda-tanda larangan merokok di area kampus v terdapat tanda-tanda larangan merokok di area kampus, namun hanya di beberapa area saja. tanda-tanda larangan cenderung kecil dan kurang dapat terlihat dengan jelas. 3 adanya sosialisasi terkait kbbr v tidak ada sosialisasi yang terlihat selama observasi berlangsung 4 adanya sanksi/ peneguran langsung terhadap mahasiswa yang merokok v tidak ada peneguran terhadap pelanggar mahasiswa selama observasi berlangsung data hasil observasi pindah kan pindah ke e2 ngerokok disitu, dosenya datang lagi keatas. dicubit” (lakilaki perokok, fgd 2) “….kebijakanya juga setengah-setengah hanya sebatas hmm sekarang pegawai sama mahasiswanya bukan menyeluruh” (laki-laki perokok, fgd 1) e. pengaruh lingkunan partisipan mengaku kuat untuk tidak merokok apabila kondisi lingkungan mendukung. partisipan mengungkapkan ketika berada di tempat yang menerapkan kbbr dengan tegas dia mampu dan kuat menahan tidak merokok di tempat tersebut. partisipan juga mengungkankan ketika berada di lingkungan orang-orang yang tidak merokok dia kuat untuk tidak m e r o k o k , n a m u n p a r t i s i p a n m e r a s a penerapan kbbr di umy masih belum tegas sehingga masih berani merokok di dalam kampus. seperti yang diungkapkan partisipan berikut ini: 140 muhammadiyah journal of nursing “kalau saya sih kalau ngerokok tu masih bisa tahan sih ya, saya bisa sadar diri lah. kayak di airport kan ada larangan untuk merokok, ya saya bisa tahan walaupun nggak ketemu tempat publik untuk merokok, bisa nahan masih nggak harus nuntut harus ngerokok gitu”. (laki-laki perokok, fgd 1) “tergantung orangnya sih mas, kalau gitu berkumpul dengan orang yang, contoh seperti kaya gini tapi kan kita posisinya diruang ini nggak ada yang ngerokok, jadi kita bisa tahan. kecuali kalau seumpama dalam suatu tempat ada yang merokok satu pasti yang perokok mesti ikut-ikutan”.(laki-laki perokok, fgd 1) “ya kalau menurutku tu (keefektifan)malah lebih rendah dari 70%. jadi 60% soalnya dosen juga kadang ngerokok bareng soalnya tu, jadi kalau orangnya sepi kita bisa merokok bareng. malah larangan itu gimana ya, kaya cuma dianggep angin lalu…” (laki-laki perokok, fgd 1) “dulu pertama kali diterapkan masih belum efektif, sampai kemarin masih ada kantin di luar umy boga itu. tapi menurut saya sekarang hanya segelintir orang yang mau ngerokok dikampus, paling pas pulang kuliah diparkiran kadang ngerokok” (perempuan perokok, wawancara mendalam) s e l a i n k o n d i s i l i n g k u n g a n ya n g mendukung pengaruh orang lain juga m e m p e n g a r u h i p e l a k s a n a a n k b b r . sebagian besar partisipan mengaku merasa ingin merokok ketika melihat orang lain merokok di dalam kampus. partisipan juga mengungkapkan dirinya merokok karena masih ada karyawan dan dosen yang merokok di dalam kampus. berikut adalah ungkapan partisipan: “karena ya kalau perokok aktif pengen lah kalau lihat orang tu mesti pengen ngerokok juga”. (laki-laki merokok, fgd 1) “… gimana ya kalau dari atasnya juga kaya gitu merokok, apalagi bawahnya bebas” (lakilaki perokok, fgd 1) “… trus mau masuk wc lagi tu dosen keluar itu bawa rokok, kayaknya tu dia habis lagi bab kali ya nikmatnya rokok dong. nah itu bawa rokok dan disitu ada abunya juga. tidak menutup kemungkinan si dosenya juga bisa ngerokok di dalam diam-diam” (laki-laki perokok, fgd 1) pembahasan pada penelitian ini ditemukan beberapa faktor yang mempengaruhi pelaksanaan kbbr di umy. faktor-faktor tersebut adalah pengetahuan tentang kbbr, sikap terhadap kbbr, kurangnya ssialisasi kbbr dan tanda larangan kbbr, tidak adanya sanksi tegas terhadap pelanggar kbbr dan pengaruh lingkungan. pengetahuan tentang kbbr menjadi salah satu faktor yang mempengaruhi pelaksanaan kbbr di umy. pengetahuan yang baik tentang kawasan tanpa rokok membuat mahasiswa lebih patuh terhadap kebijakan. hasil penelitian yang dilakukan armayati (2014) menghasilkan temuan adanya pengaruh yang bermakna faktor pengetahuan peraturan kawasan tanpa rokok terhadap kepatuhan pada peraturan kawasan tanpa rokok. pengetahuan mahasiswa dan karyawan di umy bervariasi, ada yang berpengetahuan baik tentang kbbr dan ada yang tidak tau sama sekali tentang kbbr. hal ini menyebabkan beberapa partisipan masih merokok ketika berada di wilayah kampus umy. faktor berikutnya yang mempengaruhi pelaksanaan kbbr di umy adalah sikap terhadap kbbr. sikap setuju membuat partisipan patuh dan mendukung penerapan kbbr. meski partisipan merupakan perokok aktif, namun ketika berada di lingkungan kampus dirinya tidak merokok . firdiana (2013) menunjukan bahwa mahasiswa yang memiliki sikap positif terhadap kawasan tanpa rokok di kampus unpad cenderung akan 141 muhammadiyah journal of nursing melakukan hal-hal yang diatur di dalam kawasan tanpa rokok di kampus unpad. berbeda dengan sikap setuju terhadap kbbr, sikap tidak setuju terhadap kbbr membuat partisipan tidak mendukung penerapan kbbr dengan masih merokok di sembarang tempat di dalam kampus umy. siswa yang mempunyai sikap negatif cenderung ingin diberi kebebasan (rahmadi,dkk. 2013). kurangnya sosialisasi kbbr dan tanda larangan kbbr menjadi salah satu faktor yang mempengaruhi penerapan kbbr. sebagian besar partisipan mengaku belum pernah mendapat sosialisasi tentang kbbr. nugroho (2015) dalam penelitianya mengidentifi kasi bahwa sosialisasi sk kbbr mutlak dilakukan, sebab sosialisasi ini berguna untuk pendekatan sehingga menerima dan mendukung kawasan tanpa rokok di lingkungan fik ums. menurut azkha (2013) sosialisasi yang berkesinambungan dan terarah serta tepat sasaran tidak saja hanya akan dapat memberikan perlindungan kepada perokok pasif tapi sekaligus juga akan dapat mengurangi perokok aktif. sebagian besar masyarakat kampus umy belum pernah mendapatkan sosialisasi mengenai kbbr, hal ini mengakibatkan dukungan terhadap kbbr oleh masyarakat kampus umy kurang. kemudian tanda-tanda larangan merokok juga disampaikan partisipan sebagai salah satu faktor yang mempengaruhi penerapan kbbr. tanda-tanda larangan digunakan untuk memberitahukan kepada segenap warga kampus bahwa kampus menerapkan kbbr. tanda-tanda larangan yang digunakan berupa poster, spanduk, banner, simbol dilarang merokok dan lain lain, namun dalam penerapanya tanda-tanda larangan di kampus umy masih tergolong kurang. tandatanda larangan belum terpasang di seluruh area kampus umy, tanda-tanda larangan juga terkadang tidak terlihat dengan jelas dan kurang menarik. penggunaan media yang efektif dimana pesan bisa diterima oleh kelompok sasaran memungkinkan adanya perubahan perilaku, sikap, serta keyakinan (azkha, 2013). penggunaan media oleh umy masih belum efektif, sehingga pesan yang disampaikan melalui tanda-tanda larangan merokok di kampus umy belum mampu memberikan perubahan sikap terhadap mahasiswa dan masyarakat kampus. faktor berikutnya yang mempengaruhi penerapan kbbr adalah tidak adanya sanksi tegas terhadap pelanggar kbbr. partisipan yang masih merokok di area kampus tidak jarang mendapatkan teguran langsung dari dosen. teguran ini berupa sindiran, pengambilan kartu mahasiswa, pengambilan rokok pelanggar, maupun pelanggar diminta menghadap dosen. teguran ini belum mampu membuat perokok aktif jera. sebagian besar partisipan mengaku tetap merokok di area kampus walaupun sudah pernah mendapatkan teguran. penelitian yang dilakukan prabandari, dkk (2009) pada 463 mahasiswa fk ugm menyebutkan bahwa sebagian besar mahasiswa berpendapat bahwa sanksi atau denda jika seseorang merokok di kampus diperlukan. hal ini menunjukan bahwa adanya sanksi bagi pelanggar sangat diperlukan. hasil penelitian azkha (2013) memperkuat bahwa adanya sanksi dan komitmen dari pemerintah dapat meningkatkan efektivitas kebijakan ktr ini. penerapan kbbr yang tegas dapat membatasi ruang gerak perokok aktif, yang pada akhirnya dapat menurunkan jumlah perokok aktif. hal yang lebih penting ketika ruang gerak perokok aktif terbatasi adalah terlindunginya perokok pasif dari dampak negatif rokok. faktor yang terakhir adalah pengaruh lingkungan. lingkungan yang kurang mendukung akan mempengaruhi pelaksanaan kbbr. ketika berada di area yang tidak memungkinkan untuk merokok, sebagian besar partisipan dalam penelitian ini mengungkapkan kuat untuk tidak merokok. sarana merupakan salah satu faktor yang berpengaruh dalam implementasi kebijakan agar kegiatan-kegiatan yang dilaksanakan dapat berjalan dengan efektif dan efi sien (azkha, 2013). sarana yang memadai 142 muhammadiyah journal of nursing sangat berpengaruh terhadap keberhasilan implementasi suatu kebijakan. kampus umy belum memiliki sarana yang memadai dalam penerapan kbbr ini, pengawasan dan pemantauan masih belum menyeluruh di semua area kampus. masih banyak area-area sepi yang tidak terpantau, sehingga seringkali digunakan oleh mahasiswa untuk merokok. kemudian selain sarana dan prasarana yang kurang memadai, di kampus umy juga masih teradapat banyak pelanggar. perokok aktif yang melihat temanya merokok akan terpengaruh ikut merokok. hal ini sejalan dengan penelitian widiansyah (2014) bahwa teman dalam lingkungan sekolah maupun teman bermain sangat berpengaruh dalam perilaku remaja, karena keakraban serta seringnya mereka berkumpul dan seringnya berkomunikasi maka teman yang merokok sangat mudah mempengaruhi teman yang tidak merokok menjadi merokok (widiansyah, 2014). kesimpulan dan saran faktor-faktor yang mempengaruhi penerapan kbbr di umy adalah pengetahuan tentang kbbr, sikap terhadap kbbr, kurangnya sosialisasi kbbr dan tanda larangan kbbr, tidak adanya sanksi tegas terhadap pelanggar kbbr dan pengaruh lingkungan. faktor tersebut mempengaruhi civitas akademika dalam melaksanakan kebijakan tersebut, untuk itu umy perlu meningkatkan pengetahuan civitas akademika tentang kbbr dengan cara melakukan sosialisasi secara langsung maupun menggunakan media yang tepat. umy juga perlu memberikan sanksi yang lebih tegas terhadap pelanggar kbbr, sehingga penerapan kbbr lebih efektif. daftar rujukan 1. kementrian kesehatan ri (2011). informasi tentang penanggulangan masalah merokok melalui radio . jakarta. 2. kementrian kesehatan ri (2013). riset kesehatan dasar (riskesdas) 2013. jakarta 3. widiansyah, m. (2014). faktor-faktor penyebab perilkau remaja perokok di desa sidorejo kabupaten penajam paser utara. ejurnal sosiologi (4): 1-12. diakses tanggal 23 februari 2016, dari htt p://ejournal.sos.fi sip-unmul.ac.id/ site/wp-content/uploads/2014/10/penting%20 (10-02-14-12-04-55).pdf 4. armayati, l. (2014). faktor-faktor yang mempengaruhi kepatuhan mahasiswa dan karyawan terhadap peraturan kawasan tanpa rokok di lingkungan kampus fakultas psikologi universitas islam riau. jurnal rat vol3.no3. diakses 1agustus 2016, dari htt ps:// core.ac.uk/download/pdf/11735658.pdf 5. firdiana, a. (2013) . gambaran sikap mahasiswa unpad terhadap kawasan tanpa rokok di kampus unpad. karya tulis ilmiah strata satu universitas padjadjaran. 6. nugroho, p. (2015). evaluasi implementasi kawasan tanpa rokok (ktr) fakultas ilmu kesehatan universitas muhammadiyah surakarta. karya tulis ilmiah strata satu universits muhammadiyah surakarta. 7. azkha, n. (2013). studi efektivitas penerapan kebijakan perda kota tentang kawasan tanpa rokok (ktr) dalam upaya menurunkan perokok aktif di sumatera barat. jurnal kebijakan kesehatan indonesia. diakses 20 desember 2015, dari htt p://jurnal.ugm.ac.id/ jkki/article/download/3201/2810 8. prabandadi, y., nawi., & padmawati. (2009). kawasan tanpa rokok sebagai alternatif pengendalian tembakau studi efektivitas penerapan kebijakan kampus bebas rokok terhadap perilaku dan status merokok mahasiswa di fakultas kedokteran ugm, yogyakarta. jurnal manajemen pelayanan kesehatan volume 12 hal 218-225. 9. widiansyah, m. (2014). faktor-faktor penyebab perilkau remaja perokok di desa sidorejo kabupaten penajam paser utara. ejurnal sosiologi (4): 1-12. diakses tanggal 23 februari 2016, dari htt p://ejournal.sos.fi sip-unmul.ac.id/ site/wp-content/uploads/2014/10/penting%20 (10-02-14-12-04-55).pdf indonesian journal of nursing practices 36 ijnp (indonesian journal of nursing practices) vol 5 no 1 june 2021: 36-50 kalpana jeewanthi subasinghe1, a.m. shyama deepanie pathiranage1 1faculty of allied health sciences, university of peradeniya, sri lanka corresponding author: kalpana jeewanthi subasinghe email: kalpanasubasinghe1116@gmail.com the role of the pediatric nurse in discharge planning; identifying gaps in sri lanka article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v5i1.10748 : 25 november 2020 : 14 february 2021 : 17 february 2021 abstract background: pediatric discharge planning is a complex process, and that nurses need lengthy preparations. role confusion among nurses will disrupt the smooth planning of the discharge. in sri lanka, although there is a possibility of reducing health costs through effective discharge planning led by pediatric nurses, it is questionable whether sri lankan nurses have clarified their role in this process. method: this systematic review was conducted to map the different roles of nurses in the pediatric discharge planning process. electronic databases of pubmed and cinahl were searched for peer-reviewed journal articles among the pediatric population from 2005-2019, using the keywords such as discharge planning, pediatric nurse, care transitions, transitional care, and sri lankan nurse. results: articles that resulted in the word combination ‘discharge planning and pediatric nursing (n=329) were used for screening. two hundred and forty articles out of the nursing scope and sixty articles that do not describe an apparent nursing involvement in the discharge process were excluded, based on abstract review and full-text review, respectively. sixteen studies were included in the final review. few literature was found on the topic among sri lankan pediatric population. four main categories of nurses’ roles were identified with the thematic analysis: discharge educator, discharge collaborator, post-discharge care coordinator, and family counselor. conclusion: in sri lanka, no such defined roles of a nurse have been established yet in the discharge planning of pediatric patients. these roles may help nurses carry out discharge planning effectively, and future studies are needed on this topic in sri lanka. keywords: discharge planning; nurses’ role; pediatric nurse; sri lankan nursing introduction the discharge planning concept originated in the united states in the 1960s provides safe care transitions from hospitals to homes or another health care facility using multidisciplinary approaches (lin et al., 2012). discharge planning has become an integral part of the care coordination of the patients due to the fact that proper discharge planning and adequate discharge readiness reduce the length of stay at the hospital, readmission rates within 30 days of hospital discharge, health costs, and post-discharge http://journal.umy.ac.id/index.php/ijnp http://u.lipi.go.id/1477106461 http://issn.pdii.lipi.go.id/issn.cgi?daftar&1478151103&1&& https://journal.umy.ac.id/index.php/ijnp/article/view/10748 vol. 5 no. 1 june 2021 37 complications (jack et al., 2009; weiss et al., 2014; et al., 2011). nurses played an essential role in the discharge planning process and included the concept in their care planning since the 1990s (lin et al., 2012). some studies identified nurses as “transitional coaches” to manage discharge planning activities (rosenbek & coleman, 2013). nursing care is pivotal not only in the discharge process but also in the post-discharge phase (aued et al., 2019; naylor et al., 1999; popejoy et al., 2012). discontinuity from the inpatient care causes post-discharge complications in 50% of the adults discharged from hospitals because discharging from hospitals is a vulnerable situation for patients and their families (kripalani et al., 2007). productive nursing care, which includes discharge readiness assessment, has decreased the readmission rates of adult patients (yakusheva et al., 2019). adult studies have found that nurses integrate various discharge planning activities during their care provision (foust, 2007) and the effectiveness of such activities (naylor et al., 1999; zhu et al., 2015). attitudes of the family affect the efficacy of discharge planning (chang et al., 2016; koné et al., 2018), and medical team collaboration is essential to prevent premature discharge (ofoma et al., 2018). although there are still limited studies about discharge planning, the discharge planning interventions led by nurses in the pediatric setup have proved their effectiveness in maintaining care continuity and providing support for families. such interventions include family conferences, follow-up visits, phone calls, and combining with community care (auger et al., 2018; baker et al., 2016; pickler et al., 2016). parents have concerns about healthcare delivery by health professionals, including nurses, in their child’s care plan (brenner et al., 2015). the health care team should always focus on the caregiver or the family along with the patient care. providing adequate discharge information to the caregiver can reduce the complications during home care (driscoll, 2000). in the pediatric setup, the family plays an essential role in the discharge plan as the family is constant in the child’s life and the child's sole caregiver. pediatric patients’ discharge from the hospital is stressful for both the child and the family, including siblings. families need time for adapting to the new reality; therefore, the pediatric discharge process requires time and lengthy preparations (bowles et al., 2016; brenner et al., 2015; purdy et al., 2015). nurses have frequent interactions in patients' hospitality compared to other multidisciplinary team roles (watts & gardner 2005). inadequate clarifications of the multidisciplinary team and confusion of their roles have been identified as barriers to effective discharge planning (wong et al., 2011). being a developing country where the government provides health for every citizen at free cost, the massive health-related goal is a burden for sri lanka. interventions that will lead to the reduction of health costs and readmission rates are in utmost need. in sri lanka, although nurses involve in the discharge process, their role has not been clarified well due to the lack of conceptualized guidance and very few engaging in the specific role (coleman et al., 2005; hettiarachchi & amarasena, 2014; senarath et al., 2007). this review mainly focuses on mapping the different roles of the nurse in the discharge planning process in the pediatric setup. methods this literature search was done in the electronic databases pubmed and cumulative index to nursing and allied health literature (cinahl) through hinari research in health. the search was performed in may 2020 using the search terms; “discharge planning, care transition, discharge planning guidance, discharge planning and nursing, discharge planning and pediatric nursing, discharge planning in sri lanka”. the study included peer-reviewed journal articles published from 2005 to 2019 in pediatric setups. full-text english articles were refined. quantitative studies, qualitative studies, and mixed-method studies were included. reviews, case reports, studies on medication trials, microbiological studies, studies conducted in the emergency departments, studies that describe only postsurgical management and rehabilitation were excluded. articles that describe nurses’ involvement in the discharge process or post-discharge phase were included in the final review. reference lists of each indonesian journal of nursing practices 38 article were screened manually. the contents of the articles about studies on emergency departments were again screened carefully to clarify whether they