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 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/ 64 vol. 1 no. 2 juni 2017 attitude and behavior sexual among adolescents in yogyakarta rahmah, wahyudina aaan, sari ww. pediatrics nursing department, school of nursing, faculty of medicine and health sciences university muhammadiyah yogyakarta, indonesia rahmah.umy@gmail.com yogyakarta as a tourism city given more impact on attitude and behavior sexuality among adolescents. notion and ideas about sexuality much influenced by the globally issued environment. this study is basically on the attitude and behavior about sexuality among adolescent. it is of public health importance to examine this topic to inform sex education, policymaking, prevention and intervention program. this study explored the characteristics of sexual attitudes, and high risk premarital sexual behaviors among 106 unmarried youth aged 15 to 17 years usedsexual behavior questionnareand adopted from briefsexual attitude scaleto investigate sexual attitudes. the scale measures sexual attitudes on four dimensions, being permissiveness, birth control (sexual practices), communion (investment in relationship), and instrumentality (pleasure-orientation to relationship). this study shown to female prefer low being 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 adolescents. keywords: attitude, behavior, sexuality, adolescent info artikel: masuk : 14 februari 2017 revisi : 23 mei 2017 diterima : 7 juni 2017 doi number : 10.18196/ijnp.1262 65 vol. 1 no. 2 juni 2017 1. introduction the children of today are not the children of yesterday. growth in terms of maturity and knowledge can be seen on a large scale for the adolescent population of today (guha, 2013). adolescents had a developmental stage associated with increased risk taking behaviors that contribute to negative sexual health outcomes. (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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(2011). integrating cooperative learning into classroom testing: implications for nursing education and practice. nursing education perspectives, 32(4), 270-3. hanze, m & berger, r (2007). cooperative learning jigsaw classroom motivational and student characteristic effect. experimental study comparing cooperative learning and direct instruction. institte of psychologycal. journal learning and instruction. v 17. p 29-41. huang, h, et al (2013). a jigsaw based cooperative learning approach as improvine learning outcome for mobile situated learning. journal of technology educational and society. 17 (1). p 128-140. isjoni.(2009) cooperative learning, efektifitas pembelajaran kelompok, bandung: alfabet. johnson david & roger johnson.(2000).leading the cooperative school.edina,mn: interaction book company. johnson,d.w & johnson,r.t.(2005).cooperative learning and social interdependence theory. http://www.clcrc.com. diakses 27 oktober 2015. kim, j., kim, m & svinicki, m. d (2012). situating student motivation in cooperative learning contexts; proposing different leves of goals orientation. journal of experimental education, 80(4), 352-385. mari, j. s., & gumel, s. a. (2015). effects of jigsaw model of cooperative learning on self-efficacy and achievement in chemistry among concrete and formal reasoners in colleges of education in nigeria. international journal of information and education technology, 5(3), 196-199 megahed, m. m., & mohammad, f. a. (2014). effect of cooperative learning on undergraduate nursing students’ self-esteem: a quasiexperimental study. journal of nursing education and practice, 4(11), 1. mehran takherani & zaleh sadegian, (2015). intrinsic motivation comparative investigation between nursery, midwery and medicine student in iran. procedia social and behavioral sciences 185,185-189. miftahul huda. (2015). cooperative learning metode, teknik, struktur dan penerapan.yogyakarta : pustaka pelajar. muhibbin syah. (2008). psikologi belajar. bandung : pt. remaja rosdakarya. slavin, rober t.(2008).cooperative learning theor y. usa:allymand&bacon. slavin,robert.(2013).cooperative learning(teori, riset,dan praktek). bandung: nusamedia smith-stoner, m., & molle, mary e, phd,r.n., p.h.c.n.s.b.c. (2010). collaborative action research: implementation of cooperative learning. journal of nursing education, 49(6), 312-8. doi:http://dx.doi.org/10.3928/0148483420100224-06 stahl.(1994).cooperative learning in social studies.new york:addison wesley publishing company. schwamberger, b., & sinelnikov, o. a. (2014). college students’ perspectives, goals, and strategies using cooperative learning. research quarterly for exercise and sport, 85, 1 sugiyono. (2015). statistika untuk penelitian, bandung : alfabeta. uys, l.r and gwele, n.s. (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. 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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(2019). health-related quality of life and its associated factors among thalassemic children: a review. international journal of health sciences and research, 9(5), 386–389. mardhiyah, a., philip, k., mediani, h. s., & yosep, i. (2020). the association between hope and quality of life among adolescents with chronic diseases: a systematic review. child health nursing research, 26(3), 323–328. https://doi.org/10.4094/chnr.2020.26.3.323 mariani, d., rustina, y., & nasution, y. (2014). analisis faktor yang memengaruhi kualitas hidup anak thalassemia beta mayor. jurnal keperawatan indonesia, 17(1), 1–10. https://doi.org/10.7454/jki.v17i1.375 nikmah, m., & mauliza, m. (2018). kualitas hidup penderita talasemia berdasarkan instrumen pediatric quality of life inventory 4.0 generic core scales di ruang rawat anak rumah sakit umum cut meutia aceh utara. sari pediatri, 20(1), 11. https://doi.org/10.14238/sp20.1.2018.11-6 pranajaya, r., & nurchairina. (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 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 olweus bully/victims questionare untuk mengetahui siswa yang menjadi korban bullying dan hars (hamilton anxietyraing scale) (r xx’ = 0,617) untuk mengetahui tingkat kecemasan. hasil penelitian ini adalah terapi kognitif efektif menurunkan tingkat kecemasan pada remaja korban bullying (nilai p = 0,002). temuan lain dalam penelitian ini adalah terdapat perbedaan pertemuan pada responden saat mendapatkan terapi, hal ini bergantung pada jumlah pikiran negatif dan kemampuan responden untuk mengontrol pikiran negatif. kata kunci: bullying, kecemasan, terapi kognitif abstract bullying causes many negative impacts to the victims, one of them is anxiety. anxiety influence learning achievement for student. therefore, it is important to take therapy to reduce anxiety. this study aims to determine the effectiveness of cognitive therapy in reducing anxiety in adolescents’ victims of bullying. subjects in this study were sma’s students who are victims of bullying. the research design used true experimental pre-post test with control group. sample was 22 respondents with simple random info artikel: masuk : 28 desember 2016 revisi : 13 mei 2017 diterima : 20 mei 2017 doi number : 10.18196/ijnp.1255 