describe a clear nursing role in the discharge process or post-discharge phase. prisma (preferred reporting items for systematic reviews and meta-analyses) guidelines were used for data screening. the articles resulting from the search term “discharge planning and pediatric nursing” were exported to mendeley desktop. their titles and abstracts were screened to identify those reporting on original research, followed by a fulltext screen of the remaining articles to determine which articles to include in the study. duplicate articles were removed. due to the lack of recent literature on this topic in sri lanka, internet websites were searched for additional information. both authors followed this method to screen the articles and check for gaps and discrepancies in their search results. figure 1, the prisma flow chart, represents the method of literature searching and article selection. since the study was confined to peer-reviewed journal articles, no special quality appraisal tools or guidelines were used to measure the quality of the articles. data from the finally selected articles were extracted into an excel spreadsheet. then data was systematically organized, compared, and contrasted by two authors to identify nurses’ roles in the discharge planning from the contents of the studies using thematic analysis by the general inductive approach. the inductive analysis allows the origination of concepts and themes through deeply reading the raw data (thomas, 2006). finally, the authors read selected articles several times separately, and text segments that explain the nurses’ involvement in the discharge process were highlighted and expressed in the narrative form. the highlighted text was exchanged among the authors. core meanings evident in the text relevant to nurses’ involvement in the discharge process were identified by two authors. the highlighted text segments provided a foundation to recognized categories. sub-themes and themes were developed based on the deep analytical thinking on the relationship among the categories. results of the 16 studies, 11 studies were conducted in particular health care units (arad et al., 2007; dellenmark-blom & wigert 2014; ekim & ocakci 2016; gallotto et al., 2019; góes & cabral 2017; lerret et al., 2017; meerlo-habing et al., 2009; pfeil et al., 2007; schuh et al., 2016; wells et al., 2017; smith et al., 2018), 4 in acute medical setups (auger et al., 2018; holland et al., 2014, 2015; weiss et al., 2017), and one in an emergency department (uspal et al., 2016). of the 16 studies, five studies included nurses’ involvement in the post-discharge period (auger, shah, et al. 2018; lerret et al. 2017; meerlohabing et al., 2009; pfeil et al., 2007; wells et al., 2017), eight studies included about nurses’ involvement before the hospital discharge (arad et al., 2007; gallotto et al., 2019; góes & cabral 2017; holland et al., 2014, 2015; schuh et al., 2016; weiss et al., 2017; smith et al., 2018), and 2 studies described both pre-discharge and post-discharge involvement of the nurse (dellenmark-blom & wigert 2014; ekim & ocakci 2016). the summary of the finally selected articles has been represented in table 1. four main categories were identified during the process of thematic analysis. sub-categories were generated from the evidence identified under the main categories. the summary of the categories is shown in table 2. 1.discharge educator nurses play a significant role as educators in the discharge planning process, both in inpatient and post-discharge care. this education follows the family system approach filling the parents' knowledge gaps and covers the following subcategories. 1.1 medications and red flags educating the child, family, or caregiver about medication dose, timing and side effects, and the complications that may arise that need prompt medical assistance will help ensure the child's safety in the post-disharge period. ‘road to home’ program by smith (smith et al., 2018) includes a tool kit that helps to address medication issues and emergencies after discharge and discharge education curriculums may include emergency management kits for the caregiver (gallotto et al., 2019). vol. 5 no. 1 june 2021 39 1.2. new skills for the caregiver the child may need complex treatment plans even after hospital discharge. thus, it is a must to ensure that the caregivers can demonstrate the skills necessary to continue the care provided at the hospital after the discharge (schuh et al., 2016; wells et al., 2017; smith et al., 2018). nurses should have a keen knowledge and skills on teaching methods such as explanation, observation, execution, supervision, collaboration, and assessment to provide those skills for the caregivers. these skills include technical, medication administration, nutrition, and hygiene (gallotto et al., 2019; góes & cabral, 2017). learning new skills that help to care for their child by themselves will increase the parents' confidence (dellenmark-blom & wigert, 2014). 1.3 life after discharge parents and children perceive that having a clear understanding of life after discharge will easily help them achieve expected goals (weiss et al., 2017). nurses can provide discharge teaching about life after discharge to carry out proper discharge planning (holland et al., 2015; lerret et al., 2017). furthermore, parents and clinicians see nurses as the best professionals who can provide the necessary instructions regarding life at home once the child is discharged from the hospital (góes & cabral, 2017). pre-discharge education should focus on the community services available for the family to seek help after discharge when needed (schuh et al., 2016). 1.4 written information providing written information through handbooks, booklets, flyers during the educational sessions will improve nurse and parent satisfaction (ekim & ocakci 2016; gallotto et al., 2019; smith et al., 2018). the nurse is responsible for ensuring whether the family or the caregiver has understood the provided written information (pfeil et al., 2007). 2. discharge collaborator collaboration between nurse and wide range of parties were identified during the review of evidence. the main category was again divided into the following subcategories. 2.1 social and community workers nurses are in the frontline to mediate care between family and the social workers (smith et al., 2018). public health nurses, like home visit nurses, play an essential role while interacting with necessary officials in order to receive assistance for the family. these include utilizing financial and social resources available in the community to fulfill post-discharge care needs (wells et al., 2017). 2.2 in-hospital medical team efficient collaboration with health providers inside the hospital will allow more opportunities for nurses to involve in the patient discharge planning, which increases patient and family satisfaction (auger et al., 2018; góes & cabral 2017; holland et al., 2015; uspal et al., 2016; smith et al., 2018). this collaborative work will work towards speeding up the recovery of the child (wells et al., 2017). the nurse should effectively communicate with necessary health professionals to fill knowledge gaps of the patient and family (gallotto et al., 2019). 2.3 family and the caregiver parental self-efficacy perception (ekim & ocakci 2016), satisfaction (arad et al., 2007; uspal et al., 2016; smith et al., 2018), experience with home care (dellenmark-blom & wigert, 2014; lerret et al., 2017), perception on care received (pfeil et al. 2007), care giver’s comfort and needs (gallotto et al., 2019; góes & cabral, 2017) have been assessed because every discharge planning intervention needs collaboration with a parent, caregiver or the family of the child (weiss et al., 2017). assessment of discharge readiness of the patient and family is an essential aspect of the discharge process, which needs interactions with them throughout the stay (schuh et al., 2016). collaboration between nurses and the family will help nurses identify the parenting roles' strengths and weaknesses and prepare interventions to address the issues, including sibling needs (dellenmark-blom & wigert, 2014; lerret et al., 2017). 3.post-discharge care coordinator nurses carry out post-discharge care coordination to ensure the care continuity of the child under two subcategories. 3.1 home visiting home visits led by nurses allow them to assess the child's home environment, the child’s safety at home, the child's physical well-being and make indonesian journal of nursing practices 40 necessary modifications collaborating with the family members (ekim & ocakci, 2016; pfeil et al., 2007). these visits will help nurses identify the family's social, emotional, and financial issues and refer them to necessary professionals. home visiting is an opportunity to evaluate the discharge education provided at the hospital and renew parental knowledge on the child’s treatment course (meerlo-habing et al., 2009). since family is a constant in the child’s life, being at home with the family will help the child emotionally; therefore, early discharge can be implemented if the nurses are allowed for home visiting once the child’s discharge (pfeil et al., 2007; wells et al., 2017). parents may feel uncomfortable in the common discharge education sessions at the hospital (smith et al., 2018) but feel more comfortable at their home being more open to the nurse disclosing their concerns (dellenmark-blom & wigert, 2014; pfeil et al., 2007). the feeling of being cared for even after hospital discharge will enhance parental emotional stability (dellenmark-blom & wigert, 2014; lerret et al., 2017). 3.2 telephone counseling frequent contact with the nurse and the parents after discharge will increase nurse and parent satisfaction (pfeil et al., 2007). these contacts allow the family to discuss their problems and resolve them with the nurse. every discharge planning model should include counseling sessions to ensure continuity and the quality of the care provided (ekim & ocakci 2016; wells et al. 2017). telephone call follow-ups will help families to return to their regular routine easily (auger et al., 2018; pfeil et al., 2007) and help health professionals to evaluate the effectiveness of their discharge planning interventions (arad et al., 2007). 4. family counselor nurses function as supporters for the family to identify their concerns and solutions, implying a counselor role. this role can be described under two sub-categories. 4.1 emotional support of parents parents are facing a variety of challenges once the child is again at home after discharge, including balancing the care of the child and sibling needs, establishing a new routine, lack of sleep, fatigue, anxiety, fear of child’s future, attending school needs of the child and follow up appointments (dellenmark-blom & wigert, 2014; lerret et al., 2017; meerlo-habing et al., 2009). the nurse can help them anticipate these issues in the discharge education process and find solutions early (ekim & ocakci, 2016; gallotto et al., 2019; turrell et al., 2005; smith et al., 2018). then the families will feel safe and prepared for the encountered problems. the reassurance gained from the nurse in the postdischarge period also reduces parental stress (arad et al., 2007; dellenmark-blom & wigert, 2014; góes & cabral, 2017; pfeil et al., 2007; schuh et al., 2016; wells et al., 2017). 4.2 siblings’ needs siblings may feel neglected and less attentive with a sick child at home (lerret et al. 2017). nurses can involve in such situations to increase support from other family members or finding a home care nurse for the family (wells et al., 2017; smith et al., 2018). during the assessment of discharge readiness, siblings’ readiness also should be assessed (schuh et al., 2016). discussion as previously discussed, a transition from hospital to home will be an anxiety-provoking situation for the sick child, parents, and other family members (purdy et al., 2015). however, with proper transitional care, it can be turned into a situation where the clients see it positively, again more than a loss and an opportunity more than a crisis (chick & meleis 1986). this systematic review has identified different nursing roles in the pediatric discharge planning process, bringing positive outcomes for transitional care, and needs to be incorporated with the sri lankan context. out of the studies that we have selected, most studies have been conducted in the usa, where discharge planning emerged. studies in asian countries were hardly found during the literature search on the topic. if the nurses cannot provide adequate information and reassurance for the patients and family, their uncertainty will lead to unnecessary utilization of health care facilities. parents’ health literacy is essential in the disease prevention of children (sanders et al., 2009). the discharge educator role vol. 5 no. 1 june 2021 41 was found in most of the studies, which implies the need for more time for nurses for educational sessions for the patient and the family. an educator nurse should have teaching skills and sound knowledge of educational theories, knowledge of family-centered care approaches, and related practices. in sri lanka, nurses' shortage of nurses and increased patient turn-over rate have led to a situation where nurses work under stressful conditions with a heavy workload (de alwis & shammika., 2015; de silva & rolls., 2010). it is a challenge for sri lankan nurses to spare adequate time for discharge teaching in such a situation. although the nursing training schools have included the patient teaching methods in their curriculum, there will be a gap between the nurses’ knowledge and the practice when it comes to the actual practice. the middle-range theory of transitions developed by meleis et al. (chick & meleis 1986) describes that the community in which an individual belongs and its resources will significantly affect his/her transition from hospital to home or another health care facility. therefore, nurses involved in discharge planning should collaborate with necessary parties in the community where the child and the family belong. these may include welfare services, school officials, religious leaders, co-workers of the parents, and relatives of the family. the nursing role as a collaborator implies the need for communication skills for nurses. during discharge planning, communication with the community care sector is essential. nurses should have sound knowledge of the available facilities and contact methods in the community. maintaining better continuity of care, communication, and interaction between the health professionals is essential (page et al., 2016). this collaboration should not be confined to the community outside the hospital but also with the persons involved in the child's care during the hospital stay. our study also found that nurses could function as counselors and post-discharge care coordinators. these skills can be incorporated into nurses and other health professionals (maguire & faulkner, 1988). as we found, nurses can coordinate postdischarge care through follow-up home visits and telephone counseling. new nursing specialties such as family care nurse, public health nurse home visiting nurse have emerged along with the discharge planning nurse (dpn) profession due to the increasing need for adequate post-discharge care. care coordination through telephone counseling might be a challenge for nurses in some communities due to the lack of access to the facility and lack of literacy of the clients. in previous literature, the nurse's counseling role is limited to school nurses and community care nurses (alizadeh et al., 2011). since counseling is a broad area of practice with ethical concerns, necessary skills should be possessed by nurses to provide quality care. therefore, these aspects should be included in the nursing curriculums and professional training to allow nurses to anticipate the issues and find solutions. in terms of the sibling issue, they will have unmet needs such as communicating information, maintaining their usual daily routine, and activities with having a sick child at the hospital. they may undergo severe emotional crisis with loneliness, guilt, and jealousy where nurses should intervene the supportive acts (wilkins & woodgate, 2016). nurses have a responsibility to help the siblings to master their ability to get accustomed to the new situation. the opportunity to engage in the care of the sick child during the stay and after the discharge will help siblings understand the reality of the transition they have to undergo with the discharge of the sick child. discharge care should strengthen the family bonds and cohesion as the family relationships have been identified as an indicator for a successful transition (chiang et al., 2012). in recent years, with the increasing medical needs of the pediatric population, sri lanka has a massive burden in providing health care facilities (ministry of health., 2019). therefore interventions which lead to reducing health cost while providing efficient care is in need. with the existing knowledge, it is obvious that proper discharge support will help to achieve this goal. sri lanka public hospitals do not include a separate department for discharge planning and the nursing specialty ‘discharge planning nurse’ still has not been well established in sri lanka. world health organization (who) has identified neonatal, infant, and under-five children’s mortality rates as crucial health indicators of sri lanka (ministry of health., 2019), implying the importance of children’s health. indonesian journal of nursing practices 42 long-term complications that may arise physically, mentally, and socially in children should be prevented as health issues in childhood lead to health problems in the later years of life affecting the future development of a country. in sri lanka, although pediatric nurses do not have a conceptualized guidance on discharge planning and discharge support, nurses function as information providers for the family. however, due to busy ward rounds and inadequate beds, discharge planning has neglected or unobservable in the ward setups. only special care units provide follow up care, and written information for the discharging patients. although specialties like diabetic education nursing officers (denos) have been established, those roles have been limited to adult care setup. there is no much evidence of studies on post discharge health care utilization of the pediatric patients in sri lanka. home visits by nurses have been limited to public health sector and palliative care sector in sri lanka and due to the lack of adequate nursing staff in hospital setup interactions between nurse and the family have been limited. family centered care practices are visible in some instances such as having one parent by child’s side throughout the hospital stay, siblings visiting policies and attending the mother and the child at home by public health midwives. therefore, sri lanka pediatric nurses may have knowledge on the importance of implementing discharge planning for pediatric patients but due to the role confusion and lack of guidelines, implementing the process in the real practice may have been a challenge for them. there are two limitations of this study. studies published only in english in two databases were considered, which may not account for studies on other languages. moreover, grey literature was not considered. conclusion and implications for practice according to our knowledge, very few recent literature is available on discharge planning support by sri lankan pediatric nurses. therefore, more studies are needed on the topic in sri lanka. policymakers should take the discharge planning process to their consideration to reduce health costs and care burden. in sri lanka, special pediatric nursing training is implemented only at a post-basic level under the supervision of the ministry of health. thus, establishing the discharge planning nurse profession in the pediatric setup is essential to widen the post-graduate educational opportunities for pediatric nurses. our study has identified various nursing roles in the pediatric discharge planning process. these identified roles can be incorporated into the discharge planning interventions, models, and guidelines for sri lanka pediatric nurses in the future. it will give rise to new nursing trends and specialties in the sri lanka nursing profession. declaration of conflicting interests the author(s) declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article. references alizadeh, v., törnkvist, l., & hylander i. 