2 sampling technique. researchers used olweus bully / victims questionnaire to identify students who are victims of bullying and hars (hamilton anxietyrating scale) (rxx ‘= 0.617) to identify anxiety before and after therapy. the results of this study was cognitive therapy reduce anxiety level in adolescent’s victim of bullying (p-value= 0,002). another finding in this study, there was a difference of quantitative meetings on respondents when getting therapy, it depends on the number of negative thoughts and the ability of respondents to control negative thoughts. keywords: bullying, anxiety, cognitive therapy pendahuluan kecemasan pada remaja salah satunya diperoleh dari perilaku agresif yang dilakukan oleh teman sebaya. james (2010) mengatakan bahwa bullying pada umumnya terjadi di sekolah yang termasuk jenis perilaku agresi. data dari plan international and interational center for research on woman (icrw) bahwa 84% anak di indonesia dengan kisaran usia 1217 tahun mengalami bullying, angka ini lebih tinggi dibading negara lain di kawasan asia. seperti yang ditimbulkan oleh agresi, perilaku bullying juga menimbulkan bahaya, baik mental, fisik, kognitif ataupun emosional yang hal tersebut dilakukan secara sengajarivers, ian, & noret (2012). pada umumnya, bullying menjadi tradisi sekolah yang dilakukan oleh senior jika tak mengikuti aturan mereka, meskipun banyak juga bullying teman sebaya. korban bullying biasanya enggan untuk mengadukannya ke pihak lain termasuk orang tua karena kecemasan akan mendapat perlakuan yang lebih buruk lagi. hal inilah yang membuat tindakan bullying semakin merajalela jika tidak tertangani dengan tepat. beragam dampak buruk yang ditimbulkan oleh bullying. eimerbrink, scielzo, & campbell (2015) dalam studinya menemukan bahwa bullying dapat memberikan efek kecemasan, berpengaruh pada harga diri, dan mengakibatkan depresi pada korbannya. studi lain yang dilakukan oleh kowalski, robin,& limber (2012) menyatakan bahwa kecemasan karena bullying menjadi factor terbesar anak-anak enggan untuk pergi ke sekolah. olivarez, sanchez, & lopez (2009) menyebutkan bahwa terdapat tiga aspek dalam kecemasan yaitu, bentuk penghindaran sosial dan rasa tertekan yang dialami secara umum, bentuk penghindaran sosial dan rasa tertekan dalam situasi yang baru atau ketika berhubungan dengan orang baru/orang asing, sertaketakutan terhadap evaluasi negatif dari orang lain. kecemasan juga menimbulkan beberapa dampak, antara lain remaja dengan tingkat kecemasan yang tinggi memiliki teman yang lebih sedikit, adanya persepsi negatif terhadap diri sendiri, gangguan fungsi sosial, dan mengalami hambatan dalam mengembangkan kemampuan dalam lingkungan masyarakat (festa & ginsburg, 2011; ling lai, ye & chai, 2008) penanganan kecemasan korban bullying harus segera mungkin dilakukan untuk meminimalkan dampak. terapi yang dapat digunakan untuk mengatasi kecemasan pada korban bullying adalah terapi kognitif. menurut gavino (2013), terapi kognitif adalah suatu terapi yang mengidentifikasi pemikiran negatif dan merusak yang mendorong ke arah kecemasan dan depresi yang menetap. terapi kognitif dapat membantu menghentikan pikiran negatif dan membantu penderita melawannya, terapi ini bertujuan untuk mengubah pikiran negatif menjadi positif, membantu mengendalikan diri (ingul, aune, & nordahl. (2013). oleh karena itu, tujuan daari penelitian ini adalah mengetahui efektivitas terapi kognitif terhadap perubahan kecemasan remaja korban bullying. metode desain penelitian ini adalah kuantitatif dengan rancangan true experimental pre-post test with control group. kecemasan sebagai variabel dependendanterapi kognitif sebagai variabel independen. kuesioner olweus bully/victims digunakanuntuk mengetahui siswa yang menjadi korban bullying dan hars (hamilton anxietyraing scale) (r xx’ = 0,617) untuk mengetahu kecemasan responden. terapi kognitif diberikan dalam 3 sesi yaitu sesi 1 identifikasi pikiran otomatis negatif, sesi 2 penggunaan 3 vol. 1 no. 2 juni 2017 tanggapan rasional terhadap pikiran otomatis negatif dan sesi 3 adalah manfaat tanggapan rasional terhadap pikiran negative. terapi dilakukan sebanyak 4-6 kali pertemuan, masing-masing pertemuan dilakukan setiap minggu berkisar 45-60 menit pada masingmasing responden. sampel sebanyak 22 responden yang terbagi pada kelompok kontrol dan perlakuan dengan metode simple random sampling. kelompok perlakuan mendapatkan terapi kognitif sedangkan kelompok kontrol tanpa terapi. tempat penelitian di salah satu sma di semarang pada siswa kelas x. analisa bivariat menggunakan uji kolmogorov smirnov dan ujimarginal homogeneity. penelitian ini telah melalui uji etik dengan no 783a.1/ s1/fik/sa/12/2016 oleh fakultas ilmu keperawatan universitas islam sultan agung tabel 2 hasil uji beda harga diri remaja korban bullying sebelum dan sesudah diberikan terapi kognitif pada kelompok perlakuan tidak cemas tingkat kecemasan setelah terapi total p ringan sedang berat panik tingkat kecemasan sebelum terapi tidak cemas 0 0 1 0 0 1 0,02 ringan 0 0 0 0 0 0 sedang 5 0 2 0 0 7 berat 1 0 0 0 0 1 panik 2 0 0 0 0 2 total 8 0 3 0 0 11 tabel 3 hasil uji beda kecemasan remaja korban bullying sebelum dan sesudah diberikan terapi kognitif pada kelompok kontrol tidak cemas tingkat kecemasan setelah terapi total p ringan sedang berat panik tingkat kecemasan sebelum terapi tidak cemas 1 1 0 0 0 2 0,03ringan 1 0 0 0 0 1 sedang 1 1 0 0 0 2 berat 1 1 0 2 0 4 panik 1 1 0 0 0 2 total 5 4 0 2 0 11 tabel 4hasil uji beda skor kecemasan remaja korban bullying sesudah diberikan terapi kognitif pada kelompok perlakuan dan kontrol harga diri total p tidak cemas ringan sedang berat panik n % n % n % n % n % tidak diberikan ct (kontrol) 5 45,4 4 36,4 0 0 2 18,2 0 0 11 0,02 diberikan ct (perlakuan) 8 72,7 0 0 3 27,3 0 0 0 0 11 4 hasil karakteristik responden tabel 1 karakteristik responden remaja korban bullying. variabel kategori kelompok kontrol n=11 kelompok perlakuan n=11 n % n % jenis kelamin laki-laki perempuan total 7 4 63,6 36,4 3 8 27,3 72,7 11 100 11 100 pekerjaan ayah tidak bekerja bekerja total 4 7 11 36,4 63,4 100 1 10 11 9,1 90,9 100 pekerjaan ibu tidak bekerja bekerja total 0 11 11 0 100 100 6 5 11 54,5 45,5 100 pendidikan ayah sd smp sma perguruan tinggi total 1 3 6 1 11 9,1 27,3 54,5 9,1 100 1 3 5 2 11 9,1 27,3 45,5 18,2 100 pendidikan ibu sd smp sma perguruan tinggi total 3 4 4 0 11 27,3 36,4 36,4 0 100 1 6 3 1 11 9,1 54,5 27,3 9,1 100 berdasarkan tabel di atas, diketahui bahwa pada kelompok kontrol sebagian besar laki laki yaitu 7 orang (63,6%), sedangkan kelompok perlakuan, sebagian besar berjenis kelamin perempuan sebanyak 8 orang (72,7%). rata-rata orang tua laki laki bekerja dan orang tua perempuan lebih banyak yang di rumah. pendidikan orang tua pada kedua kelompok paling banyak sma, sedangkan ibu rata-rata smp. data bivariat a. perbedaan tingkat kecemasan remaja korban bullying sebelum dan sesudah diberikan terapi kognitif pada kelompok perlakuan berdasarkan tabel 2 didapatkan bahwa terdapat perubahan kategori kecemasan pada kelompok perlakuan. kecemasan setelah terapi menurun menjadi menjadi tidak cemas pada 8 orang responden, bahkan dari kategori panik menurun menjadi tidak cemas. beberapa masih berada dalam kategori yang sama tetapi hanya 2 orang saja, walaupun berada dalam kategori yang sama, dari hasil skor kecemasan keduanya menurun sebanyak masing-masing 6 dan 7 poin. adapun hasil uji statistik , p-value 0,02 yang berarti ho ditolak sehingga ada perbedaan kecemasan antara sebelum dan sesudah pemberian terapi kognitif pada kelompok perlakuan. b. perbedaan kecemasan remaja korban bullying sebelum dan sesudah diberikan terapi kognitif pada kelompok kontrol berdasarkan tabel 3 didapatkan bahwa kecemasan pada responden setelah terapi menjadi 5 responden pada kategori tidak cemas sebelumnya hanya terjadi pada 2 responden. tidak cemas menjadi cemas ringan pada satu orang beberapa responden yang berada pada kategori yang sama antara sebelum dan sesudah terapi rata-rata mengalami peningkatan poin. adapun hasil ujimarginal homogeneity, p-value 0,03 yang berarti ho diterima sehingga ada perbedaan harga diri antara sebelum dan sesudah pemberian terapi kognitif pada kelompok kontrol c. perbedaan kecemasan remaja korban bullying sesudah diberikan terapi kognitif pada kelompok perlakuan dan kontrol berdasarkan hasil ujikolmogorov-smirnov pada tabel 4 didapatkan bahwa nilai p adalah 0,02 (p< 0,05) yang artinya terdapat perbedaan harga diri setelah diberikan terapi pada kelompok kontrol dan perlakuan. oleh karena itu, dapat disimpulkan bahwa ada pengaruh antara pemberian terapi kognitif dengan kecemasan pembahasan a. kecemasan remaja korban bullying sebelum dan sesudah diberikan terapi kognitif pada kelompok perlakuan 5 vol. 1 no. 2 juni 2017 hasil penelitian menyebutkan bahwa terdapat perbedaaan tingkat kecemasan pada remaja sebelum dan sesudah pemberian terapi kognitif pada kelompok intervensi atau perlakuan. data menyebutkan bahwa tidak semua responden mengalami perubahan tingkat kecemasan, namun semua responden mengalami penurunan skor kecemasan berkisar antara 6-12 skor. penurunan skor mempunyai arti bahwa terjadi perubahan tanda dan gejala ansietas menuju arah yang lebih baik walaupun masih dalam tingkat kecemasan yang sama. oleh karena itu, dapat digeneralisir bahwa terdapat perubahan kecemasan dari sisi tanda dan gejala setelah kelompok intervensi korban bulliying mendapatkan terapi kognitif. perilaku bullying merupakan perilaku berulang berupa intimidasi yang dilakukan oleh satu atau beberapa orang yang menganggap dirinya lebuh kuat daripada korban (james, 2010). carney dan merrell (2001) mengidentifikasi bahwa dampak bullying cenderung lebih besar pada depresi dan kecemasan. dampak jangka pajang berpengaruh pada psikososial perkmbangan tahap berikutnya. ansietas merupakan efek yang bisa menghasilkan efek domino pada aspek yang lain seperti penurunan prestasi karena remaja akan cenderung menghindar bertemu dengan pelaku sehingga sekolah yang notabene menjadi tempat nyaman untuk belajar berubah menjadi lingkungan yang mengancam bagi korban jika tidak mampu melakukan koping yang baik. perasaan terancam terus menerus akan mejadi teror tersendiri bagi korban sehingga bisa merambah pada aspek biologis korban (paul, 2009). hal ini bermula dari pikiran negatif yang dimiliki oleh korban seperti bahwa mereka tidak mampu melawan pelaku, bersifat pasif, serta terkadang membenarkan label negatif yang diberikan kepadanya. pikiran negatif ini timbul karena adanya persepsi yang buruk terkait diri sendiri karena mendapatkan perlakuan buruk yang terus berulang. beck (1987) menyebutnya sebagai pikiran otomatis negatif, yaitu respon yang bersifat negatif tanpa analisis rasional yang terjadi dengan cepat dengan logika yang keliru. terapi kognitif membawa dampak menurunnya tanda dan gejala kecemasan atau ansietas. power (2010) menggambarkan temuan yang penurunan tanda dan gejala depresi salah satunya adalah ketegangan karena cemas setelah diberikan terapi kognitif. ini artinya terapi kognitif secara general mampu memberikan perbaikan pada gejala kecemasan. selain tanda kecemasan umum, terapi ini juga menurunkan pikiran negative, afek sedih, dan penigkatkan afek positif. hasil ini sejalan dengan penelitian kristanti bahwa klien gagal ginjal kronik yang mengalami harga diri rendah dan depresi menunjukkan bahwa terapi kognitif dapat menurunkan perasaan harga diri rendah dan menurunkan kondisi depresi salah satunya ansetas. eimerbrink, scielzo, dan campbell (2015) menyatakan krisis pada korban bullying mengakibatkan perubahan emosi seperti takut, depresi, cemas, tidak berdaya, putus asa. jika masalah psikosoisla karena krisis ini tidak tertangani maka akan memperburuk kondisi psikososial korban. oleh karena itu, penting untuk membuat klien mampu meningkatkan kemampuan mengontrol pikiran sehingga dampak yang lebih berat tidak terjadi. pemberian psikoterapi pada penelitian ini diharapkan dapat menurunkan kecemasan korban bullying. perubahan kecemasan pada kelompok perlakuan dengan terapi kognitif menunjukkan hasil yang baik dari kondisi kecemasan sedang menjadi tidak cemas bahkan dari kondisi panic menjadi tidak cemas. ini artinya penurunan kategori yang sangat signifikan pada kelompok perlakuan. penurunan kecemasan pada kelompok yang mendapat terapi kognitif karena klien dilatih cara melawan pikiran dan mengontrol pikiran yang menganggu. klien dengan kecemasan akan mempengaruhi kemampuan kognitif seperti 6 konsentrasi menurun, berfikir, serta rentang yang menyempit pada area perhatian (stuart, 2010). b. kecemasan remaja korban bullying pada kelompok kontrol. pada kelompok kontrol, terlebih dahulu dilakukan penilaian tingkat kecemasan, setelah itu tidak diberikan intervensi apapun oleh peneliti hingga proses intervensi pada kelompok perlakuan selesai. setelah 6 minggu, dilakukan pnilaian tingkat kecemasan. berdasarkan uji analisi marginal homogeneity pada tabel sebelumnya didapatkan nilai p 0, 03 dimana p>0,05 yang mempunyai arti ada perbedaan harga diri pada kelompok kontrol sebelum dan sesudah intervensi pada kelompok perlakuan. kelompok kontrol pada penelitian ini tidak mendapatkan intervensi terapi kognitif selama penelitian dan hasil yang didapatkan adalah bahwa statistik secara umum menunjukkan adanya penurunan kecemasan. hal ini cukup menarik utnuk dianalisis. tanda dan gejala kecemasan yang diperlihatkan oleh responden dalam kelompok kontrol sebelum intervensi antara lain, cemas/ takut jika harus berbicara di depan umum, mudah tersinggung, gelisah, sedih, berdebar jika bertemu teman yang menajdi pelaku. dapat disimpulkan bahwa tanda dan gejala yang paling banyak dirasakan ada dalam konteks kognisi dan perilaku. gejala ini sejalan dengan penelitiian smith dkk. (2008) yang menunjukkan bahwa remaja korban bullying memperlihatkan beberapa gangguan terutama pada perilaku, kognisi, dan afeksi serta konsentrasi. menurunnya gejala kecemasan pada kelompok ini dapat terjadi karena proses dari program yang ada di sekolah. sekolah berbasis islam ini memiliki program spiritual anatara lain sholat dhuhur berjamaah, membaca asmaul husna sebelum memulai pelajaran setiap pagi, shalawat dan membaca alquran bersama. aktivitas yang lain adalah setiap jam istirahat selalu diputarkan musik bernuansa islam atau shalawat.mata pelajaran yang diajarkan pun menggaet mata pelajaran khusus