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(n=1) records included in the final review (n=16) exclusion based on abstract review (n=242) 1. review articles 2. case reports 3. medication trials 4. microbiology studies 5. studies conducted in emergency departments 6. articles explaining only about post surgical managements and rehabilitation. indonesian journal of nursing practices 48 problem identified during the home visit. schuh et.al 2016 canada tertiary care pediatric cardiology unit an observationa l descriptive study quantitative method parents or guardians self-reported questionnaire for parents or guardians of the child. a pre-discharge questionnaire containing information on the child’s treatment course, demographics, and hospital discharge scale assesses readiness for discharge. the postdischarge questionnaire sought information on a post-discharge treatment course, care transition measures, and quality of discharge teaching scale. providing discharge education, providing appropriate skills for parents that may need to care for the child at home, emotional support for the parents, and adequate information on community services that the child may need after hospital discharge. arad et.al 2007 israel the department of neonatology comparison studya qualitative method mothers of singleton newborn infants. telephone interviews information delivery at discharge by a staff nurse, including written instructions. ekim & ocakci 2016 turkey hospitalbased pediatric respiratory clinic a quasiexperimental study quantitative method parents of children who are newly diagnosed with asthma face to face interviews follow-up phone calls and home visits assessing discharge needs of the parent and the child. developing a discharge plan. assessing home environment and planning for necessary modifications. asthma management education. phone call interviews and counseling. home visiting. holland et.al 2014 usa pediatric acute care nursing unit predictive correlation studymixed method parent/guar dian of the child structured data collection forms were used in the interviews by the investigators and record interviews nurse clinicians have been identified as experts to evaluate subjects to determine early referral for discharge planning holland et al. 2015 usa pediatric acute care setting quasi experimental non equivalent comparison group design quantitative method staff registered nurse, clinical nurse specialist, parents assessments of the parent/guardian by the nurses using face-to-face interviews. assessment of current and post-discharge needs of the patient and family. discharge teaching. getting the family ready for home care. participating in discharge planning rounds. meerlohabing et.al 2009 netherla nd neonatal unit of a large district case-control study mothers of preterm infants parents were interviewed six months after the follow-up visits by a pediatric nurse specialist. vol. 5 no. 1 june 2021 49 general hospital quantitative method delivery via telephone calls by a pediatric nurse. pfeil et.al 2007 united kingdom department of children, university hospital cohort control studymixed method families of post uncomplicat ed appendecto my children approximately ten days after discharge, the researcher contacted each family via telephone. the semi-structured interviews considered the child’s recovery and physical well-being as well as open questions concerning the families’ experiences of the time following discharge nurses who monitored the child’s recovery after uncomplicated appendectomy visited the family within 24 hours after discharge. keep in contact with the family after discharge via telephone calls. f. goes and cabral 2017 brazil a public pediatric teaching hospital descriptive qualitative method children, family members, health professional s semi-structured interviews and medical record analysis, creativity and sensitivity dynamics nurses educate and help families gaining nursing competencies for home care of children with special care needs. this teaching is based on demonstrating necessary skills transmitting the responsibility of procedural care needed by the child to the family dellenmarkblom & wigert 2014 sweden neonatal home care setting an interview study with a phenomenol ogical hermeneutic approach. qualitative method parents open-ended interviews advising parents on feeding, growth checks, and support of parent-child interactions during the hospital stay. families have regular home visits by the pediatric nurse specialist (pns) every week. auger et.al 2018 usa tertiary care children's hospital randomized controlled triala qualitative method family telephone survey and analyses of hospital administrative documents by a researcher ensure child’s recovery, reassure parents, discharge instructions and postdischarge red flags via telephone conversation follow-up for complications that may need further medical care. lerret, johnson and haglund 2017 usa pediatric transplant hospitals the qualitative component of a more extensive mixed methods longitudinal study parents telephone call interviews with open-ended questions teaching new skills needed. addressing psychosocial issues. wilson smith, sachse and perry usa urban academic descriptive survey nurses, families post-discharge telephone calls for families, discharge education. preparing the family for postdischarge home care indonesian journal of nursing practices 50 2018 medical center quantitative method feedback from caregivers, nurses satisfaction survey providing tool kits needed for the care of the child at home. gallotto et.al 2019 usa children’s hospital descriptive study home parenteral nutrition nurses bedside nurses interviews and discussions. educating the parents about skills needed for home parenteral nutrition administration. bedside nurses involve in practicing and demonstrating the skills. weiss et.al 2017 usa pediatric academic medical center quantitative study secondary analysis of data from a longitudinal pilot study of a family selfmanagemen t discharge preparation intervention. parents questionnaire on the day of discharge (quality of discharge teaching scale; readiness for hospital discharge scale), at 3 weeks post-discharge (post-discharge coping difficulty scale), and from electronic records (readmission, ed visits) discharge teaching assessment of discharge readiness. family support. uspal et.al 2016 usa pediatric academic medical center used lean methodolog y. retrospectiv e beforeand-after analysis completed after process implementat ion qualitative method and staff survey patients and families extraction from the electronic medical record. additional data on elopement/agitatio n events, physical restraint use, and security physical intervention events were obtained through an existing security services database maintained for quality improvement purposes evaluate mental health patients provide education to the families table 2. themes identified through general inductive approach no main categories sub categories 1 discharge educator medications and red flags, new skills for the caregiver, life after discharge, written information 2 discharge collaborator social and community workers, inhospital medical team, family and the care-giver 3 post-discharge care coordinator telephone counseling, home visiting 4 family counselor emotional needs of parents, siblings’ needs. 5. 10748-kalpana j subasinghe; bookmark_clean.pdf 5. 10748-kalpana j subasinghe-lampiran_clean.pdf vol. 7 no. 1 june 2023 ©2023 ijnp (indonesian journal of nursing practices). this is an open-access article distributed under the terms ofthe creative commonsattribution 4.0 international license https://creativecommons.org/licenses/by/4.0/ 9 open access volume 7, issue 1, june 2023, p. 9-17 age and comorbidities as the main factors of mortality in covid-19 patients anni fitrhiyatul mas’udah1, lina ema purwanti1* , hery ernawati1, naylil mawadda rohmah1, vanesha awaliya muslimah2, vanesya isnaya muslimah2 1department of nursing, faculty of health science, universitas muhammadiyah ponorogo, indonesia 2faculty of health science, universitas muhammadiyah ponorogo, indonesia corresponding author: lina ema purwanti email: emapurwantilina@umpo.ac.id article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) :10.18196/ijnp.v7i1.17347 : 29 december 2022 : 08 april 2023 : 12 april 2023 abstract background: the high mortality rate in covid-19 patients is associated with demographic factors and comorbid conditions. this is supported by research which shows that a history of comorbidities causes 88% of deaths in sarscov-2 positive patients. consequently, it is important to identify factors associated with poor outcomes among covid-19 patients. objective: the purpose of this study was to determine the main factors that cause covid-19 mortality in indonesia. methods: the research design used a retrospective cohort. the population of this study was all covid-19 patients treated at the 'aisiyah ponorogo general hospital from march to december 2021, totalling 881. the data was arranged based on the completeness of the medical records, and seven respondents had to be excluded due to incomplete data. therefore, the total number of samples used was 874 patients. data was analyzed using logistic regression. result: the multivariate analysis showed that patients aged 46-65 years had a 1.45 times greater potential to die than than patients who were 0-25 years old. the risk factors for comorbidities had an effect on the mortality of patients with confirmed cases of covid-19. the variables that had a significant effect on the mortality of covid-19 included diabetes mellitus (or=1.36), hypertension (or = 1.78) and heart disease (or = 1.4). conclusion: the most common causes of mortality in covid-19 patients are age and comorbidities diseases, there are diabetes mellitus, hypertension and heart disease keywords: age; comorbidities; mortality; covid-19 introduction the world health organization classified the covid19 epidemic as a pandemic on march 11th, 2020 (who, 2020). as of september 9th 2020, the indonesian government had reported 8336 fatalities and 203,342 verified cases of covid-19 (who, 2022). according to data from china, older individuals are more likely than younger individuals to experience severe covid-19-related illness and death, especially if they have major underlying medical conditions (clark et al., 2020). although most covid-19 cases recorded in china were minor (81%), about 80% of fatalities involved adults under 60 (cdc covid-19 response team, 2020). in the united states, the fatality rates for covid-19 patients ranged from 3% to 11% for those 65 and older and 10% to 27% for those under 85, according to the first early description of results (djaharuddin et al., 2021). the mortality of covid-19 was 4.3%, and severe cases (treated in the icu) were older people (chen et al., 2020), more likely to have underlying comorbidities, dyspnea and anorexia (li et al., 2020). based on data compiled by the indonesian covid-19 handling task force as of https://creativecommons.org/licenses/by/4.0/ mailto:emapurwantilina@umpo.ac.id http://journal.umy.ac.id/index.php/ijnp https://portal.issn.org/resource/issn/2548-4249 https://portal.issn.org/resource/issn/2548-592x https://journal.umy.ac.id/index.php/ijnp/article/view/17347 https://orcid.org/0000-0003-2864-1523 https://crossmark.crossref.org/dialog/?doi=10.18196/ijnp.v7i1.17347&domain=pdf indonesian journal of nursing practices 10 october 13th, 2020, from the total confirmed positive cases of covid-19, 1488 patients were recorded as having co-morbidities. the highest percentage of co-morbidities includes hypertension at 50.5%, followed by diabetes mellitus at 34.5% and heart disease at 19.6%. while from the 1488 cases of patients who died, it was found that 13.2% had hypertension, 11.6% had diabetes mellitus, and 7.7% had heart disease (indonesian health ministry, 2020). in general, the co-morbidities that can increase the risk of death in covid-19 patients include hypertension, diabetes mellitus, copd, cvd, liver disease, obesity, renal disease, malignancy, asthma, pneumonia, hiv, heart disease, hematologic, cva (ejaz et al., 2020) (rozaliyani et al., 2020)(satria et al., 2020)(bajgain et al., 2021). however, information regarding the demographic characteristics and comorbid disease features that impact mortality rates in relation to covid-19 patients has still not been investigated. in this study, we will determine the main factors that cause the mortality of covid-19 patients in indonesia. method we retrospectively reviewed the medical records of all in-patients diagnosed with covid-19 at the 'aisyiyah ponorogo general hospital. the study design used a retrospective cohort. the population of this study was all covid-19 patients treated from march to december 2021, which totaled 881. the data was then sorted based on the completeness of the medical records and seven respondentswere excluded due to incomplete data. the final number of samples used was 874 patients. the research ethics commission of rsu 'aisiyah approved this research by decree no. rsua/01.a/170/ec/a/ii/2021. data was analyzed using logistic regression. results the results of the descriptive analysis related to the characteristics of the respondents can be seen in the following table. table 1. characteristics of respondents variable category frequency percentage (%) gender male 453 51.8 female 421 48.2 age (years) 0-25 34 3.9 26-45 139 15.9 46-65 477 54.6 >65 224 25.6 diabetes mellitus history of dm 162 18.5 no history of dm 712 81.5 hypertension history of hypertension 346 39.6 no history of hypertension 528 60.4 heart disease history of heart disease 277 31.7 no history of heart disease 597 68.3 final status die 279 31.9 life 595 68.1 vol. 7 no. 1 june 2023 11 table 2. relationship between age, gender, diabetes mellitus, hypertension, and heart disease on the final status of covid-19 patients variable category final status total or pvalues 95% ci die life n % n % age (years) 26-45 46-65 28 153 20.1 32.1 111 324 79.9 67.9 139 477 0.97 1.92 0.954 0.168 0.384-2.463 0.775-4.275 >65 91 40.6 133 59.4 224 2.64 0.029 1.102-6.318 0-25 7 20.6 27 79.4 34 ref gender male 146 32.2 307 67.8 453 1.03 0.840 0.774-1.369 female 133 31.6 288 68.4 421 ref diabetes mellitus history of dm 64 39.5 98 60.5 162 1.51 0.022 1.060-2.149 no history of dm 215 30.2 497 69.8 712 ref hypertension history of hypertension 142 41.0 204 59.0 346 1.99 0.000 1.487-2.653 no history of hypertension 137 25.9 391 74.1 528 ref heart disease history of heart disease 105 37.9 172 62.1 277 1.48 0.010 1.10-2.00 no history of heart disease 174 37.9 423 70.9 597 based on the data presented in table 2, it can be seen that patients aged 46-65 years have an increased potential to die that is 0.168 times greater than patients who are > 65 years old, and male patients have a 0.840 percent higher chance to die than female patients. patients with comorbid dm, ht, and heart disease have the potential to experience death within a range of 0.00-0.022 times greater than patients without comorbidities. from the results of the chi-square test, it was found that the p-value was 0.02, indicating there was a relationship between age and the patient's final status; the p-value of dm comorbidities was 0.022 indicating there was a relationship between comorbidities and the patients’ final status; the pvalue of comorbid hypertension is 0.00 or <0.05 so that there is a relationship between co-morbidities and the patients’ final status; the p-value of comorbid heart disease is 0.010 indicating there is a relationship between co-morbidities and the patients’ final status. based on the results of bivariate analysis between the main independent variables and potentially confounding variables, it shows that the p-value is > 0.05. the selection was carried out for multivariate analysis. the selection was completed by removing variables starting with the highest p-value. if the change in or was <10% then the variable was excluded, if not then it was included in the confounding variable. furthermore, multivariate analysis was carried out to determine the relationship between the surviving variables and potential confounding variables together with the patient's final status variable (die or life). indonesian journal of nursing practices 12 table 3. relationship between age, gender, diabetes mellitus, hypertension, and heart disease on the final status of covid-19 patients variable category b or se p-value 95% ci age (years) 26-45 46-65 >65 0-25 -0.07 0.37 0.70 0.93 1.45 2.02 ref 0.44 0.64 0.91 0.890 0.402 0.123 0.36-2.40 0.60-3.45 0.83-4.92 diabetes mellitus history of dm no history of dm 0.30 1.36 ref 0.25 0.102 0.94-1.96 hypertension history of hypertension no history of hypertension 0.58 1.78 ref 0.27 0.000 1.32-2.40 heart disease history of heart disease no history of heart disease 0.34 1,4 ref 0.22 0.031 1.03-1.92 through the multivariate analysis, it was found that the variables were highly related and had significant impact on the patients’ final status, namely the age group 46-65 years (or=1.45), diabetes mellitus (or=1.36), hypertension (or=1.78) and heart disease (or=1.4). from these results it was found that co-morbidities or comorbid disease risk factors had an effect on the final status of patients with confirmed cases of covid-19. in the multivariate analysis, it was found that paitents aged 46-65 years had a 0.37 times risk of dying compared to those aged <45 years, and those with comorbid dm had a 0.3 times risk of dying when compared to those who did not have comorbid dm. those who had comorbid hypertension had a risk of 0.58 times dying when compared to those who did not have comorbid hypertension. furthermore, paitents who had a comorbid heart disease had a 0.34 times higher risk of dying when compared to those who did not have a comorbid heart disease. based on the data in table 2, it can be seen that patients aged 46-65 years had the potential to die 1.45 times greater than patients who were 0-25 years old. patients with comorbid diabetes mellitus, hypertension, and heart disease were more likely to experience death than patients without comorbidities. based on the results of bivariate analysis, between the main independent variables and confounding variables, it showed that the pvalue is > 0.05. the selection was carried out for multivariate analysis. selection was completed by removing variables starting with the highest p-value. if the change in or <10% then the variable was excluded, if not then it was included in the confounding variable. furthermore, multivariate analysis was carried out to see the relationship between the survival variables and potentially confounding variables together with the patients’ final status variable. through the multivariate analysis, it was found that the variables were highly related and had a significant impact on the patients’ final status, namely the age group 46-65 years (or=1.45), diabetes mellitus (or=1.36), hypertension (or=1.78) and heart disease (or=1.4). from these results it was found that co-morbidities or comorbid disease risk factors had an effect on the final status of patients with confirmed cases of covid-19. in the multivariate analysis, it was found that paitents aged 46-65 years had a 1.45 times higher risk of dying compared to those aged 0-25 years, and those with comorbid diabetes mellitus had a 1.36 times risk of dying when compared to those who did not have diabetes mellitus comorbid. those who have comorbid hypertension had a risk of 1.78 times higher of dying when compared to those who did not have comorbid hypertension. furthermore, those who had comorbid heart disease have a risk of 1.4 times dying when compared to those who did not have comorbid heart disease. discussion in this study, we have reported that the clinical characteristics of the patients indicated that age and underlying diseases were the most significant risk factors for death. with regard to underlying diseases, the most common disease was hypertension, followed by heart disease and diabetes mellitus. from these results, it was found that co-morbidities or comorbid disease risk factors vol. 7 no. 1 june 2023 13 had an effect on the final status of patients who had covid-19. in this multivariate analysis, it was found that aged 46-65 years had a 1.45 times higher risk of dying compared to those aged 0-25 years, and those with comorbid diabetes mellitus had a 1.36 times greater risk of dying when compared to those who did not have diabetes mellitus comorbid. those who have comorbid hypertension had a risk of 1.78 times dying when compared to those who did not have comorbid hypertension. furthermore, those who had comorbid heart disease had a risk of 1.4 times dying when compared to those who did not have comorbid heart disease (table 2). age and covid -19 based on the data from table 2, out of 874 patients who were positive for covid-19, it was found that the average age of patients was 46-65 years, namely 477 (54.6%) with 153 cases of death (32.1%). in indonesia, 40% of covid-19 patients who died were aged over 60 years, and 56% were in the age range of 50-59 years (matla ilpaj & nurwati, 2020). this demonstrates that age can be another risk factor for covid-19 patients. 