islam seperti fiqih, tarikh, bahasa arab, membaca alquran. hal ini membawa nuansa tersendiri di sekolah tersebut. sekolah dengan program spiritualitas yang baik membawa kebaikan pada siswanya pun pada kelompok kontrol korban bullying. seperti studi yang dilakukan oleh sharma, charak,& sharma (2009) kebangkitan makna dan tujuan membawa kembali harapan dan semangat untuk menghadapi kesulitan hidup. penelitian tersebut menemukan bahwa untuk setiap kenaikan 10 poin di religiusitas intrinsik seseorang, ada peningkatan 70% dalam pemulihan dari gejala depresi pasca penyakit fisik. studi lain yang ditemukan oleh torabi dkk. (2016) bahwa pelaksanaan perawatan spiritual oleh perawat dapat mempengaruhi situasi mental remaja dengan kanker dan merupakan metode yang cocok untuk mengurangi kecemasan. oleh karena itu perlu bagi perawat untuk menggunakan intervensi spiritual selama pelaksanaan asuhan keperawatan yang komprehensif. c. kecemasan sesudah diberikan terapi kognitif pada kelompok perlakuan dan kontrol. berdasrkan tabel sebelumnya didapatkan data analisis bahwa terapi kognitif memberikan pengaruh pada perubahan tingkat kecemasan remaja korban bullying. terapi kognitif dalam penelitian ini bertujuan untuk mengendalikan pikiran negative yang timbul karena perilaku bullying yang mengakibatkan kecemasan atau pikiran buruk lain yang terjadi karena menjadi korban bullying. pikiran yang mengakibatkan ansietas dapat mengganggu seseorang sehingga berakibat menjadi kurang bahkan tidak produktif. seperti pengakuan beberapa responden bahwa mereka menjadi enggan ke sekolah karena cemas bertemu dengan pelaku bullying. hal ini akan mengakibatkan ketidaknyamanan psikologis. jika terus berlanjut berakibat pada penurunan prestasi yang pada 7 vol. 1 no. 2 juni 2017 akhirnya menghambat perkembangan anak secara kognitif di sekolah, tentu ini akan berpengaruh pada masa depan korban jika tidak tertangani. oleh karena itu, penting diberikan terapi pengontrolan pikiran negative melalui terapi kognitif. pelaksanaan terapi kognitif diharapkan memberikan dampak signifikan pada kemampuan klien yang berkaitan dengan kemampuan koping yang adaptif serta pemecahan masalah. latihan secara teratur menjadi kunci tercapainya hal tersebut, jika dilakukan terus menerus diharapkan klien akan secara otomatis akan terbiasa memandang suatu peristiwa dari sisi positif. kelompok kontrol yang tidak mendapat terapi kognitif memang menunjukkan penurunan kecemasan, tetapi justru ada yang meningkat. kondisi ini menggambarkan pentingnya intervensi keperawatan jiwa, khususnya psikoterapi untuk membantu klien menurunkan kecemasan dengan peningkatan kemampuan mengontrol pikiran yang tidak menyenangkan. studi yang dilakukan derubeis, webb, tang, dan beck (2010) menemukan bahwa adanya variasi pertemuan terapi kognitif, pelaksanaan berulang ulang pada terapi ini dapat memiliki efek secara biologis. sementara ini pada penelitian ini, belum ditemukan perubahan kecemasan yang signifikan dari sisi biologis. saat terapi berlangsung, masing-masing responden memiliki pertemuan yang berbeda bergantung pada banyaknya pikiran negative yang dimiliki responden serta kemampuan dalam berlatih mengendalikannya. inilah dua factor yang ditemukan oleh peneliti dalam pelaksanaan terapi kognitif. sesi yang diberikan sama pada setiap responden yaitu 3 sesi, hanya saja jumlah pertemuan yang berbeda antar mereka. perbedaan terletak pada sesi ke-2 yaitu tentang latihan mengontrol pikiran negative dimana pada sesi ini masing-masing responden membutuhkan jumlah pertemuan yang berbeda bergantung pada banyaknya pikiran negatif dan kemampuan mengendalikannya. kesimpulan penelitian ini menunjukkan bahwa terdapat pengaruh terapi kognitif terhadap penurunan kecemasan remaja korban bullyingdengan nilai p 0,02. oleh karena itu terapi kognitif dapat diaplikasikan sebagai terapi untuk mengurangi kecemasan remaja korban bullying. selanjutnya, perlu dikembangkan penelitian yang mengkolaborasikan terapi kognitif dengan aspek spiritual sebagai salah satu terapi yang dapat digunakan untuk remaja korban bullying referensi carney, a. g. & merrell, k. w. (2001) perspectives on understanding and preventing an international problem. school psychology international, 22:364-82. eimerbrink, scielzo, & campbell. (2015). the impact of social and relational victimization on depression, anxiety, and loneliness: a meta-analytic review. journal of bullying and social aggression. 1(1). issn 2375-5849 festa, c.c. & ginsburg, g.s., (2011).parental and peer predictors of social anxiety in youth. gavino, m.f. (2013). group therapy for adolescent bullying victims (cognitive approach). de la salle university ingul, j.m, aune, & nordahl. (2013). a randomized controlled trial of individual cognitive therapy, group cognitive behaviour therapy and attentional placebo for adolescent social phobia. psychother psychosom journal 2014;83:54–61. doi: 0.1159/000354672. diunduh dari http://www.ncbi. nlm.nih.gov/pubmed/24281563 james, a.( 2010). school bullying. research briefing kowalski, robin m., & limber, s. p. (2012). psychological, physical, and academic correlates of cyberbullying and traditional bullying. journal of adolescent health, 53 (1), s13-s20. doi: 10.1016/j.jadohealth.2012.09.018 ling lai, ye & chai. (2008). bullying in middle scool: an aisan-pasicif regional study. asia pacific education review. 9 (4) :393-405 liputan6. (2015). survey icrw. diunduh februari 2016. http://news.liputan6.com olivarez, j., sanchezgarcia, r., lopez-pina, j. (2009). 8 the liebowitz social anxiety scale for children and adolescents. journal of psicothema. 21 (3) power, d. (2010). emotion-focused cognitive therapy. john wiley: oxford malden rivers, ian, & noret, n. (2012).potential suicide ideation and its association with observing bullying at school. journal of adolescent health, 53(1), s32-s36. doi: 10.1016/j.jadohealth.2012.10.279 sharma, p., charak, r., & sharma, v. (2009). contemporary perspectives on spirituality and mental health. indian journal of psychological medicine, 31(1), 16–23. http:// doi.org/10.4103/0253-7176.53310 smith, p. k., mahdavi, j., carvalho, m., fisher, s., russell, s. and tippett, n. (2008) cyberbullying: its nature and impact in secondary school pupils. journal of child psychologyand psychiatry, 49:376-385. stuart, g.w. (2010). principles and practice of psychiatric nursing. 10th ed. canada: mosby, inc torabi f, sajjadi m, nourian m, borumandnia n, &shirinabadi fa.(2016). the effects of spiritual care on anxiety in adolescents with cancer. supportive and palliative care in cancer 2016; in press.http://journals. sbmu.ac.ir/spc/article/view/11007 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 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. 