40% of covid-19 patients who died were aged over 60 years, and 56% were in the age range of 50-59 years (matla ilpaj & nurwati, 2020). the in-patient population is predominantly over 50 years old (42.7% of the population) and 11.4% is over 75 years old, but this age accounts for 84.4% of the total number of deaths (casas-deza et al., 2021). among covid-19 patients, elderly patients have higher mortality rates due to high case fatality rate (cfr) and symptomatic infection rates. between 80% and 90% of deaths occured in patients aged between 70 years and 60 years in korea and italy (kang & jung, 2020). (kang & jung, 2020). in a retrospective cohort study from china, hospitalized patients were predominantly men with a median age of 56 years, and there was a 28% mortality rate (zhou et al., 2020). the death rate for covid-19 increases exponentially with age. this occurs especially in patients who have age-related diseases, such as diabetes and hypertension, because these diseases are a manifestation of aging as a result of decreased cellular function. the pseudo-programmed aging hyperfunction theory explains age-dependent covid-19 susceptibility (blagosklonny, 2020). age is one of the factors that affects the condition of infected patients, the older the paitent, the worse the condition will be, particularly when coupled with co-morbidities. when imposing contact or job restrictions during the covid-19 pandemic, it is important to precisely define risk groups relating to the severity of the illness. this study demonstrates that mortality and hospitalization rates rise with age and that there is no specific age cut-off for a significant increase in risk. main comorbidity factors this study found several co-morbidities in paitents with covid-19. the results of this study also provide information that co-morbidities affect the final status of covid-19 patients in indonesia. co-morbid diseases in the form of hypertension 346 (39.6%), heart disease 277 (31.7%), and diabetes mellitus (dm) 162 (18.5%). the findings relating to these cases showed co-morbidities are one of the factors that influence a patient's final status. based on data from 2020, it is known that hypertension is the most common comorbid case in cases of covid-19 patients in indonesia(52.1%) (hooper, 2020). this is supported by a meta-analysis which showed that hypertension is the most common comorbid, namely 21.1% (yang et al., 2020). diabetes mellitus is the second most comorbid in covid-19 patients in indonesia with cases of 33.6% (hooper, 2020). in addition, the results of research in wuhan china, found many patients who died from respiratory failure (92%) and had comorbidities, namely hypertension (64%), dm (40%), heart problems (32%) (li et al., 2020). hypertension is the main comorbid found in several countries. diabetes mellitus (dm) and covid-19 based on the data in table 3, out of 874 patients who tested positive for covid-19, 162 cases (18.5%) were found to have comorbid diabetes mellitus, with 64 cases resulting in death (39.5%). diabetes mellitus is comorbid that is often found in covid-19 patients with the highest mortality rate. it can be concluded that there is a relationship between covid-19 patients who have comorbid diabetes mellitus and the patient's final status, condition and severity. based on the results of this study, it has been found that dm has a significant effect on the final status of covid-19 patients, with a value of 0.102 (or: 1.36; ci 0.94-1.96) (see table 2). in research conducted in wuhan, china, odds ratio (or) was obtained by logistic regression with an or of 1.68 (95% ci 0.80-3.52). in a retrospective observational study using the administrative hospital episode statistics dataset with logistic regression, metastatic carcinoma increased or 1.14 indonesian journal of nursing practices 14 (95% ci 1.10-1.19) (gray et al., 2021). . high blood sugar levels are accompanied by disturbances in carbohydrate, lipid and protein metabolism as a result of insufficiency of insulin function into multiple etiologies of chronic metabolic disorders or what is often known as diabetes mellitus. disturbance or deficiency of insulin production by langerhans beta cells of the pancreatic gland or lack of responsiveness of the body's cells to insulin causes insulin function insufficiency (kementerian kesehatan ri., 2020). the mechanism of immunity and angiotensin-converting enzyme-2 (ace-2) is the pathophysiology that forms the basis of the relationship between dm and covid-19. the increased risk of a cytokine storm arises from a proinflammatory condition in patients with dm, which leads to shock, acute respiratory distress syndrome (ards), and worsening of covid-19 symptoms leading to death. this is indicated by higher d-dimer levels in covid-19 patients with dm than those without dm. dm sufferers will be more susceptible to infection, so their experience impaired immune responses and longer viral clearance mechanisms. hypertension and covid-19 based on the data above, out of 874 patients who tested positive for covid-19, 346 cases (39.6%) were infected with covid-19 with comorbid hypertension, with death resulting in 142 cases (41.0%). whereas comorbid diabetes mellitus was the most common comorbid found in patients with confirmed covid-19 that resulted in dealth hypertension was the comorbid that most influecnes the condition and severity of covid-19 patients. this is related to ace 2 angiotensin converting enzyme type 2 (ace-2) disorders in covid-19 patients with hypertension. based on the results of this study, hypertension has a significant effect on the final status of covid-19 patients, with a substantial value of 0.000 (or: 1.78; ci 1.32-2.40). this reflects the results of the 2020 study by ejaz et al., which found that hypertension is generally the most common type of comorbidity found in patients infected who have covid-19. uncontrolled blood pressure is associated with covid-19 infection and a high case fatality rate (cfr). in china, 23% of hypertensive covid-19 cases were reported with a cfr of 6%, and the number continued to increase due to pandemic fears. hypertension or high blood pressure is an increase in systolic blood pressure of more than 140 mmhg and diastolic blood pressure of more than 90 mmhg in two measurements with an interval of five minutes in calm conditions. the pathophysiology of hypertension is influenced by genetics, age, smoking habits, diet, and activation of the sympathetic nervous system (sns), vasodilation of blood vessels, and the renin-angiotensinaldosterone system (perhimpunan dokter hipertensi indonesia, 2021). when the heart pumps greater amounts resulting in more muscular heart muscle contractions and greater blood flow through the arteries, the elasticity of the arteries decreases and increased blood pressure (parasher, 2021). for patients suffering from hypertension, ace-2 inhibitors and angiotensin receptor blockers (arbs) are often used for medicinal purposes. if this inhibitor is used in high amounts, it can increase the expression of ace-2 receptors, thereby causing an increased susceptibility to sars-cov-2 infection. angiotensin converting enzyme type 2 (ace-2) was identified as a target receptor for sars-cov-2 (cevik et al., 2020). ace-2 is a specific functional receptor for sars-cov-2 and is the starting point for covid19 infection (ni et al., 2020) (parasher, 2021). the disease is more prone to occur when the expression of lung receptor cells is higher, and the possibility of severe lung damage and an increased chance of respiratory failure can occur. the reninangiotensin-aldosterone system (raas) increases the risk of death in covid-19 patients with hypertension. hypertension can be prevented and controlled by screening and early detection of correct and regular blood pressure measurements so that it can reduce the severity of infection, especially covid-19 (perhimpunan dokter hipertensi indonesia, 2021). heart disease and covid-19 there were 277 cases (39.6%) of patients infected with covid-19 who had comorbid heart disease, with 105 cases resulting in death (37.9%) (table 1). comorbid heart disease is commonly found in patients with confirmed covid-19 and issues of death in covid-19 patients with comorbidities. based on the results of this study, it was found that heart disease had a significant effect on the final status of covid-19 patients, with a substantial value of 0.031 (or: 1.4; ci 1.03-1.92). this is in line with previous research, where cardiovascular disease vol. 7 no. 1 june 2023 15 was shown to be connected with the risk of death in patients infected with covid-19. prior research which has been carried out includes a retrospective observational study conducted at hankou hospital in wuhan, china. the odds ratio (or) was obtained by logistic regression with an or of 2.02 (95% ci 0.90-4.54) (bajgain et al., 2021). dying of covid-19 with cardiovascular comorbidities of 10.6% (or 4.319) was the highest risk factor for covid-19 death in this study (satria et al., 2020). disturbances in the function of the heart and blood vessels cause cardiovascular disease. diseases that often occur in the cardiovascular system are coronary heart disease and stroke. in patients with cardiovascular disease, the immune system tends to be weak in responding to viruses (mishra et al., 2021). cardiovascular sufferers infected with covid-19 have a higher risk of serious illness or death because the pathophysiological process of ace-2 receptors in the cardiovascular system is the entry point for the covid-19 virus and increases the risk of cardiovascular disorders in sufferers of covid-19, especially in a diseased heart which must work harder to produce blood and deliver oxygen throughout the body (nishiga et al., 2020). a diseased heart has problems pumping efficiently and burdens the body's system as a whole. there is anagement and prevention that can be carried out for covid-19 patients with comorbid conditions in orderto reduce the risk of morbidity and mortality, namely by monitoring the state of the body by the doctor, maintaining a healthy lifestyle, and managing diet according to comorbid conditions, complying with health protocols by implementing 5m (wearing masks, keeping distance, washing hands, keeping the environment clean, reducing mobility and interaction), avoiding stress and undertaking regular exercise adapted to comorbid conditions. conclusion the co-morbidities that are the main cause of death in cases of covid-19 are diabetes mellitus (18.5%), hypertension (39.6%), and heart disease (31.7%). male patients and the elderly are more vunrable to covid-19. dm sufferers will be more susceptible to infection, as sufferers experience impaired immune responses and longer viral clearance mechanisms. in hypertensive patients, the heart will pump a greater amount which results in stronger contractions of the heart muscle resulting in greater blood flow through the arteries, reducing arterial elasticity and increasing blood pressure. in patients with cardiovascular disease, the immune system tends to be weak in response to viruses. cardiovascular patients who are infected with covid-19 have a higher risk because the pathophysiological process of ace-2 receptors in the cardiovascular system is the entry point for the covid-19 virus and increases the risk of cardiovascular disorders in sufferers of covid-19. therefore, cardiovascular disease has a significant relationship with risk of death in patients infected with covid-19. acknowledgement the author expresses his gratitude to universitas muhammadiyah ponorogo. references bajgain, k. t., badal, s., bajgain, b. b., & santana, m. j. 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of spiritual well-being and stress level in college students: a correlational study muhammad ari arfianto*, shabrina naulal haqqiyah, sri widowati, muhammad rosyidul ibad department of nursing, faculty of health sciences, universitas muhammadiyah malang, indonesia corresponding author: muhammad ari arfianto email: muhammad_ari@umm.ac.id article info online issn doi article history received revised accepted : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) :10.18196/ijnp.v7i1.17914 : 14 february 2023 : 27 may 2023 : 31 may 2023 abstract background: students often experience stress with varying intensity. spiritual well-being is considered to have a role in controlling student stress levels. but there are many students who experience stress even though they already have good spiritual well being. objective: this study aims to explore the correlation between spiritual well-being and stress levels in college students. methods: this a cross-sectional l study involved 104 students. the sample was selected using an accidental sampling technique. the independent variable of this study was the students' level of spiritual well-being, while the dependent variable was the level of student stress. data collection uses the spiritual well being scale questionnaire and hassless assessment scale for students in college questionnaires which have been tested for validity and reliability. this research’s results were analyzed using the spss application with the spearman rho test. most of the respondents had spiritual welfare in the high category, namely 82.7%. most of the stress levels experienced by students were at a mild stress level (63.5%). results: the study found a significant correlation between spiritual well-being and stress level among collge student (p = 0.000 ) with a correlation coefficient of -0.392. conclusion: this study indicates that there is a significant relationship between spiritual well-being and stress levels in college students, with a weak correlation level and a negative correlation direction, this means that students who have high spiritual well-being have a lower probability of stress. keywords: college students; spiritual well-being; stress introduction student’s often experience high stress due to emotional and physical tension caused as a result of academic and non-academic stimuli that occur around them (musabiq & karimah, 2018). stress can also be caused by a lack of spirituality or a lack of connection with god. therefore the spirituality of students can be increased to resolve the stress (aditama, 2017). students can increase worship such as reading holy books, performing religious rituals and applying spiritual behavior in everyday life. spiritual well-being is a factor that contributes to reducing stress levels in college students (taliaferro et al., 2009). mental health problems are one of the most commonly suffered conditions and ranks 4th worldwide in 2013 and 2nd in 2020. the prevalence of stress based on 2013 riskesdas data states that as many as 6% (14 million) of indonesia's population over 15 years displayed symptoms of depression and anxiety (ambarwati et al., 2019). previous research involving 152 students in indonesia found that 37.7% of respondents experienced moderate stress in the first year and 61.2% in the second year of university student (adryana et al., 2020). the incidence of stress worldwide is also relatively high, around 75% of the adult population in america experiencing severe stress, a number that continues to increase each year (legiran et al., 2015). in https://creativecommons.org/licenses/by/4.0/ mailto:muhammad_ari@umm.ac.id https://crossmark.crossref.org/dialog/?doi=10.18196/ijnp.v7i1.17914&domain=pdf vol. 7 no. 1 june 2023 27 addition, more than one million (1.33 million) indonesians experience mental health problems or stress. the high prevalence of stress in the world is evident with nearly 350 million people globally experiencing stress (erindana et al., 2021; musabiq & karimah, 2018). other research states that college students are particularly vulnerable to stress. the cause of this stress is due to changes in adult education methods where there are many assignments due with deadlines (adryana et al., 2020; erindana et al., 2021). in nursing students, stress is also often caused by the laboratory learning process. they often feel symptoms of stress such as anxiety when approaching practical laboratory exams (salistia budi et al., 2016). nursing students’ stress also occurs towards the end of study. this condition is often caused by the student completing their thesis (purukan et al., 2022). in addition, stress can also be caused by a lack of student spirituality or a lack of relationship with god. spirituality one coping mechanism available to students. one way to help students manage their stress levels is by increasing the spirituality of these students (aditama, 2017). students can increase worship and apply spiritual behavior in everyday life. the level of spiritual wellbeing is a factor that contributes to reducing stress levels in students (taliaferro et al., 2009). students are one of the subjects who readily experience academic stress related to education while in college. this is because students carry out many academic and non-academic activities (b & hamzah, 2020). someone who has sound spiritually will find it easier to face and solve