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(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 indonesian journal of nursing practices 124 indonesian journal of nursing practices mar’atun ulaa1, wiwin lismidiati2, elsi dwi hapsari2 1 school of nursing stikes muhammadiyah palembang 2 school of nursing faculty of medicine, universitas gadjah mada email: maratunulaa@gmail.com differences use of yoga and self tapping towards long pain of primary dysmenorrhea on adolescent info artikel masuk revisi diterima doi number : : 15 september 2017 : 15 november 2017 : 30 november 2017 : 10.18196/ijnp.1370 abstract background: dys menorrhea i s a common compl ai nt i n young women, characteri zed by pai n. dys menorrhea pai n has a s i gni fi cant i mpact on women's l i ves , s uch as l i mitati ons i n dai l y acti vi ti es . pri mary dys menorrhea can be treated us i ng yoga and s el f-tappi ng. objective: unders tandi ng di fferences on us e of compl ementary and al ternati ve medi ci ne (cam), s uch as yoga and s el f-tappi ng towards changi ng l ong pai n of pri mary dys menorrheal . method: study was conducted by quas i experi ment wi th nonequi val ent pretes t-pos ttes t control group des i gn. study was conducted on november 2016 unti l february 2017 i n smk “a” pedan kl aten and smk “b” kl aten. sampl e of s tudy amounted 88 res pondent di vi ded on 47 res pondents on experi mental group and 41 res pondent as control group. the experi mental group was gi ven a yoga i nterventi on; control group was gi ven s el f-tappi ng. meas uri ng tool us ed numeri cal rati ng scal e (nrs). data anal ys i s us ed t-tes t for i ndependent s ampl e, mann-whi tney tes t and wi l coxon. result: stati s ti cal l y yoga and s el f-tappi ng were equal l y effecti ve i n reduci ng the l ong pai n of pri mary dys menorrheal wi th p val ues of 0.000 and 0.012 res pecti vel y. cl i ni cally yoga i s more effecti ve i n reduci ng the l ong pai n of pri mary dys menorrhea wi th mean 1,49 compared wi th s el f-tappi ng 0,46. conclusion: yoga become more effecti ve i nterventi on on reducti on l ong pai n of pri mary dys menorrhea compared to s el f-tappi ng. keywords: pri mary dys menorrhea, yoga, s el f-tappi ng, l ong pai n, adol es cent. mailto:maratunulaa@gmail.com vol. 1 no. 3 desember 2017 125 introduction dysmenorrhea is a common complaint and often occurs on girls adolescent and women in reproductive age with marked cramps in lower abdominal area during menstruation. primary dysmenorrhea occurred without pathological conditions in female reproductive organs. the heaviest duration of pain usually occurred on 48 to 72 hours in a single menstrual cycle 1, 2, 3. pain period have a significant impact o n women's lives. the highest prevalence of primary dysmenorrhea occurred on girls adolescent, ranging from 20% 90%, sixty percent occurred on adolescents aged 12-17 years old and peaks at the age of 20-24 years. based on research conducted by rodrigues (2011), 62.8 % of respondents experience menstrual pain and 65.7% experience limitations in daily activities due to dysmenorrheal 4. prevalence of limitations in daily activities was influenced by the intensity and duration of pain. a similar study was conducted in canberra and western australia showed an estimated prevalence of adolescents absent from school due to menstrual symptoms of 80% -94% 1, 3, 5, 6, 7. the prevalence of primary dysmenorrhea in indonesia is estimated to be 55% in women of reproductive age 8. based on mardiyah et al’s research (2015) who study on adolescents in madrasah aliyah negeri (man) 1 semarang result, it was found that 65.2% of respondents experiencing dysmenorrhea 9. wijayanti (2008) conducted research on the students sma muhammadiyah 1 yogyakarta 63.6% of the students had primary dysmenorrhea 10. management of primary dysmenorrhe a can be done by pharmacological and nonpharmacological approaches. nonpharmacological approaches have been used with some degree of success. based on data from the 2007 national health interview survey (nhis), forty percent of adults use complementary therapies such as acupuncture, deep breathing exercises, massage therapy, meditation, naturopathy and yoga 11, 12, 13. yoga is a mind-body practice derived from ancient indian philosophy, consisting of physical posture (asana), breathing exercises (pranayama), and meditation (dhyana), which integrate the balance of body and mind in harmony 14. in addition, therapy that can be used to overcome the pain is self-tapping. self-tapping is a tapping touch is a thorough maintenance technique using a rhythmic touch. gentle massage helps to reduce the tension in the body and mind and increase feelings of prosperity and positive thoughts 15. based on preliminary study was conducted in smk “a” pedan klaten, girls have experienced dysmenorrhea pain during menstruation on 1-3 days of 200 students (59%). sixty point five percent feel annoyed at the time of learning and 56% cannot learn effectively. based on the above description, researchers are interested to know the difference between the use of yoga an d self-tapping on changes in the long pai n of primary dysmenorrhea. this is supported by the absence of a study comparing yoga and self-tapping interventions to address long pain of primary dysmenorrhea. indonesian journal of nursing practices 126 methods study was conducted by quasi experiment with nonequivalent pretestposttest control group design, by dividing the respondents into experimental groups (smk “a” pedan klaten) and control groups (smk “b” klaten). in the experimental group given yoga intervention and control group given self-tapping intervention. pain measured by numerical rating scale (nrs) with validity value r>0,86 and reliability based on value of test-rete st r=0,96 and r=0,95. this research was conducted on 22 november 2016 until 27 february 2017, with total population of 641 students aged 14-18 years, with criteria inclusion have got menstruation, experiencing primary dysmenorrhea, menstrual cycle regularly in the last 2 months, coming from the javanese tribe and willing to be a respondent. while the criteria for the exclusion are consuming drugs or drink pain relievers, consuming alcohol , body time index <18.5, experiencing anxiety with score ≥ 55 and performing at least 2 times of the week (including yoga, classical ballet, and athletics). the number of samples in this study was calculated using the formula lemeshow, et al (1997), the results obtained sample of 45 people, to anticipate the drop out rate, a 10% of the total sample was added. the samples in this study were 50 people i n each group (experimental and contro l ) . a total sample of 100 people taken using simple random sampling technique by way of drawing. fifty respondents in the experimental gro u p who participated in the study, only 47 respondents completed the study according to the study protocol, 3 respondents drop out. while in the control group of 50 respondents who participated in the study, only 41 respondents completed the study according to the study protocol, 9 respondents drop out. this research was conducted after obtaining the approval or feasibility of ethical research from the ethics commission in faculty of medicine, gadjah mada university with referen ce number: ke/fk/1261/ec/2016 november 21, 2016. the researcher was assisted by two research assistants, who had previously done a perception equation on how to disseminate and guided the screening questionnaire, state trait anxiety inventory form y (stai-y), numerical rating scale (nrs). the researcher also uses 1 person facilitator