problems, especially when the individual is experiencing severe stress (tumanggor, 2019; utama, 2018). if the stress is not resolved, it can trigger other psychosomatic symptoms such as disturbed sleep patterns and lack of concentration while learning (waliyanti & pratiwi, 2017). besides this, stress is also a factor that can trigger aggressive behavior including bullying (sari et al., 2022). spirituality is a complex concept that is unique to each individual, coupledwith a variety of experiences that are felt by most people who seek their limits and find meaning and purpose through relationships with other humans, nature, or god (potter et al., 2021; potter & perry, 2009). the spiritual aspect triggers the formation of the meaning in one's life through intrapersonal interactions, interpersonal interactions, and transpersonal interactions to solve challenges that may be experienced (aditama, 2017). the spiritual aspect is an important factor in belief that can help individuals achieve the balance necessary to maintain health and well-being through a spiritual relationship with god. spirituality is an intrinsic factor for someone who is an important influence in solving problems (alorani & alradaydeh, 2018; taliaferro et al., 2009). spiritual well-being is a condition in which the individual has fulfilled their happiness spiritually or psychologically (alorani & alradaydeh, 2018). the individual's spiritual condition is a form of selfemphasis in relation to god, oneself, and the environment simulatenouslu. spiritual well-being forms part of the needs of every individual. someone who is spiritually fufilled will find it easier to face and solve problems, especially when the individual is experiencing severe stress (lee, 2014; pant & srivastava, 2019). the concept of spiritual well-being is inseparable from the definition framework laid out by the national interfaith coalition on aging (nica) in washington dc, which states that spiritual well-being is "the affirmation of life in a relationship with god, self, community and environment that nurtures and celebrates wholeness.” spiritual well-being forms the basis for all aspects of a person's well-being that combines physical, psychological and social health. spiritual health is a dynamic and fluctuating condition. it is necessary to achieve a peaceful life (tumanggor, 2019). spiritual well-being can be achieved by increasing religious activities. research shows that there is a relationship between the intensity of participating in religious activities and the individual's spiritual level (muslimah et al., 2019). this means that efforts to improve spiritual well-being can be carried out through religious activity programs. undertaking religious activities are one way to improve coping mechanisms (novianty & garey, 2021). regular religious activities can increase individuals’ ability to deal with stress. religious activities can be carried out incidentally or planned within the educational curriculum. in islamic-based educational institutions these religious activities are already a part of the educational curriculum (handayani et al., 2021). religious activities are formally programmed and must be attended by all students. in this study, indonesian journal of nursing practices 28 respondents were students from universities with islamic backgrounds, and therefore should have better spiritual coping mechanisms because they attend a college with an islamic-based learning curriculum. the quantity of religious activities has been scientifically proven to increase individual spirituality, but several studies have shown that the level of stress experienced by students in islamic educational institutions is still high (el-azis, 2017). other research also shows that many students at islamic boarding schools experience stress during learning activities even though they regularly participate in religious activities (rauzana et al., 2021). other findings show that students' stress levels are high despite them studying at a religionbased institution (sugiarto et al., 2023). researchers identified a trend during a preliminary study at the research site, that 20 out of 26 students were complaining of symptoms of stress and experiencing psychosomatic symptoms such as difficulty sleeping, difficulty concentrating during learning, loss of appetite, anxiety and others. interestingly most of the students said that they routinely participated in religious and worship activities during their study period. this study aims to identify the relationship between spiritual well-being and stress in college students. method research design this study used a correlation description design with a cross sectional approach. setting, population and sample the population of this study was 449 college students from the faculty of health sciences, university of muhammadiyah malang, indonesia. 104 respondents were selected using accidental sampling. researchers distributed questionnaires online and then all the answers received were selected based on criteria, respondents' answers that did not meet the inclusion criteria and were incomplete were not used. instrument, collection, data analysis data was collected using an online data survey in march 2022. the independent research variable was spiritual well-being as measured by the spiritual well being scale questionnaire (swbs). the swbs questionnaire consists of 20 statements consisting of two subscales religion well-being (rwb) and extensional well-being (ewb). the swbs questionnaire uses a linkert scale with a value of 16 for each statement item. the dependent variable of the study is the stress level as measured by the hassless assessment scale for students in college (hass/col) questionnaire. the measuring instrument consisted of 54 questions with 4 answer choices that have a value, score 0 = never, 1 = sometimes, 2 = often, and 3 = always. before data collection, researchers conducted validity and reliability tests. all questionnaire questions have a valid status, because the value of r count (corrected item-total correlation) > r table is 0.195. the reliability test results obtained cronbach alpha values, 0.903 and 0.871 and met the requirements, > 0.600 indicating that the variables used were reliable. the independent and dependent variable data types are ordinal data, spiritual well being and stress levels are categorized into 3 levels: low, moderate and high. data was analyzed by sperman rank correlation analysis with spss version 23. ethic the research has passed the ethical standards of the health research ethics commission at the university of muhammadiyah malang with number no.e.5.a/053/kepk-umm/iii/2022. result the results of the study can be seen in table 1 and table 2 where respondents had an average age of 21.24 years, the majority of whom were femalehalf of the respondents were in their 3rd year of study, living at home alone (with their parents), and their parents' income was more than 5 million rupiah. in addition, almost all respondents were muslim. this research’s results found that most of the respondents had high levels of spiritual well being and low stress levels. vol. 7 no. 1 june 2023 29 table 1. demographic data (n=104) variabel n % age (mean, years) 21.24 gender male 12 11.5 female 92 88.5 year of study 3rd 51 49.0 2nd 27 26.0 1st 26 25.0 religion islam protestan katolik 99 4 1 95.2 3.9 0.9 residence with parent clive in the boarding house others 52 35 17 50.0 33.7 17.3 parents' income (rupiah) 1 million – 2 million 5 4.8 2 million – 3 million 9 8.6 3 miliion – 5 million 32 30.8 > 5 million 58 55.8 table 2. spiritual well-being and student stress (n=104) variabel n % spiritual well-being low moderate high 0 18 86 0 17.3 82.7 stress level low moderate high 66 36 2 63.5 34.9 1.9 table 3. relationship between spiritual well-being and student stress levels (n=104) stress level total low moderate high spiritual wellbeing low 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) moderate 6 (5.8%) 10 (9.6%) 2 (1.9%) 18 (17.3%) high 60 (57.7%) 26 (25.0%) 0 (0.0%) 86 (82.7%) total 66 (63.5%) 36 (34.6%) 2 (1.9%) 104 (100.0%) p value (α=0.05) 0.000 (r = -0.392) based on the results of table 3, it can be seen that the majority of respondents who have spiritual wellbeing fall into the moderate stress category. the majority of respondents who had spiritual wellbeing in the high category experienced moderate stress. a high level of spiritual well-being had a moderate level of stress. in addition, it could also seen that there is a relationship between spiritual well-being and stress levels in students (p value = 0.000) with a coefficient of -0.392. the significance value is < level of significance (α = 5% or 0.05). it can be concluded that there is a significant relationship between spiritual well-being and stress levels in students. the coefficient value is negative, meaning indonesian journal of nursing practices 30 that when spiritual well-being increases, it is followed by a decrease in stress levels in students. conversely, if students experience increased stress, spiritual well-being has the potential to decrease. the level of closeness of the relationship between the two variables is sufficient, meaning that the variable spiritual well being is a factor related to the level of stress. discussion spiritual well-being in college student this research showed that most students have a high level of spiritual well-being. this study did not find any students who had a low level of spiritual well-being. all students showed moderate to high spiritual well-being. these results are similar to leung & pong's (2021) research which also showed that the level of spiritual well-being of students at a university was at a moderate to high level. in this study, the small standard deviation of spiritual wellbeing indicated that there is no significant variation between the levels of spiritual well-being among college students. therefore, students can be said to have equivalent level of spiritual well-being students who have a moderate level of spiritual well-being showed a minimum value scale range of 58 to 86. meanwhile, students who had high levels of spiritual well-being were in the range of a value scale of 87 to 97. the results of this study were similar to research conducted by momennasab et al. (2019) which stated that nursing and midwifery students in southern iran had a high level of spiritual well-being. almost all students in this study expressed satisfaction when they prayed to god and believed that they received god's love and care. this level satisfaction felt by students shows that respondents have high indicators of religious wellbeing. the score results show that the highest average score is religious well-being at 52.36. most of the students described that they did not enjoy their life journey and felt dissatisfied when they undertook worship. spirituality can be interpreted as self-knowledge, relationship with god, and a higher form of the human journey (wagani & colucci, 2018). the students indicated they believed that there was a real purpose in every human life along with feelings of happiness when worshiping god. they stated they believed god was a source of strength and support for them in carrying out their lives. by praying, students felt like their life became full of meaning and it was easy to complete daily activities, such as lecture activities. in addition, students believed god would always help them to solve problems regarding learning difficulties and activities that have to potential to be stressors for students. this could trigger a high level of spirituality in students because there was learning included in the curriculum that interprets religion and was associated with the application of knowledge. this process of applying good nursing knowledge related to humans and the surrounding environment shows that students also had good existential well-being. in general, sociodemographic variables such as gender, age, place of residence, parents' income and year of college entry are not directly related to spiritual well-being. it was only the respondent's religiosity thatthat was mentioned in many studies that greatly determines spiritual well-being. religious well-being in students showed a higher value compared to existential well-being, this can be because students understand more deeply the meaning of the relationship between themselves and god compared to the relationship between humans or the environment. a good relationship with god can be considered to be capable of creating calm in a person so as to improve their overall coping skills regarding stress and subsequently be able to reduce student stress levels. one study explained that spiritual education can improve the spiritual well-being of university students (hasanshahi & mazaheri, 2016). in addition, a study states that college students show a high level of religiosity when they embrace a religion (kimura et al., 2015). all respondents in this study adhered to a certain religion. this could be a factor that caused the respondent's spiritual wellbeing level to be at moderate and high levels. although the majority of the respondents in this study indicated they were muslim, it could not be demonstrated that religiou type was related to the level of spiritual well-being. although religious adherents are more significant in higher spirituality, the type of religion has not been found to be related to the level of spirituality. spiritual well-being is more influenced by how individuals understand and vol. 7 no. 1 june 2023 31 carry out values in their religion (garssen et al., 2021). stress level college students more than half of the students in this study experienced mild category stress. the results of this study are contrary to results of dyrbye et al. (2006) which found that health science students have a moderately high level of psychological stress compared to the general population. study results from ganjoo et al. (2021) found that as many as 92.4% of health science faculty students experienced moderate to high levels of stress. another study stated that health science students tend to demonstrate higher levels of stress compared to applied science students due to a higher level of academic difficulty (asdaq et al., 2021). in this study, the majority of students indicated they felt bored with lecture activities. indeed, nearly half of the respondents experienced difficulties in completing lecture assignments, especially in crowded places. previous research has found that student stress levels are also influenced by the kindness of the social community and acceptance in the lecture environment (ding et al., 2021). research supports that stress levels in students will increase when they are undergoing the final exam period (white, 2022). sociodemographic factors can also be an influential factor in stress. age is a factor that affects emotional mental disorders in vulnerable adolescents and young adults. this period is a period of great emotional and physicaltransition, even though during this time individuals are developing stronger self-control (malfasari et al., 2020). however, these issues can be supported by social support or family support. more than half of the respondents in this study live with their families. living with family is a factor that causes the respondent's stress level to be more controlled. families have a direct influence in providing support on a daily basis (arfianto et al., 2020). family support factors are also strengthened by socio-economic conditions. socio-economic conditions are also a factor triggering stress. all respondents in this study were students whose economic needs were still met by their parents. as such the income of their parents will directly affect. parents' income is a significant factor relating to the incidence of emotional mental disorders. adolescents with low-income parents are at high risk of experiencing emotional mental disorders (prihatiningsih & wijayanti, 2019). gender factors can also affect stress, but in this study the majority of respondents were women. so no determinations can regarding the stress levels of male students, as well as the year of study factor. other research shows that the year of college is not significantly related to the occurrence of stress. this tendency is caused because at each year level students have different and unique stressor characteristics, so that each level of education has the same level of stress (melizza et al., 2022). stress on students is often caused by physical and family problems, pressure to meet high success standards, social and emotional problems, and final assessments on campus (murphy et al., 2010; yusoff et al., 2013). college students have good relationships with their families and friends. this psychological stress can be reduced with emotional coping to deal with stressors and support from friends and family (akbar & aisyawati, 2021). in addition, listening to music, chatting with friends and parents, sleeping, and doing activities according to hobbies can reduce stress levels in students (sreeram & mundada, 2021). even though sometimes students in this study indicated they felt that communicating with classmates or study groups was not pleasant, they still considered that the communication they onduted was a normal thing for every student to experience. this study found that students who experienced severe levels of stress were female. this result is supported by a study which proves that women are more prone to experiencing academic stress in lectures compared to men (graves et al., 2021). correlation of spiritual well-being and stress level the spearman rho correlation test showed that p value was 0.000 (p<0.05). these results indicate that there was a significant relationship between spiritual well-being and stress levels in nursing students. in addition, the research results shows that increasing spiritual well-being can reduce student stress levels (coeff. -0.392). the coefficient value in this study indicated that the relationship between spiritual well-being and student stress levels was weak. in this study there were factors other than spirituality that can trigger stress, such as age, gender, biological, psychological, indonesian journal of nursing practices 32 and physical conditions. respondents who were older were likely able to apply stressor control strategies more frequently and effectively compared to young adults or adolescents which aim to reduce or prevent the negative effects of stress (scott et al., 2013). gender can also be a factor in the occurrence of stress on a person. this can be due to differences in the hormonal system between men and women, differences in gonadal steroids and menstrual cycles, psychoneuroimmunological markers, the relationship between neuroimaging and problem-solving strategies, genetics and a person's character, as well as cognitive structure. genetically (biologically), susceptibility to coping with stress, a person's character type, and social support are significantly related to the occurrence of stress. in addition, a person's psychological condition is also greatly influenced by physical and psychological conditions. the results of the univariate test based on gender found that the majority were women, with a total of 92 (88.5%). male studentshad the least number of respondents, namely 12 with a percentage of 11.5. almost half of the respondents in this study were in the 2018 cohort(49%). there was no significant difference in the number of respondents for the 2019 and 2020 batches. taking the research sample using the cluster sampling method caused an imbalance in the number of research respondents in each class. there were 2 times the amount of respondents from the 2018 class group than from the 2019 and 2020 class groups. the limited face-toface student learning process made it difficult for students to understand the learning material presented by lecturers in the lectures. according to research by cao et al. (2020) and li et al. (2021) stressors for students during the covid-19 pandemic were limited campus access, delayed graduation processes, and unclear expectations for future jobs. the decline in intra-campus learning activities presented a a challenge for students and increased the incidence of stress on students (white, 2022). according to gade, chari, & gupta (2014), problems related to academics are a cause of high stress on health science students. the results of this study were supported by previous research which states that the spiritual well-being of college students was related to the emergence of 3 symptoms of psychological disorders, such as stress, anxiety, and depression (leung & pong, 2021). a study also found that spiritual well-being in the personal and communal domains had a significant relationship on the presence of stress symptoms in college students (lee, 2014). students who had a high level of spiritual well-being had a mild level of stress. students who believe in a religion had a high level of religiosity, but this variable had a weak relationship with stress events (kimura et al., 2015). students who had moderate levels of spiritual wellbeing still had the possibility of experiencing severe levels of stress. students who had severe levels of stress said that they often received unpleasant treatment from the people around them and did not have high satisfaction in their relationship with god. meanwhile, students who believed in deep spirituality in life can provide a strong meaning in life (wagani & colucci, 2018). these students felt that they did not have a clear enough purpose in life. this lack of meaning and purpose in life caused a feeling of helplessness and lack of resilience (wagani & colucci, 2018). students who have a clear purpose in life show low psychological disorders (schafer, 1997). however, in this study, students with moderate levels of spiritual well-being still had the possibility of experiencing severe levels of stress. students with severe levels of stress said that they often received unpleasant treatment from the people around them and did not have high satisfaction in their relationship with god. meanwhile, students who believed in deep spirituality in life can provide a strong purpose in life (wagani & colucci, 2018). poor student relationships with family and friends can be a contributing factor to high stress. this is due to a lack of support for students in carrying out lecture assignments. in addition, psychological parenting mistakes during childhood on college students have a negative impact on spiritual well-being directly and indirectly (arslan, 2021). however, in depth communication between students and their families can reduce student stress levels related to their spiritual well-being. conclusion this study demonstrates that there is a relationship between spiritual well-being and stress levels in vol. 7 no. 1 june 2023 33 college students with a weak correlation level and the direction of a negative relationship means that if spiritual well-being increases, it is followed by a decrease in stress levels in college students. the weak level of coefficient correlation indicates that apart from the spiritual well-being factor, there are also other factors that affect the stress level of students. these factors need to be investigated further in subsequent studies. the results of this study also recommend the importance of programs to improve student spirituality as a source of coping mechanisms to manage stress during the academic semester. the results of this study indicate that the spiritual well-being of students can improve student performance and their completion of learning activities. in addition, low stress levels can trigger students to be more enagaged in participating in academic and non-academic activities, which subsequently may generate more productive and innovative students. therefore, educational institutions can collaborate with nurses to provide spiritual enhancement therapy programs for students in order to minimize stress levels. acknowledgement the researchers express their gratitude for the funding from the faculty of health sciences university of muhammadiyah malang, with the assignment letter. the researchers also thank to the all participants who contributed to the application of the research. references aditama, d. 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(ramos et al. 2015) attitude towards sex have been changing dramatically, with premarital sex, even high risk sexual behavior and adolescent pregnancy present a serious social and public health problem. the 2012 data center and information of indonesia health ministry documented the prevalence of premarital sexual behavior has increased from 3.7% in 2007 to 4.5 % in 2012 among indonesia young man (unmarried) aged 15 – 19 years. (http://www.depkes.go.id, 2014). the data indicating that many adolescent are at risk for pregnancy. according to data center and information of indonesia health ministry (2014), the prevalence of young woman (15-19 years aged) had a pregnancy is 1.28%. early childbearing is often associated with a young woman’s failure to complete her education, thus limiting her future job prospects and her child’s economic well being (eggleston e, jackson j, hardee k, 1999). early adolescence is considered to be the most critical stage of development, a period of accelerated growth and change. the behavior patterns which are adopted in these years can have lifelong consequences, both positive and negative for an individual from inappropiate information about sexuality. premarital sexual behavior can cause various negative impacts on adolescents, both psychological, physical and social impact. psychological effects such as feelings of anger, fear, anxiety, depression, low self-esteem, guilt and sinning while physical effects can lead to unwanted pregnancies and abortions as well as the development of sexually transmitted diseases (stds) among adolescents. sexually transmitted diseases can cause infertility and may increase the risk of contracting hiv / aids and will produce a quality generation (sarwono, 2011), from the social point of view, the impacts that are being treated are ostracized, dropping out of school for pregnant female adolescents, and changing the role of mother or father, as well as the stigma of society who denounces and rejects the situation. the success of the population in the adult age group is highly dependent on adolescence. if the age of adolescence is passed well then the quality of the population concerned in the adult age phase will tend to be better and then.if not well prepared teens are very risky to premarital sexual behavior. early adolescence a time of opportunity and risk and a positive school environment is critical to ensuring this age group’s learning, social and physical needs are met along with that the support and guidance from parents is one of the most important facet which can mold the individual in the best positive way or the least positive way. such information is necessary for health professionals to prevent and intervene on not only unmarried young people sexual behavior, but also other negative consequence (yip et al, 2013) .the purpose of this study is to describe sexual attitude and behavior among adolescents. 2. experimental details the design used is descriptive quantitative design. the study was conducted in high school in the city of yogyakarta in february 2016. the population of this study is adolescents aged 15-17 years. the number of samples from this study was 106 people. the research ethical test from faculty of medicine and health sciences, universitas muhammadiyah yogyakarta, indonesia.the sexual attitudes of this study were measured by the “brief sexual attitude scale (bsas)” questionnaire developed by hendrick et al. (2006). bsas consists of 23 questions classified based on fourth category of sexual attitudes, being permissiveness, birth control (sexual practices), communion (investment in relationship), and instrumentality (pleasure-orientation to relationship). brief sexual attitude scale (bsas) is an empirically reliable and valid empirical questionnaire with x2 (21,525) = 29.88, p <.001. this reliability test results in get r table number 0.396. each question in a measurement concept is considered reliable if the reliability coefficient ≥ 0.396. based on the reliability test results used alpha cronbach, note that the value of alpha of 0.861. (comotto, 2010) the questionnaire of sexual behavior used was a questionnaire from tara (2015) adopted from elizar (2010). the questionnaire contains ten statements that will be answered by the respondent by giving a checklist (√) on the yes or no answer. each category of responses, then will be 66 in percentage using the frequency distribution. data analysis used a descriptive analysis in the form of frequency display and percentage with the help of computer. 3. result and discussion table.1 characteristics of respondents sexual attitude and behavior in adolescents in yogyakarta, 2016 (n = 106) variable f (%) gender male 64.6 female 42.4 age group 15 16.1 16 39.4 17 51.5 information about sexuality friend 32.7 parents 11 social media 28.3 electronic media 39 communication with parents about sexuality yes 34.3 no 72.7 socio demographic characteristics of the respondents as shown in table 1, 64.6% of the youth are male, with 51.5% were 17 years old. this age feared didn’t have life skills. in recent times rather in the present society at large it is very important to impart sex education changes too that are taking place in the body structure; particularly in the sex organ, making the teenager curious to explore these change and added to all these factors there is an immense urge in taking risks in life o indulge what is forbidden combined with the absence of adequate wisdom to control these impulses. the sexual arena is in constant focus among the teens; in the absence of proper guidance, this can results in more harm than good. 39 % of the adolescent getting information about sexually from electronic media and 72.7 % without communication about sexuality with their parents. there are various aspects which need to be followed when a parent is having a talk with their children especially on topics like sex and sexuality. the first aspect understands the fact that adolescents have a culture of their own and the parents cannot be a part of that culture. the culture gap ( between parents and adolescents) can become a real wall between the parent and the adolescents. it is important for the parents to understand their child’s need for a javanese culture. the parents also have to choose the areas of disagreement. the second factor which should be taken consideration is timing where scheduling a certain time each week to talk to the adolescent may be needed. the parents should act as if they are looking forward to them and enjoy them and discussion like that should be completely informal. adolescent should be completely informal. adolescents should feel relaxed and open up to their parents. the third and fourth aspect is listening and feeling, a parent should listen to what their adolescent kid has to say and also feel empathetic and through touching and giving the love and assurance makes the communication more effective and helpful for both the adolescent and their parents(guha, 2013). table.2 percentage of sexual attitude in adolescents in yogyakarta, 2016 (n =106) attitudes male (%) female (%) permisiveness low 42.2 88.1 moderate 37.5 9.5 high 20.3 2.4 brith control low 9.4 14.3 moderate 25.0 23.8 high 65.6 61.9 communion low 12.5 28.6 moderate 14.1 45.2 high 73.4 26.2 instrumentally low 20.3 61.9 moderate 31.3 31.0 high 48.4 7.1 as shown in table 2 female being permissiveness lower than male, 88.1% female is low permissivemess. 67 vol. 1 no. 2 juni 2017 and 65.6 % of youth male have a high birth control (sexual practices), 73.4 % of youth male have a high communion (investment in relationship), and 61.9% of youth female have a low instrumentality (pleasureorientation to relationship). through a study by hulton et al in 2000, he illustrated that youth were aware about the problems that early sexual encounters had, but had difficulties to face the reality about how to act on that knowledge due to gender roles as it was also shown that boys’ sexual activity is forgiven as an excuse for boys to represent their manhood, while the boys themselves had lack of responsibility of what they had done and in this way, girls felt more powerless. due to the complicated sexual and gender expectations, it poses threats for girls. it is believed that boy’s and men are allowed to have intercourse, but pointing out that girls need to be protected, isolated and restricted in their movements in order to avoid possible sexual encounters with boys or men generally tend to “move around freely”. culturally, the girls are expected to become more protective to them and restricted themselves to romance and sex. (eggleston e, jackson j, hardee k, 1999) . table 3.percentage of premarital sexual behavior in adolescents in yogyakarta, 2016 (n=106) statement male female yes no yes no dating 50 10.4 37.7 1.9 hand in hand 51.9 8.5 34 5.6 embracing 44.3 16.1 22.0 17.6 kissing 33.0 27.4 24.5 15.1 masturbation 39.6 20.8 0.9 38.7 necking 20.8 39.6 13.2 26.4 petting 20.8 39.6 4.7 34.9 rubbing the genitals 14.2 46.2 0.9 38.7 sexual intercourse 11.3 49.1 0.9 38.7 oral sex 12.3 48.1 0.9 38.7 as shown in table 3 reported 11.3% male and 0.9% female had already sexual intercourse. the boys and girls have suggested experienced sexual intercourse indicated that curiosity and love so if you really love your boyfriend or girlfriend, you should have sexual intercourse with them. the family, as the first-life education-teachers, need to be aware of the strong influence of gender norms on the attitudes and behavior of boys and girls regarding relationships, sex and reproduction. it is needed to set up some programs to help adolescents developing the skills to make informed decisions about engaging in sexual intercourse and using contraceptives in a social context that sometimes encourages risky sexual behavior (eggleston e, jackson j, hardee k, 1999). adolescents of either sexual orientation experience similar mechanisms of sexual arousal. masturbation facilitates sex citement and frequently serves as an outlet for adolescents. successful transitions depend on how to maintain positive feelings about self, engaging in sexual experiments without intercourse, and engaging in intercourse with commitment. (rosenhan & seligman, 1995). 4. conclusion. this study shown to female prefer low permissiveness and male prefer high birth control , communion, and instrumentality for aspect sexual attitude. the male shown to prefer high premarital sexual behavior than female. adolescents still have high risk sexual behavior, so parent, school and government should arrange intervention program together toward sex education for adolescent acknowledgments this project supported by school of nursing faculty of medicine and health sciences, university of muhammadiyah yogyakarta, indonesia. references and notes anonim, situasi kesehatan reproduksi remaja. pusat data dan informasi kementrian kesehatan indonesia, 2014http://www.depkes.go.id/resources/download/ pusdatin/infodatin/infodatin%20reproduksi%20 remaja-ed.pdf comotto, nicholas ryan. (2010). memories for sexual encounters: sexual attitudes, personality, gender, and evidence for personal flashbulb effects. undergraduate honors thesis collection. paper 68 eggleston e, jackson j, hardee k: sexual attitudes and behavior among young adolescents in jamaica: 68 international family planning perspectives 1999, 25(2): 7884 & 91 guha s : attitude, knowledge and behavior about sexuality among adolescents. iosr journal of humanities and social science 2013, 18(5): 05-19 kajianprofilpendudukremaja (10-24 thn). jakarta timur: pusatpenelitiandanpengembangankependudukan – bkkbn 2011 ramos vg, bouris a, lee j, mccarthy k, michael ls, barnes ps, dittus p: paternal influences on adolescent sexual risk behaviors: a strustured literature review. pediatrics 2012, 130(5): e1313-e1325 rosenhan, d. l, & seligman, e. p. (1995). abnormal psychology (3rd ed.). new york: w. w. norton & company.home.olemiss.edu/~cooker/web/chapter07.doc sarwono. s.w. psychology for adolescents 2011, jakarta: pt raja grafindo persada. yip sfp, zhang h, lam th, lam kf, lee am, chan j, fan s: sex knowledge, attitudes, and high risk sexual behaviors among unmarried youth in hongkong 2013, 13(691): 1-10 tara, p. (2015). hubungan pola asuh orangtua dengan perilaku seksualpada remaja sltp di kecamatan cangkringan pasca erupsi merapi. available from http://etd. repository.ugm.ac.id (diakses tanggal 2 mei 2016) 61 vol. 1 no. 1 desember 2016 peningkatan hasil belajar kognitif dan harga diri mahasiswa melalui metode cooperative learning tipe jigsaw vita purnamasari1, sri sundari1, galuh suryandari2 1 magister keperawatan universitas muhammadiyah yogyakarta,jl. lingkar selatan, kasihan, tamantirto, bantul, daerah istimewa yogyakarta 55183, indonesia. 