and 6 facilitator assistants, research facilitator is yoga instructor from yoga first klaten certified studio, licensed yoga alliance and has experience of yoga teaching for more than 5 years. the yoga facilitator was assisted by three facilitators from the first yoga studio klaten. they were certified and have at least 2 years of yoga experience. as for self-tapping is taught by a research assistant who has been trained to teach self tappping movements. the self-tapping facilitato r will be assisted by 3 assistants who have previously performed apperception related to the procedure and research implementation. implementation of data collection begins with screening using questionnaires and measurements of height and weight to all prospective respondents who previously had been given explanation of the research. prospective respondents who fulfilled inclusion and exclusion criteria were vol. 1 no. 3 desember 2017 127 taken 100 people (each school 50 people). further explaining the research process and informing consent, and distributing nrs instruments (pretest) and explaining how to fill it. the collection of pretest data was d o n e by asking respondents to fill in nrs instruments every day during menstruation. the first pain intensity measurements were performed for up to 10 hours after the first day's menstruation, for subsequent measurements taken at the same time as the first day of measurement. nrs instrument filling is monitored by researchers and research assistants either directly or through social media such as whatsapp group (wa group), blackberry messenger group (bbm group) or short message service (sms ) . after menstruation is complete respondents are asked to collect back nrs instruments that have been filled to researchers or research assistant. subsequently given health education, the respondents were divided into tw o groups (experimental group and control group). experimental group was taught yoga and control group taught self tapping. the facilitator explains the general guidelines of yoga practice or self tapping, followed by demonstration of yoga or self-tapping procedures assisted by assistant facilitators followed by all responde nts. after the demonstration the respondents were divided into 4 smaller groups (consisting of 12-13 people), each group was guided by the facilitator's assistant until the respondent was able to intervene properly using the teach-back technique (re demonstration) and evaluated using the observation sheet in the form check list. furthermore, researchers will distribute nrs (posttest) instruments, monitorin g sheets and health education evaluatio n questionnaires after intervention. respondents were asked to complete nrs instruments and monitoring sheets daily as long as the respondent had menstruation. measuring the intensity of pain, blood pressure and heart pu l s e on the first day was performed maximum of 10 hours after the respondent intervened (yoga intervention was done for 30 minutes each session while self-tapping was done for 20 minutes each session). for the next measurement is done at the same time with the first day measurement time. researchers and research assistants monitor the implementation of nrs instrument intervention and completeness as well as monitoring sheets directly or indirectly through social media, as described previously. after the menstruation is complete th e respondent is asked to reassemble the nrs (posttest) instrument and the completed monitoring sheet completely. data analysis was performed using t-test for independen t sample, mann-whitney and wilcoxon test. results after analyzing data can be presented characteristics and homogeneity of respondents by age, age of menarche, body mass index (bmi), long periods and anxiety in table 1: indonesian journal of nursing practices 128 table 1. characteristics of research and homogeneity of experimental and control group in smk “a” pedan klaten and smk “b” klaten 2017. characteri s ti cs group p experi ment (n=50) control (n=50) mean ± sd mean ± sd age of res pondents (years ) 15,14±0,49 15,20±0,53 0,50 age of menarche (years ) 12,70±0,76 12,54±0,71 0,49 body mas s index (bmi) (kg / m2) 20,50±3,13 20,16±2,69 0,73 long mens truati on (day) 5,90±1,11 6,28±1,13 0,69 anxi ety stai-y1 anxi ety stai-y2 44,28±7,60 44,24±6,01 43,82±6,24 42,78±7,08 0,24 0,20 *p val ue was obtai ned bas ed on t-tes t for i ndependent s ampl e table 1 shows the respondents in this study homogeneous with the overall p value greater than 0,05 based on the homogeneity test result using t-test f o r independent sample. homogeneity test on long pain between experimental group and control group, as shown in table 2: table 2. description of homogeneity of data on long pain prior to intervention of experimental and control group in smk “a” pedan klaten and smk “b” klaten 2017. vari abl e experi ment control p* n medi an (mi n-max) mean ± sd n medi an (mi n-max) mean ± sd pai n intens i ty 50 3,00 (1-8) 3,54±1,681 50 3,00 (1-7) 3,32±1,301 0,574 * p val ues were obtai ned bas ed on the mann-whi tney tes t based on homogeneity test results in table 2 above shows that the characteristics of long pain before the intervention between the experimental and control groups is homogeneous, with a value of p≥0.05. the change of long pain before and after intervention in experiment and control group, as shown in table 3 below: table 3. an illustration of the long pain of experimental and control group before and after intervention in smk “a” pedan klaten and smk “b” klaten 2017. group pretest posttest mean di fference p* n medi an (mi n-max) mean ± sd n medi an (mi n-max) mean ± sd experi ment control 47 41 3,00 (1-8) 3,00 (1-6) 3,53±1,718 3,12±1,166 47 41 2,00 (0-6) 3,00 (0-5) 2,04±1,574 2,66±1,109 1,49 0,46 0,000 0,120 * p values are obtained based on the wilcoxon test in table 3 above shows that statisticall y there was a significant decrease in l o n g pain before and after intervention o n l y in the experimental groups, whereas the control group did not have significant decrease in long pain. clinically, the mean difference of decrease in long pain before and after vol. 1 no. 3 desember 2017 129 intervention of the experimental gro u p was higher than control group. discussion characteristic of respondent included age, age of menarche, body mass index (bmi), menstrual period and anxiety of respondents. according to potter and perry (2006) several factors that potentially affected pain such as age. average age of respondents on treatment group was 15,4 years old an d 15,2 years old on control group16. according to banikarim et al (2015) prevalence of primary dysmenorrhea i n girls adolescent ranged from 60-93%17. primary dysmenorrhea is common in women less than 25 years old18, 19. another risk factor for dysmenorrhea i s age of menarche. this is the age at which a woman receives the first menstruation that occurs in the age range 10-16 years or at puberty before entering the reproductive period8. the mean age of menarche in this study was more than 12 years. according to kolhe (2016), age of menarche affects primary dysmenorrhea, this opinion is in line with perry et al (2014) which