2 stikes surya global yogyakarta, jl. ring road selatan, blado, potorono, banguntapan, bantul, daerah istimewa yogyakarta 55196, indonesia. e-mail: vitafkikumy@gmail.com abstrak cooperative learning tipe jigsaw merupakan metode pembelajaran inovatif, lima pokok elemen cooperative jigsaw dapat meningkatkan hasil belajar, ketrampilan interpersonal, harga diri serta motivasi. tujuan penelitian untuk mengetahui pengaruh cooperative learning terhadap hasil belajar dan harga diri mahasiswa stikes surya global yogyakarta. desain penelitian quasy eksperimen rancangan pretes postest with control group design, subyek penelitian mahasiswa stikes surya global semester 2 dengan total sampling,jumlah responden 221 mahasiswa. analisa data menggunakan wilcoxon signed rank test dan mann whitney test. hasil penelitian menunjukkan terdapat perbedaan yang signifikan antara kelompok intervensi dan kelompok kontrol dengan p = 0.000 untuk variabel hasil belajar kognitif dan nilai p = 0.000 untuk variabel harga diri. kesimpulan penelitian adalah cooperative learning tipe jigsaw meningkatkan hasil belajar mahasiswa dan harga diri mahasiswa stikes surya global yogyakarta . kata kunci : cooperative learning, harga diri, hasil belajar, kognitif abstract cooperative learning jigsaw type is an innovative learning, the five principal elements of cooperative jigsaw can improve learning outcomes, interpersonal skills, self esteem and motivation. the purpose of research to determine the effect of cooperative learning on learning outcomes and selfesteem students stikes surya global yogyakarta. the research design is quasy experimental design of posttest pretest with control group design, research subjects of stikes surya global 2nd semester with total sampling, the number of respondents is 221 students. data analysis using wilcoxon signed rank test and mann whitney test. the results showed that there were significant info artikel: masuk : 14 september 2016 revisi : 24 november 2016 diterima : 7 desember 2016 doi number : 10.18196/ijnp.1153 62 differences between intervention group and control group with p = 0.000 for cognitive learning and p = 0.000 for self esteem. the conclusion of this research is cooperative learning jigsaw improve cognitive and student’s self esteem stikes surya global yogyakarta. keywords:cognitive, cooperative learning, learning outcomes, self-esteem. pendahuluan pendidikan di bidang ilmu kesehatan mengalami perubahan pada pola dan cara belajar mahasiswa. awalnya proses pembelajaran yang berpusat pada dosen atau teacher centered learning (tcl) bergeser menjadi student centered learning (scl). fenomena mengajar secara konvensional yang kurang melibatkan mahasiswa secara langsung dalam proses belajar mengajar mengakibatkan mahasiswa menjadi kurang aktif dalam proses pembelajaran. proses pembelajaran yang kurang maksimal menjadikan hasil belajar yang diperoleh mahasiswa kurang memuaskan (uys, 2005). hal ini dapat dilihat dari nilai ujian akhir semester mahasiswa yang tergolong rendah. selain itu, nilai hasil belajar yang kurang memuaskan ini juga berdampak pada saat pelaksanaan uji kompetensi ners indonesia (ukni). cooperative learning merupakan salah satu pembelajaran student centered learning yang dapat diterapkan untuk memotivasi mahasiswa untuk lebih memahami materi pembelajaran. cooperative learning merupakan pembelajaran inovatif yang dilakukan dengan cara berdiskusi dengan teman secara aktif. cooperative learning merupakan pembelajaran yang didalamnya terdapat kerja sama antara mahasiswa yang dapat meningkatkan prestasi yang lebih tinggi oleh semua peserta (lie, 2014). peserta didik saling membantu, dengan demikian membangun sebuah komunitas yang mendukung, yang kemudian dapat meningkatkan kinerja masing-masing anggota. kinerja dari masing-masing anggota kelompok tersebut akan meningkatkan harga diri mahasiswa. harga diri merupakan salah satu komponen utama yang mempengaruhi tingkat kinerja pada suatu profesi. harga diri mempunyai pengaruh dalam keberhasilan pekerjaan, prestasi sekolah, dan hubungan interpersonal. harga diri merupakan kebutuhan yang penting yang harus dimiliki oleh seorang perawat. harga diri yang tinggi dapat membuat kinerja perawat yang lebih baik serta dapat meningkatkan keberhasilan dalam bekerja (coopersmith, 2006). cooperative learning tipe jigsaw merupakan salah satu tipe pembelajaran kooperatif yang menekankan mahasiswa untuk belajar secara berkelompok dan mengajarkan kepada mahasiswa untuk berkomunikasi yang baik di dalam kelompok. cooperative learning jigsaw merupakan salah satu metode pembelajaran yang inovatif sehingga diperlukan penelitian untuk menjawab adakah peningkatan kognitif dan harga diri mahasiswa melalui penerapan cooperative learning jigsaw. metode desain penelitian menggunakan quasy eksperimen rancangan pretes postest with control group design. penelitian dilakukan januari maret 2017. intervensi dilakukan sebanyak 6 kali pertemuan dengan menggunakan intervensi metode cooperative learning untuk kelompok intervensi dan kelompok kontrol diberikan metode pembelajaran konvensional ceramah. penelitian ini sudah lulus uji etik dari fakultas kedokteran dan ilmu kesehatan universitas muhammadiyah yogyakarta dengan ethical clearance no. 040/ep-fkikumy/i/2017. subyek penelitian yang digunakan sebanyak 221 mahasiswa stikes surya global yogyakarta semester 2, pengambilan sampel dilakukan dengan cara total sampling. kelompok intervensi terdiri dari 105 responden dan kelompok kontrol 116 responden. selama penelitian berlangsung tidak terdapat responden yang drop out. instrument yang digunakan adalah rosenberg self esteem scale untuk mengukur variabel harga diri, kuesioner berisi tentang pernyataan yang berkaitan dengan penerimaan di lingkungan dan penghargaan dari orang lain. pengukuran variabel kognitif dengan menggunakan soal multiple choice yang sebelumnya sudah dilakukan item review soal. 63 vol. 1 no. 1 desember 2016 uji normalitas yang digunakan adalah kolmogorov smirnov. analisis data penelitian menggunakan wilcoxon signed rank test dan mann whitney test karena data tidak berdistribusi normal. uji normalitas data menggunakan uji kolmogorov smirnov. hasil hasil analisis karakteristik responden meliputi jenis kelamin, usia dan asal sekolah digambarkan pada tabel di bawah ini. tabel 1. karakteristik responden karakteristik responden kelompok perlakuan kontrol n % n % jenis kelamin laki-laki perempuan usia 15-20 tahun >20 tahun lulusan slta umum smk kesehatan 0 105 98 7 88 17 0 100 93.33 6.67 83.80 16.20 15 101 100 16 111 5 12.93 87.06 86.20 13.79 95.68 4.32 tabel 1 menunjukkan responden kelompok kontrol dan kelompok perlakuan berjenis kelamin perempuan. umur responden kedua kelompok paling banyak berumur 1520 tahun. proporsi responden dengan latar belakang pendidikan juga hampir sama yaitu dari lulusan slta umum atau smk non kesehatan. perbedaan hasil belajar kognitif dan harga diri mahasiswa sebelum dan sesudah dilakukan intervensi dapat dilihat pada tabel berikut ini: tabel 2. hasil belajar kognitif mahasiswa stikes surya global sebelum dan sesudah dilakukan metode pembelajaran cooperative jigsaw kelompok variabel mediaan p intervensi pretest 53.00 0.000 postest 93.00 kontrol pretest 53.00 0.000 postest 76.00 tabel 2 menunjukkan bahwa nilai hasil belajar mahasiswa antara kelompok intervensi dan kelompok kontrol mengalami peningkatan. hasil uji statistik menunjukkan bahwa kelompok intervensi dan kontrol mengalami peningkatan yang bermakna p= 0.000; α=0.05 hasil dari harga diri mahasiswa sebelum dan sesudah dilakukan perlakuan dapat dilihat pada tabel di bawah ini: tabel 3.harga diri mahasiswa stikes surya global sebelum dan sesudah dilakukan metode pembelajaran cooperative jigsaw. kelompok rendah (%) sedang (%) tinggi (%) p intervensi pretest 31.4 54.3 14.3 0.000 postest 0 5.7 94.3 kontrol pretest 21.6 70.7 7.8 0.012 11.2 81.9 6.9 tabel 3 menunjukkan prosentase harga diri meningkat pada kelompok intervensi. peningkatan harga diri pada kelompok intervensi secara statistik signifikan dengan nilai p= 0.000;α=0.05. hasil belajar kognitif dan harga diri mahasiswa pada kelompok intervensi dan kelompok kontrol pretest dan potest dilakukan uji untuk mengetahui perbedaan diantara kedua kelompok. uji tersebut menggunakan mann whitney test untuk kedua variabel. hasil uji variabel kognitif tersebut dapat dilihat pada tabel berikut ini: 64 tabel 4. perbedaan hasil belajar kognitif kelompok intervensi dan kelompok kontrol sebelum dan sesudah intervensi. kelompok median p pretest kognitif intervensi kontrol 53.50 52.14 0.865 postes kognitif intervensi kontrol 92.55 73.93 0.000 hasil belajar kognitif antara kelompok intervensi dan kelompok kontrol pada saat pretest tidak berbeda secara signifikan nilai p = 0.865 (α=0.05) serta nilai rata-rata hasil belajar kognitif pada kedua kelompok sebelum intervensi relatif sama. hasil belajar antara kelompok intervensi dan kelompok kontrol setelah dilakukan intervensi berbeda secara signifikan nilai p=0.000 (α=0,05). hasil uji maan whitney untuk variabel harga diri dapat dilihat pada tabel berikut ini: tabel 5. perbedaan harga diri mahasiswa kelompok intervensi dan kelompok kontrol sebelum dan sesudah intervensi. kelompok p pretest harga diri intervensi kontrol 0.550 postes harga diri intervensi kontrol 0.000 harga diri pada kelompok intervensi dan kelompok kontrol sebelum dilakukan intervensi juga tidak berbeda signifikan dengan nilai p=0.550 (α=0.05). setelah dilakukan intervensi terdapat perbedaan yang signifikan antara kelompok intervensi dan kelompok kontrol yaitu dengan nilai p=0.000 (α=0.05). pembahasan hasil penelitian menujukkan bahwa skor hasil belajar kognitif pada kelompok intervensi yang mendapatkan intervensi metode kooperatif jigsaw mengalami peningkatan. penelitian menunjukkan bahwa pembelajaran menggunakan cooperative jigsaw memberikan hasil yang memuaskan (smith, 2010). penelitian lain juga menunjukkan bahwa dengan penerapan metode cooperative jigsaw terjadi peningkatan dalam hasil belajar (swachberger, 2014). hasil penelitian juga menunjukkan peningkatan hasil belajar kognitif tidak hanya terjadi pada kelompok intervensi saja, kelompok kontrol yang tidak mendapatkan metode kooperatif juga mengalami peningkatan median. peningkatan median pada kelompok kontrol tidak setinggi peningkatan median pada kelompok intervensi. hal tersebut menunjukkan bahwa kelompok mahasiswa yang mendapatkan intervensi kooperatif lebih meningkat dibandingkan dengan kelompok kontrol yang mendapatkan metode konvensional ceramah. peningkatan median pada kelompok kontrol dapat terjadi karena responden sudah mengalami pembelajaran terhadap materi tersebut dengan metode konvensional. kedua kelompok baik intervensi ataupun kelompok kontrol sudah mendapatkan materi dengan cara yang berbeda. perubahan median hasil belajar pada kedua kelompok tersebut dikarenakan responden sudah mengalami pembelajaran. belajar merupakan kegiatan individu untuk memperoleh pengetahuan, ketrampilan, dan perilaku dengan cara mempelajari suatu materi atau bahan ajar (sagala, 2009). perubahan hasil belajar tersebut merupakan akibat dari proses pembelajaran yang telah dilalui. pencapaian hasil belajar pada kedua kelompok tersebut tidak hanya merupakan hasil dari proses belajar di kelas saja, karena terdapat beberapa faktor yang mempengaruhinya yaitu factor intrinsik dan extrinsik. kemampuan teacher untuk menjadi role model akan membawa pengaruh dan perubahan terhadap aktifitas belajar mahasiswa. hasil penelitian dapat dipengaruhi oleh dosen yang mengajar di kelompok kontrol merupakan salah satu dosen yang menjadi role model dari bagi mahasiswa, sehingga dapat meningkatkan motivasi mahasiswa dalam belajar, yang pada akhirnya dapat meningkatkan pengetahuan mahasiswa pada materi yang diajarkan. 65 vol. 1 no. 1 desember 2016 proses pembelajaran juga mengandung input, proses, serta output yang dapat mempengaruhi hasil belajar. metode pembelajaran termasuk salah satu komponen proses yang mempengaruhi hasil belajar. kelompok intervensi dan kelompok kontrol menggunakan metode pembelajaran yang berbeda sehingga peningkatan hasil belajar yang dicapai juga berbeda walaupun kedua kelompok mengalami peningkatan ratarata setelah mendapatkan proses pembelajaran. penilaian tharga diri mahasiswa terlihat dari penghargaan terhadap keberadaan dan keberartian diri. dalam proses pembelajaran mahasiswa akan mempunyai harga diri yang tinggi ketika mahasiswa tersebut merasa diterima oleh pengajar ataupun teman dalam lingkungan belajarnya. harga diri juga mencakup evaluasi dan penghargaan terhadap dirinya sendiri dan menghasilkan penilaian tinggi atau rendah terhadap dirinya sendiri. harga diri mahasiswa ketika proses pembalajaran merupakan penilaian mahasiswa itu sendiri saat proses pembelajaran berlangsung. mahasiswa akan merasa dan meyakini bahwa dirinya dianggap mampu, penting , dan berharga saat proses pembelajaran. m e t o d e p e m b e l a j a r a n c o o p e r a t i v e j i g s a w didalamnya terdapat langkah pembelajaran yang melibatkan semua mahasiswa menjadi tim ahli terhadap topik tertentu dalam metode pembelajaran. semua mahasiswa dalam tim ahli juga akan diberikan kesempatan untuk mengajarkan topiknya ke teman kelompok asalnya. kesempatan mahasiswa menjadi tim ahli tersebut dapat meningkatkan harga diri mahasiswa karena mahasiwa akan merasa bahwa dirinya mampu, penting dan dibutuhkan oleh anggota kelompok yang lainnya. peserta didik saling membantu, dengan demikian membangun sebuah komunitas yang mendukung, yang kemudian dapat meningkatkan kinerja masing-masing anggota. kinerja dari masing-masing anggota kelompok tersebut akan meningkatkan harga diri mahasiswa. hasil penelitian ini diperkuat oleh penelitian yang telah dilakukan sebelumnya. hasil penelitian sebelumnya menunjukkan bahwa penerapan metode cooperative jigsaw dapat meningkatkan nilai akademik dan motivasi intrinsik mahasiswa dibandingkan dengan metode pembelajaran langsung (direct instruction). penelitian yang dilakukan dengan responden mahasiswa keperawatan menunjukkan bahawa terdapat pengaruh metode pembelajaran cooperative learning terhadap harga diri mahasiswa dibandingkan dengan pembelajaran ceramah atau konvensional (lie, 2014). penelitian ini mendukung dari hasil penelitian yang telah dilakukan megahed tahun 2015 yaitu metode pembelajaran cooperative jigsaw dapat meningkatkan harga diri mahasiswa hasil belajar pada kelompok intervensi jauh lebih tinggi dibandingakan dengan kelompok kontrol karena intervensi yang diberikan berbeda. kelompok intervensi mendapatkan metode pembelajaran cooperative jigsaw yang didalamya terdapat lima unsur pokok yaitu saling ketergantungan positif, tanggung jawab perseorangan, tatap muka, komunikasi antar anggota kelompok, dan evaluasi proses kelompok. kelima unsur pembelajaran kooperatif tersebut dapat memberikan dampak positif terhadap kemampuan interpersonal mahasiswa di dalam pembelajaran dibandingkan dengan pembelajaran konvensional atau pembelajaran individualistik. selain itu dampak positif dari pembeajaran kooperatif jigsaw adalah kepuasan individu ketika proses pembelajaran berlangsung, karena setiap individu di dalam kelompok dapat berkontribusi dalam kelompok dan membenatu anggota kelompok yang lain untuk dapat memahami materi, hal ini yang dapat meningkatkan percaya diri, motivasi serta harga diri mahasiswa dalam belajar(earl, 2009). manfaat pembelajaran kooperatif jigsaw yaitu dapat meningkatkan motivasi mahasiswa, meningkatkan kemampuan responden dalam berpikir kritis, adanya motivasi intrinsik yang lebih besar untuk belajar dan mencapai sikap yang lebih positif terhadap pembelajaran serta harga diri yang lebih tinggi (isjoni, 2009). proses pembelajaran cooperative jigsaw merupakan salah satu model pembelajaran yang dikembangkan oleh slavin di universitas jonh hopkins. model ini 66 merupakan salah satu model pembelajaran kooperatif yang mengupayakan peserta didik mampu mengajarkan kepada peserta didik lain dan berusaha mengoptimalkan ke seluruh anggota kelompok yang lain sebagai satu tim untuk maju bersama (arend, 2008). dalam proses pembelajaran inilah mahasiswa dapat membangun pengetahuannya sekaligus perasaan yang diwujudkan dari perilaku peduli terhadap orang lain. model pembelajaran kooperatif ini dalam pelaksanannya peserta didik mampu memiliki banyak kesempatan mengemukakan pendapat dan mengolah informasi yang didapat, dapat meningkatkan ketrampilan komunikasi, anggota kelompok bertanggung jawab terhadap keberhasilan kelompoknya. pembelajaran kooperatif jigsaw merupakan suatu model pembelajaran yang fleksibel. banyak riset yang telah dilakukan berkaitan dengan pembelajaran kooperatif jigsaw. riset tersebut secara konsisten menunjukkan bahwa dengan pembelajaran kooperatif ini mahasiswa yang terlibat memperoleh prestasi belajar yang lebih baik, mempunyai sikap yang lebih baik serta lebih postif terhadap pembelajaran. penelitian tentang pembelajaran kooperatif model jigsaw hasilnya menunjukkan bahwa interakasi kooperatif memiliki berbagai pengaruh positif terhadap peserta didik. pengaruh positif tersebut adalah (1) meningkatkan hasil belajar peserta didik, (2) meningkatkan daya ingat. (3) dapat mencapai penalaran yang lebih tinggi, (4) mendorong tumbuhnya motivasi intrinsik, (5) meningkatkan hubungan interpersonal, (6) meningkatkan sikap positif peserta didik terhadap sekolah, (7) meningkatkan sikap positif peserta didik terhadap guru, (8) meningkatkan harga diri peserta didik, (9) meningkatkan perilaku sosial dan (10) meningkatkan keterampilan hidup bergotong royong (lie, 2008). hasil penelitian tentang pengembangan model pembelajaran kooperatif jigsaw dalam upaya untuk meningkatkan kemandirian dan hasil belajar. hasil penelitian menunjukkan bahwa penerapan metode kooperatif jigsaw meningkatkan kemandirian dan hasil belajar peserta didik (wardani, 2010). penelitian ini mempunyai beberapa keterbatasan penelitian yaitu kelompok kontrol dan kelompok intervensi berada dalam satu tempat penelitian yang sama sehingga dapat menjadi faktor perancu yang tidak dikendalikan oleh peneliti. pengambilan data postest antara kelompok intervensi dan kelompok kontrol tidak dilakukan pada waktu yang bersamaan sehingga dapat mempertinggi bias terhadap hasil penelitian. kesimpulan kesimpulan penelitian ini adalah terdapat peningkatan hasil belajar kognitif dan harga diri mahasiswa melalui penerapan metode cooperative learning jigsaw. saran untuk penelitian selanjutnya adalah dapat meneliti tentang penerapan metode cooperative learning tipe lainnya selain jigsaw, dan dapat meneliti dengan variabel dependen yang lainnya seperti kerjasama kelompok atau critical thingking. referensi anita, lie. (2008). cooperative learning, jakarta :pt grasindo gramedia widiasarana indonesia. chinmin, h (2012). the efectiveness of cooperative learning. journal of engineering education, 101 (1), 119 137. chinminhsiung (2010). identification of dysfunctional cooprative learning teams based on student’s achievemnent. journal of engineering education, 99 (1),45-54. coopersmith, stanley. (2006). the antecedents of self esteem. san fransisco: w. h. freeman. direktorat jendral pendidikan tinggi pembelajaran dan kemahasiswaan (2015). pedoman kurikulum pendidikan tinggi, jakarta. earl, g. l., pharmd. (2009). using cooperative learning for a drug information assignment. american journal of pharmaceutical education, 73(7), 1-132. retrieved hall, e. w. (2004). regarding cooperative learning in rural special education classes. the exceptional parent, 34, 31-32,34. etchberger, r. c. 