states that severe dysmenorrhea is always associated with early menarche 18, 19. women who have menarche less than 12 years have a risk to experience pain during menstruation 20, 21. body mass index (bmi) is a measure that compares the weight (in kilograms) with the square of the height (in meters). body mass index between th e experimental group and control group in this study was homogeneous (p = 0.73), with mean ≥18.5. according to osayande et al (2014) a low body mass index is a risk factor for dysmenorrhea21. according to perry et al (2014) the average duration of menstrual blood discharge is 5 days, with a range of 3-6 days19. the mean duration of menstruation between the experimental and control groups in th i s study was 5.9 and 6.28 days. according to acog (2015), most women experience menstruation for 2-7 days. in this study, the instant anxiety score (state anxiety) as measured by sta i y1 instrument between the experimental group and the homogeneous control group, as well as the trait anxiety measured using the staiy-2 instrumen t having a homogeneous score. respondents in this study did not experience the momentary anxiety an d basic anxiety. anxiety has a reciprocal relationship with pain perception. when anxiety increases then the perception of pain will increase, in other hand if the perception of pain increases then anxiety will increase. people who have stable emotions will more easily tolerate pain than people who have unstable emotions. base d o n the results of research dhayita (2011) there is a significant relationship between emotional stability before menstruation with the emergence of dysmenorrhea. wijayanti (2008) examined the relationship of stress with the incidence of primary dysmenorrhea, the results statistically there is a significant relationship between stress with the incidence of primary dysmenorrhea in adolescents10. according to kolhe (2016) psychosocial factors play a role in the perception and severity of pain. 1. differences long pain of primary dysmenorrhea before and after yoga. the results of this study were statistically significant differences in the long pain of primary dysmenorrhea indonesian journal of nursing practices 130 before and after yoga (table 3). the results of this study confirm previous research conducted by rakhshaee (2011). there was a significant difference in intensity and duration of pain before and after intervention in the yoga group 24. siahaan (2011) also conducted a study that aims to determine the influence of yoga on dysmenorrhea level, the result is influence of yoga on dysmenorrhea25. based on research rani et al (2011) yoga nidra can also reduce the intensity of pain, gastrointestinal symptoms. 2. differences long pain of primary dysmenorrhea before and after sel f tapping. in this study the control group was given self tapping intervention, the result statistically not significant difference of long pain before and afte r self tapping (table 3). this study are statistically inconsistent with research conducted by akbar (2015), the result there is a significant difference of pain intensity primary dysmenorrhea before and after self tapping27. 3. differences long pain of primary dysmenorrhea experimental group who performed yoga with a contro l group that performed self tapping. the results of this study statistically showed decrease in long pain before and after intervention only in yoga intervention. the mean difference of decrease in long pain before and after yoga intervention in the experimental group were higher than the control group (table 3). so the conclusions of interpretation of long pain in the experimental group were statistically and clinically compatible, whereas in the control group were statistically an d clinically incompatible. the results of this study confirm previous research conducted by sakuma et al (2012), the results were statistically significant differences in pain intensity before and after intervention between yoga groups compared with the control group. while the clinical average decrease in intensity of menstrual pain group gi v e n by intervention home-based simple yoga is higher than the control group14. manurung (2015) also conducted a study on the effectiveness of yoga on dysmenorrhea pain in adolescents, the results were statistically significant differences in pain intensity before an d after intervention in the experimental group taught yoga compared to the untreated control group28. conclusion yoga become more effective intervention on reduction long pain of primary dysmenorrhea compared to self tapping. acknowledgements the authors thank to dr. heny suseani pangastuti, s.kp, m.kes and widyawati , s.kp, m.kes.,phd, who has provided much input in this research. ministry o f ayurveda, yoga and naturopathy, unani, siddha and homoeopathy (ayush) india and shindu pujiastuti who has given permission to use the common yoga protocol. nana from yoga first klaten as well as research teams and assistants (ratna, erlita and oktavia) which has helped in the research process, as well as students o f class x smk “a” pedan klaten and smk “b” klaten who have participated in this research. vol. 1 no. 3 desember 2017 131 references 1. zhu x, proctor m, bensoussan a, wu e and smith ca. 2008. chinese herbal medicine for primary dysmenorrhoea (review). the cochrane library, issue 2. 2. fedorowicz z, nasser m, jagannath va, beaman jh, ejaz k and van zuuren ej. 2012. beta2 adrenoceptor agonists for dysmenorrhoea (review). the cochrane library.issue 5. 3. sugumar r, krishnaiah, charnnavera gs and mruthyunjaya s. 2013.comparison of the pattern, efficacy, and tolerability of self medicated drugs in primary dysmenorrhea: a questionnaire based survey. indian j pharmacol; 45(2): 180–183 4. rodrigues ac, gala s, neves a, pinto c, meirelles c, frutuoso c and vitor me. 2011. dismenorreia em adolescentes e jovens adul tas prevalencia, factores associado s e limitacoes na vida diaria. acta med port; 24 (s2): 383-392. 5. azurah agn, sanci l, moore e & gover s, 2013. the quality of life of adolescents with menstrual problem.j pediatr adolesc gynecol; 26; 102-108. 6. dmitrovic r, kunselman ar and legro rs. 2013. sildenafil citrate in the treatment of pain in primary dysmenorrhea a randomized controlled trial. human reproduction, vol.28, no.11 pp. 2958–2965 7. azima s, bakhshayesh h, kaviani m, abbasnia k and sayadi m. 2015.comparison of the effect of massage therapy and isometric exercises on primary dysmenorrhea a randomized controlled clinical trial. j pediatr adolesc gynecol; xxx; 1-6. 8. proverawati a dan misaroh s. 2009.menarche menstruasi pertama penuh makna.yogyakarta: nuha medika 9. mardhiyah u, rosidi a dan purwanti ia. 2015. pola dysmenorrhea primer pada remaja di man 1 semarang. the 2nd university reasearch coloquium. 10. wijayanti e. 2008. hubungan stres dengan kejadian dysmenorrhea primer pada remaja di sma muhammadiyah 1 yogyakarta.skripsi. universitas gadjah mada. 11. johnson 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2011. effect of three yoga poses (cobra, cat and fish poses) in women with primary dysmenorrhea: a randomized clinical trial. j pediatr adolesc gynecol; 24; 192 – 196 25. siahaan k, erniati dan maryati i. 2011. penurunan tingkat dismenore pada mahasiswi fakultas ilmu keperawatan unpad dengan menggunakan yoga.fik unpad. 