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(2005) curriculum development in nursing: process and innovation. london: routledge), pp. 1-40 wardani., d & novianti (2010). model jigsaw dalam perkuliahan ilmu ekonomi untuk meningkatkan hasil belajar. jurnal program pendidikan ekonomi. v 13(1) p.46-54. wyatt, t. h., krauskopf, p. b., gaylord, n. m., ward, a., huffstutler-hawkins, s., & goodwin, l. (2010). cooperative m-learning with nurse practitioner students. nursing education perspectives, 31(2), 109-13. yueh-min, h., yi-wen, l., shu-hsien huang, & hsin-chin, c. (2014). a jigsaw-based cooperative learning approach to improve learning outcomes for mobile situated learning. journal of educational technology & society, 17(1), 128-140. zulharman, (2008). inovation of medical education. diakses 30 november2015 ,darihttp://zulharman79.wordpress. com/2007/07/15problembasedlearning/pbl. 55 vol. 1 no. 1 desember 2016 gambaran karakteristik pasien gagal jantung usia 45 – 65 tahun di rumah sakit pku muhammadiyah gamping sleman yayang harigustian1, arlina dewi2, azizah khoiriyati3 1 magister keperawatan universitas muhammadiyah yogyakarta, alamat : jl lingkar selatan, kasihan, tamantirto,bantul, yogyakarta, 55183 2 magister manajemen rumahsakit universitas muhammadiyah yogyakarta, alamat : jl lingkar selatan, kasihan, tamantirto,bantul, yogyakarta, 55183 3 staf pengajar magister keperawatan universitas muhammadiyah yogyakarta, alamat : jl lingkar selatan, kasihan, tamantirto,bantul, yogyakarta, 55183 e-mail : yayangharigustina@gmail.com abstrak penyakit gagal jantung merupakan penyakit yang dapat menyebabkan kematian. sekitar 5,1 juta orang di amerika serikat mengalami gagal jantung. tahun 2009, satu dari sembilan kematian di sebabkan karena menderita gagal jantung. di indonesia prevalensi penyakit gagal jantung tahun 2013 sebesar 0,13%,estimasi jumlah penderita penyakit gagal jantung di provinsi daerah istimewa yogyakarta sebanyak 6.943 orang (0,25%). berdasarkan data riskesdas tahun 2007 menunjukkan chf merupakan penyebab kematian nomor tiga di indonesia setelah stroke dan hipertensi. tujuan penelitian ini untuk mengetahui karakteristik pasien gagal jantung usia 45 – 65 tahun di poli jantung rs pku muhammadiyah gamping sleman pada bulan september – november 2016. penelitian dilakukan menggunakan penelitian deskriptif. sampel penelitian 32 responden . karakteristik pasien gagal jantung di poli jantung rs pku muhammadiyah gamping sleman yaitu umur responden paling tinggi rentang 61-65 tahun yaitu 59,38%, jenis kelamin terbanyak adalah perempuan yaitu 53,12%, pendidikan terahir terbanyak adalah sd yaitu 34,38%, pekerjaan paling banyak adalah pns yaitu 31,25%, hampir semua responden stadium 2 yaitu 93,75%. kesimpulan dari penelitian ini yaitu sebagian besar responden berada pada usia 61 – 65 tahun,jenis kelamin responden lebih besar perempuan dari pada laki laki, pendidikan terahir paling banyak sekolah dasar, pekerjaan sebagian besar pegawai negeri sipil, dan hampir semua responden mengalami gagal jantung stadium 2. hasil penelitian ini diharapkan dapat mejadi acuan untuk mengetahui gambaran karakteristik pasien gagal jantung sehingga dapat dilakukan pencegahan ataupun intervensi untuk mengurangi kekambuhan pasien gagal jantung. kata kunci :karakteristik, gagal jantung. info artikel: masuk : 9 september 2016 revisi : 25 november 2016 diterima : 4 desember 2016 doi number : 10.18196/ijnp.1152 56 abstract heart failure is a disease that can caused death. about 5.1 million people in the united states had heart failure. in 2009, one in nine deaths caused by heart failure. in indonesia, the prevalence of heart failure in 2013 was 0.13%, the estimated number of heart failure patients in yogyakarta was 6,943 (0.25%). based on data from 2007 indicated chf riskesdas the third cause of death in indonesia after stroke and hypertension. the purpose of this study to determine the characteristics of heart failure patients in the poly heart gamping sleman pku muhammadiyah hospital in september-november 2016. the study was conducted using a descriptive design. the sample was 32 respondents. characteristics of patients with heart failure in poly heart pku muhammadiyah hospital gamping sleman highest respondent’s age range 6165 years was 59.38%, the highest gender was female 53.12%, the last education was elementary 34.38%, the worst job many are civil servants was 31.25%, stage 2 was 93.75%. the conclusion of this study is that most of the respondents are at the age of 61-65 years old, the sex of the respondents is bigger than the male, the most recent primary school education, the work of most civil servants, and almost all respondents had heart failure stage 2. the results of this study are expected to be a reference to know the description characteristics of patients with heart failure so that prevention or intervention can be done to reduce the recurrence of patients with heart failure. keywords: characteristics, heart failure. pendahuluan congestive heart failure (chf) atau sering dikenal dengan gagal jantung merupakan keadaan dimana jantung mengalami kegagalan dalam memompa darah untuk mencukupi kebutuhan nutrien dan oksigen sel – sel tubuh secara adekuat sehingga mengakibatkan peregangan ruang jantung (dilatasi) yang berfungsi untuk menampung darah lebih banyak untuk dipompakan keseluruh tubuh atau mengakibatkan otot jantung kaku dan menebal (udjianti, 2010). gejala khas pasien gagal jantung, yaitu : sesak nafas saat beristirahat atau beraktivitas, kelelahan, dan edema tungkai, sedangkan tanda khas gagal jantung adalah takikardia, takipnea, suara nafas ronki, efusi pleura, peningkatan vena jugularis, edema perifer dan hepatomegali (perki, 2015). penyakit gagal jantung merupakan penyakit yang dapat menyebabkan kematian. sekitar 5,1 juta orang di amerika serikat mengalami gagal jantung. tahun 2009, satu dari sembilan kematian di sebabkan karena menderita gagal jantung. sekitar setengah dari orangorang yang menderita gagal jantung meninggal dalam waktu 5 tahun setelah didiagnosis. perkiraan biaya yang dikeluarkan oleh negara pada pasien gagal jantung sebesar $ 32 milyar setiap tahun (centers for disease control and prevention, 2015). di indonesia prevalensi penyakit gagal jantung tahun 2013 sebesar 0,13% atau diperkirakan sekitar 229.696 orang, sedangkan berdasarkan gejala yang muncul sebesar 0,3% atau diperkirakan sekitar 530.068 orang. estimasi jumlah penderita penyakit gagal jantung di provinsi daerah istimewa yogyakarta sebanyak 6.943 orang (0,25%) (kementrian kesehatan ri, 2014). kelangsungan hidup pasien dengan gagal jantung dipengaruhi beratnya kondisi yang dialami masing – masing pasien. setiap tahun mortalitas pasien dengan gagal jantung berat lebih dari 50 %, mortalitas pada pasien dengan gagal jantung ringan lebih dari 10 %, sedangkan morbiditas pasien gagal jantung juga dipengaruhi oleh beratnya penyakit masing – masing pasien (ball,1996 dalam mutaqqin, 2009). pasien dengan gagal jantung berat hanya mampu melakukan aktivitas yang sangat terbatas, sementara itu pasien dengan gagal jantung yang lebih ringan juga harus tetap melakukan pembatasan terhadap aktivitasnya. pembatasan terhadap aktivitas menjadi salah satu penyebab pasien gagal jantung mempunyai kapasitas latihan yang menurun, walaupun pasien sudah menjalani pengobatan modern (mutaqqin, 2009). berdasarkan hasil studi pendahuluan di pku muhammadiyah gamping sleman yogyakarta jumlah pasien dengan gagal jantung pada tahun tahun 2014 ada 472 pasien dan tahun 2015 ada 580 pasien, sedangkan jumlah pasien rawat jalan poli jantung dengan diagnosa gagal jantung setiap minggu ada 10 – 15 pasien. 57 vol. 1 no. 1 desember 2016 tujuan penelitian penelitian ini dilakukan untuk mengetahui karakteristik pasien gagal jantung di poli jantung rs pku muhammadiyah gamping sleman. metode penelitian penelitian ini dilakukan menggunakan metode penelitian deskriptif. penentuan sampling menggunakan non probability sampling dengan pendekatan consecutive sampling. jumlah sampel pada penelitian 32 responden. hasil penelitian karakteristik pasien gagal jantung rs pku muhammadiyah gamping sleman yogyakarta. variabel jumlah prosentase (%) umur 45-50 tahun 51-55 tahun 56-60 tahun 61-65 tahun 7 1 5 19 21, 88 3,12 15,62 59,38 jenis kelamin laki – laki perempuan 15 17 46,88 53,12 pendidikan terahir tidak sekolah sd sltp slta pt 0 11 5 8 8 0 34,38 15,62 25 25 pekerjaan irt pns/pensiun wiraswasta 7 10 7 21,875 31,25 21,875 variabel jumlah prosentase (%) petani swasta 4 4 12,5 12,5 stadium stadium 1 stadium 2 stadium 3 0 30 2 0 93,75 6,25 pembahasan gagal jantung menjadi penyakit yang terus meningkat kejadiannya terutama pada lansia. studi framingham dalam penelitian sani (2007) memberikan gambaran yang jelas tentang gagal jantung. pada studinya disebutkan bahwa kejadian gagal jantung per tahun pada orang berusia > 45 tahun adalah 7,2 kasus setiap 1000 orang laki-laki dan 4,7 kasus setiap 1000 orang perempuan. di amerika hampir 5 juta orang menderita gagal jantung (sani, 2007). hasil penelitian menunjukkan bahwa rentang umur responden sebagian besar umur 61 – 65 tahun. seiring dengan bertambahnya usia seseorang beresiko mengalami penyakit gagal jantung dikarenakan semakin bertambahnya usia maka terjadi penurunan fungsi jantung. hal ini didukung oleh penelitian yang dilakukan oleh harikatang, rampengan, & jim (2016) bahwa kelompok usia terbanyak responden gagal jantung yang diteliti ialah kelompok 60-70 tahun dimana usia tersebut merupakan 50% dari jumlah responden keseluruhan. penelitian lain dilakukan oleh sari, rampengan & panda (2012),yaitu 30 kasus yang diteliti ditemukan 12 kasus (40%) merupakan pasien dengan gagal jantung kronik berusia 60-69 tahun, kemudian disusul oleh kelompok umur 50-59 tahun dengan 11 kasus (37%), kelompok umur 40-49 tahun dengan 4 kasus (13%), dan yang paling sedikit adalah kelompok umur 30-39 tahun dengan 1 kasus (3%). prevalensi gagal jantung sebagai salah satu penyakit kardiovaskuler menurut aha (2012) di amerika pada tahun 2008 dialami sekitar 5,7 juta untuk 58 semua tingkat usia. distribusi penyakit chf atau chf kongestif meningkat pada usia 40 tahun keatas. hal ini berkaitan dengan proses menua yang menyebabkan peningkatan proses aterosklerosis pada pembuluh darah. aterosklerosis menyebabkan terganggunya aliran darah ke organ jantung sehingga terjadi ketidakseimbangan antara kebutuhan oksigen miokardium dengan suplai oksigen. menurut hou, et al (2004) menyebutkan bahwa usia merupakan faktor risiko utama terhadap penyakit jantung dan penyakit kronis lainnya termasuk di dalamnya gagal jantung. menurut karavidas, et al (2010), pertambahan umur dikarakteristikkan dengan disfungsi progresif dari organ tubuh dan berefek pada kemampuan mempertahankan homeostasis. hasil penelitian yang dilakukan oleh ewika (2007) menunjukkan bahwa chf atau chf kongestif paling banyak terjadi pada usia< 60 tahun atau pada kelompok usia dewasa dibanding pada kelompok usia lanjut atau > 60 tahun yaitu dengan persentase 55,55%. responden pada kelompok intervensi dan kelompok kontrol antara jenis kelamin perempuan dan laki – laki memiliki jumlah yang hampir sama. responden berjenis kelamin perempuan yaitu 17 orang (53%) dan berjenis kelamin lakilaki yaitu 15 orang (47%) dengan jumlah responden perempuan sedikit lebih banyak dari pada responden laki – laki. penelitian yang dilakukan oleh lupiyatama (2012), didapatkan jumlah pasien pria sebanyak 60 (49,6%) dan pasien wanita sebanyak 61 (50,4%), hasil ini juga sesuai dengan penelitian yang telah dilakukan oleh biteker ( 2010), yaitu pada didapatkan jumlah pasien gagal jantung pria dan wanita dengan jumlah yang hampir sama. di negara – negara industri, cad (coronary artery disease) menjadi etiologi terbanyak gagal jantung kongestif pada pria dan wanita, yaitu sekitar 60 – 75%, kemudian disusul oleh hipertensi dan penyebab lainnya (mann, 2008). menurut penelitian yang dilakukan oleh waty & hasan (2013), bahwa gagal jantung disebabkan paling banyak oleh cad, disusul campuran antara hhd (hipertensi hearth disease) dan cad, dan hhd. di negara berkembang sepereti di indonesia penyakit hipertensi berhubungan erat dengan kejadian gagal jantung (cowie, 2008). jenis kelamin pada perempuan lebih beresiko mengalami hipertensi. hal ini berhubungan dengan faktor hormonal yang lebih besar dari dalam tubuh perempuan daripada pada laki – laki. faktor hormonal dapat menyebabkan peningkatan lemak dalam tubuh atau obesitas. obesitas pada perempuan juga dapat disebabkan karena kurangnya aktivitas, lebih mudah stres pada perempuan dan lebih sering menghabiskan waktu untuk bersantai di rumah (junaidi, 2010). hasil penelitian yang sesuai dengan penelitian ini adalah penelitian yang dilakukan vani (2011), dimana didapatkan bahwa penyakit chf lebih banyak terjadi pada perempuan dengan persentase 57,5%. perempuan lebih banyak menderita chf pada penelitian ini disebabkan karena sebagian besar perempuan yang menjadi responden dalam penelitian ini telah berumur lanjut. pada umur lanjut perempuan umumnya mengalami menopause, dimana pada saat itu kolesterol ldl meningkat yang menyebabkan perempuan lebih banyak menderita penyakit gagal jantung. responden pada kelompok intervensi sebagian besar yaitu 6 orang (37,5%) pendidikan terahir sd (sekolah dasar), responden pada kelompok kontrol sebagian besar yaitu 5 orang (31,25) pendidikan terahir sd (sekolah dasar) dan 5 orang (31,25%) pendidikan terakhir pt (perguruan tinggi). menurut penelitian yang dilakukan agrina, rini, & hairitama (2011), seseorang yang memiliki pendidikan lebih tinggi akan mudah menyerap informasi dan memiliki pengetahuan yang lebih baik dari pada seseorang dengan tingkat pendidikan yang rendah. semakin tinggi pendidikan yang dimiliki seseorang maka semakin mudah menerima informasi yang diberikan. penelitian lain dilakukan oleh bradke (2009), bahwa salah satu faktor yang dapat mempengaruhi pasien dirawat inap berulang pada pasien gagal jantung di rumah sakit adalah rendahnya tingkat pendidikan. sebagian besar responden yaitu 10 orang (31,25%) bekerja sebagai pns (pegawai negri sipil). menurut atika 59 vol. 1 no. 1 desember 2016 (2016), etos kerja dan kinerja yang tinggi sulit dicapai apabila pns mengalami stress kerja. seseorang yang mengalami stress mempunyai resiko terkena penyakit hipertensi, hipertensi dapat menyebabkan terjadinya hipertrofi ventrikel kiri yang dihubungkan dengan terjadinya disfungsi diastolik dan meningkatkan resiko gagal jantung. pekerjaan yang berat, terus menerus dan kurang beristirahat dapat meningkatkan kerja jantung dalam memompa darah ke seluruh tubuh untuk memenuhi kebutuhan tubuh dalam beraktivitas (kaplan dan schub, 2010). pekerjaan yang berat diketahui dapat menjadi beban dan menyebabkan terjadinya gangguan kesehatan, terutama pada sistem kardiovaskuler (rochmi, 2010 dalam yenni et all, 2014). responden hampir semuanya menderita gagal jantung stadium 2. penelitian yang dilakukan oleh sari, rampengan & panda (2012), ditemukan pasien yang datang berobat ke poliklinik jantung dengan kelas fungsional ii atau sekitar 43% dengan gejala berupa palpitasi dan dispnea timbul pada saat aktifitas fisik biasa. penelitian lain dilakukan pudiarifanti, pramantara & ikawati (2015) sebagian besar yaitu 73% responden stadium 2 dan 52% responden menderita gagal jantung > 1 tahun. fungsi jantung pada penderita gagal jantung stadium 2 mengalami penurunan dan terjadi penurunan cardiac out put. penurunan cardiac out put akan membuat jantung terkompensasi untuk bekerja lebih kuat dengan harapan mampu memenuhi kebutuhan tubuhnya, tetapi dengan kronisnya kondisinjantung semakin gagal dalam memompa (mariyono & santoso, 2007). kekurangan penelitian kekurangan pada penelitian ini yaitu pengambilan sampel dengan jumlah yang tidak banyak yaitu 32 responden. kesimpulan hasil penelitian ini telah mengidentifikasi karakteristik umur, jenis kelamin, pendidikan terahir, pekerjaan, dan stadium gagal jantung. sebagian besar responden berada pada usia 61 – 65 tahun,jenis kelamin responden lebih besar perempuan dari pada laki laki, pendidikan terahir paling banyak sekolah dasar, pekerjaan sebagian besar pegawai negeri sipil, dan hampir semua responden mengalami gagal jantung stadium 2. hasil penelitian ini diharapkan dapat mejadi acuan untuk mengetahui gambaran karakteristik pasien gagal jantung sehingga dapat dilakukan pencegahan ataupun intervensi untuk mengurangi kekambuhan pasien gagal jantung. peneliti selanjutnya dapat melakukan penelitian dengan memberikan sebuah intervensi untuk pasien gagal jantung dengan jumlah sampel yang lebih besar. referensi agrina, rini,s., & hairitama, r. (2011). kepatuhan lansia penderita hipertensi dalam pemenuhan diet hipertensi. riau : universitas riau. american hearth asosiation.(2012). heart disease and stroke statistic. http://ahajournal.org.com. atikah. (2016). hubungan antara prokastitansi kerja dengan stres kerja pada pns. universitas muhamadiyah surakarta. biteker m, duman d, dayan a, can mustafa m, tekkeşin ilker a.(2011). inappropriate use of digoxin in elderly patients presenting to an outpatient cardiology clinic of a tertiary hospital in turkey. tűrk kardiyol den arş. 2011;39(5):366. bradke, p. (2009). transisi depan program mengurangi readmissions untuk pasien gagal jantung. http://www.inovations.ahrq.gov/content. aspx%3fid%3d2206. centers for disease control and prevention (cdc). (2015). heart failure fact sheet. departement of health and human services usa. http://www.cdc.gov/dhdsp/ data_statistics/fact_sheets/fs_heart_failure.htm cowie, m.r., dar, q., (2008). the epidemiology and diagnosis of heart failure. in: fuster, v., et al., eds. hurst’s the heart. 12th ed. volume 1. usa: mcgrawhill, 713. ewika, d. n. a. (2007). perbedaan etiologi gagal jantung kongestif usia lanjut dengan usia dewasa di rumah sakit kariadi januari – desember 2006. eprints.undip. ac.id/22675/1/desta.pdv 60 harikatang,a., rampengan,s., & jim, e.(2016).hubungan antara jarak tempuh tes jalan 6 menit dan fraksi ejeksi pada pasien gagal jantung kronik terhadap kejadian kardiovaskular. jurnal e-clinic (ecl), volume 4, nomor 1, januari-juni 2016. hou, n.(2004). relationship of age and sex to health-related quality of life in patients with heart failure. am j crit care 2004 march; 13(20:153-61). junaidi,i. (2010). hipertensi : pengenalan, pencegahan, dan pengobatan. jakarta : pt bhuana ilmu populer. kaplan & schub. (2010). hearth failure in women. cinahl information system. 1:57-63. karavidas, et al. (2010). aging and the cardiovaskular system. hellenic journal of cardiology. 51-421-427. kementrian kesehatan ri. (2014). situasi kesehatan jantung. pusat data dan informasi kementrian kesehatan ri. lupiyatama, s.(2012). gambaran peresepan digoksin pada pasien gagal jantung yang berobat jalan di rsup dr. kariadi semarang. karya tulis ilmiah. program pendidikan sarjana kedokteran fakultas kedokteran universitas diponegoro semarang. mann, d.l..(2008). heart failure and cor pulmonale. in: fauci, a.s., et al., eds. harrison’s principles of internal medicine. volume 2. 17th ed. usa: mcgraw-hill, 1443. mariyono & santoso. (2009). definisi, klasifikasi, diagnosis d a n pe n a n g a n a n g a g a l j a n t u n g . r s u p s a n g l a h , denpasar. http://download.portalgaruda.org/article. php?article=13160&val=927 akses 11 maret 2017. muttaqin, arif. (2009). asuhan keperawatan klien dengan gangguan sistem kardiovaskuler dan hematologi. jakarta : salemba medika. notoatmodjo,s.(2007). metodologi penelitian kesehatan. jakarta : rineka cipta. perhimpunan dokter spesialis kardiovaskuler indonesia (perki). (2015). pedoman tata laksana gagal jantung. national cardiovascular center harapan kita hospital. pudiarifantil, n., pramantara,d., & ikawati,z. (2015).faktorfaktor yang mempengaruhi kualitas hidup pasien gagal jantung kronik. jurnal manajemen dan pelayanan farmasi. volume 5 nomor 4 – desember 2015. p-issn: 2088-8139. e-issn: 2443-2946. sani, a.(2007).heart failure : current paradigm. jakarta : medya crea. cetakan pertama. sari, p., rampengan, s.h & panda, s. (2012).hubungan kelas nyha dengan fraksi ejeksi pada pasien gagal jantung kronik di bblu/rsup prof. dr. r.d. kandou manado. fakultas kedokteran universitas sam ratulangi manado. slater, m renee.,phillips denise m.,elizabeth k (2008). cost effective care a phone call a nurse management telephonic pragram for patient chronic heart failure. journal of nursing economics oi, 26/no1. udjianti, wajan juni. (2010). keperawatan kardiovaskuler. jakarta : salemba medika. vani, s. c. (2011). penyakit penyerta dan gaya hidup pada penyakit congestive heart failure (chf) di rs. dr. wahidin sudirohusodo dan rs.stella maris makassar. http:// repository.unhas.ac.id/bitstream/handle/123456789/385/ bab%20v%20vani.docx?sequence=3 waty,m & hasan, h. (2013). prevalensi penyakit jantung hipertensi pada pasien gagal jantung kongestif di rsup h.adam malik prevalence of hypertensive heart disease in congestive heart failure patients at rsup h.adam malik. e-journal fk usu vol 1 no 1, 2013. yenni, e.,nurchayati.s., & sabrian.f.(2014). pengaruh pendidikan kesehatan latihan rehabilitasi jantung terhadap pengetahuan dan kemampuan mobilisasi dini pada pasien congestive heart failure (chf). program studi ilmu keperawatan universitas riau. 1 vol. 1 no. 2 juni 2017 penurunan kecemasan remaja korban bullying melalui terapi kogitif betie febriana1 1 departemen keperawatan jiwa, fakultas ilmu keperawatan, universitas islam sultan agung, jl. kaligawe km.4 semarang, 50112, indonesia e-mail: betie.febriana@gmail.com abstrak bullying menimbulkan dampak negatif bagi remaja, salah satunya adalah kecemasan yang dapat mempengaruhi prestasi belajar. oleh karena itu dibutuhkan terapi untuk menurunkan kecemasan. penelitian ini bertujuan untuk mengetahui efektifitas terapi kognitif dalam menurunkan kecemasan remaja korban bullying. subjek dalam penelitian ini adalah siswa sma kelas x yang menjadi korban bullying. desain penelitian yang dipakai adalah true experimental pre-post test with control group dengan jumlah sampel 22 responden dengan teknik simple random sampling. penelitian ini menggunakan olwe