26. rani k, tiwari sc, singh u, agraw al gg, and srivastava n. 2011. sixmonth trial of yoga nidra in menstrual disorder patients: effects on somatoform symptoms . ind psychiatry j; 20(2): 97-102. 27. akbar hw. 2015. pengaruh self tapping terhadap penurunan level nyeri dysmenorrhea primer pada mahasiswi program studi ilmu keperawatan fakultas kedokteran universitas gadjah mada. skripsi. universitas gadjah mada. 28. manurung mf, utami s dan rahmalia s. 2015. efektifitas yoga terhadap nyeri dismenore pada remaja.jom vol. 2 no. 2 http://www.uptodate.com/ vol. 1 no. 3 desember 2017 115 indonesian journal of nursing practices cahya indra lukmana1, falasifah ani yuniarti1 1 universitas muhammadiyah yogyakarta email: aniyulhaq@gmail.com gambaran tingkat pengetahuan kesehatan reproduksi remaja pada siswa smp di yogyakarta info artikel masuk revisi diterima doi number : : 6 september 2017 : 21 november 2017 : 30 november 2017 : 10.18196/ijnp.1369 abstrak latar belakang : juml ah remaj a di indones i a s angat besar, maka remaj a s ebagai penerus bangs a perl u di s i apkan menj adi manus i a yang s ehat j as mani, rohani, dan mental s erta s pi ri tual. remaj a merupakan mas a peral i han dari mas a anak-anak menuj u mas a dewas a dengan masa trans i s i yang uni k dan di tandai ol eh berbagai perubahan s ecara fi s ik, emos i dan ps i ki s. tujuan : penel i ti an i ni bertuj uan untuk mengetahui gambaran ti ngkat pengetahuan s i s wa tentang kes ehatan reproduks i di s al ah s atu smp s was ta di yogyakarta metode penelitian : penel i ti an i ni menggunakan j enis penel i ti an non eks peri mental yang bers i fat des kri ptif dengan pendekatan cross sectional. penel i ti an ini di l akukan di s al ah s atu smp swas ta berbas i s islam yogyakarta, dengan j uml ah res ponden 90 s i s wa . al at ukur yang di gunakan a dal ah kui s i oner dengan menggunakan s kal a ordi nal. tekni k pengambi l an s ampel menggunakan simple random sampling. hasil : penel i ti an i ni menunj ukkan bahwa pengetahuan s i s wa dalam kategori baik ada 15 orang (16,7%), cukup ada 71 orang (78,9%), dan kurang ada 4 orang (4,4%). kesimpulan : pada penel i ti an i ni rata -rata ti ngkat pengetahuan s i s wa tentang kes ehatan reproduks i remaja adal ah cukup. hal i ni di pengaruhi ol eh beberapa faktor s al ah s atunya adalah s umber i nformas i yang di dapat oleh s i s wa. kata kunci : remaj a, pengetahuan, kes ehatan reproduks i abstract background: the number of adolescents in indonesia is very large, so adolescence as the successor of the nation needs to be prepared to be a healthy human body, spiritual, and mental and spiritual. adolescence is a transitional period from childhood to adulthood with a unique transition period and is characterized by physical, emotional and psychological changes. mailto:aniyulhaq@gmail.com indonesian journal of nursing practices 116 purpose: this study aimed to determine the knowledge on adolescent reproductive health among students in smp muhammadiyah 3 yogyakarta method : this a descriptive study included 90 students. an instrument for the data is questionnaire and use ordinal scala. results: it was found that adolescent’s knowledge level was good 15 children (16.7%), enough 71 children (78.9%), and poor 4 children (4.4%) conclusion: in this study the majority of students have enough knowledge on adolescent reproductive. this is influenced by several factors, including one of which is the source of information that can be accessed by students. suggestion: for nurse and school should work together to do counseling about adolescent reproductive health which also involve parent to increase student’s knowledge. keywords: adolescent, knowledge, reproductive health pendahuluan jumlah remaja dengan rentang usia 1024 tahun pada tahun 2010 adalah 63.421.563 jiwa atau 26,7% dari total jumlah penduduk indonesia. mengetahui jumlah remaja yang sangat besar, maka remaja sebagai generasi penerus bangsa perlu dipersiapkan menjadi manusia yang sehat secara fisik, mental dan spiritual. remaja merupakan masa peralihan dari anak-anak menuju dewasa dengan masa transisi yang unik, ditandai dengan berbagai perubahan fisik dan psikis. berbagai perubahan yang terjadi pada remaja dapat menimbulkan permasalahan yang dapat mengganggu perkembangan mereka di masa depan (bkkbn, 2012). hasil analisis direktorat jendral kesehatan masyarakat depkes dan kesejahteraan sosial ri (2010), menunjukkan bahwa kondisi kesehatan reproduksi di indonesia dewasa ini belum seperti yang diharapkan, bila dibandingkan dengan keadaan di negara-negara asean lainnya. indonesia masih tertinggal jauh dalam aspek kesehatan reproduksi termasuk kesehatan reproduksi remaja (bkkbn, 2012). permasalahan utama yang dialami oleh remaja indonesia yaitu ketidaktahuan terhadap tindakan yang harus dilakukan sehubungan dengan perkembangan yang sedang dialami, khususnya masalah kesehatan reproduksi remaja. hal tersebut ditunjukkan dengan masih rendahnya pengetahuan remaja tentang kesehatan reproduksi remaja. remaja perempuan yang mengetahui tentang masa subur sebanyak 29% dan remaja laki-laki sebanyak 32,2%. remaja perempuan dan remaja laki-laki yang mengetahui resiko kehamilan jika melakukan hubungan seksual untuk pertama kali masing-masing baru mencapai 49,5% dan 45,5 %. perubahan emosional selama masa remaja dan pubertas sama dramatisnya dengan perubahan fisik. remaja banyak menghadapi proses pengambilan keputusan oleh karena itu mereka memerlukan informasi yang akurat tentang sistem reproduksi remaja, misalnya tentang perubahan tubuh, aktifitas seksual, respon emosi terhadap vol. 1 no. 3 desember 2017 117 hubungan intim/seksual, penyakit menular seksual (pms), kontrasepsi, dan kehamilan (potter & perry, 2009). masa remaja usia 10-19 tahun merupakan masa yang khusus dan penting. masa remaja diwarnai oleh pertumbuhan, perubahan, munculnya berbagai kesempatan, dan sering sekali menghadapi resiko kesehatan reproduksi (putro, 2009). keterbatasan akses informasi bagi remaja indonesia mengenai kesehatan reproduksi terjadi karena masyarakat beranggapan bahwa seksualitas adalah hal yang tabu. misalnya sebagian besar orang tua di indonesia masih merasa canggung untuk membicarakan masalah kesehatan reproduksi dan seksualitas pada anaknya yang mulai tumbuh menjadi remaja, dan anak remaja cenderung merasa malu untuk bertanya dan bercerita tentang apa yang terjadi kepada orangtuanya. sehingga sedikit remaja yang memperoleh informasi mengenai kesehatan reproduksi terutama pendidikan seks dari orangtuanya (bkkbn, 2012). sebuah penelitian menunjukkan bahwa faktor yang berpengaruh terhadap perkembangan kesehatan reproduksi remaja adalah orang tua ( 64%) dan teman (68,4%) (utama, 2013). hal ini menjadi salah satu ciri khas remaja, dimana remaja cenderung tertutup pada orang dewasa atau orang tua namun lebih dekat dan terbuka terhadap kelompok teman sebaya. keterbatasan akses informasi terutama dari orang tua membuat remaja mencari akses dan mengeksplorasi sendiri. remaja sering kali menggunakan media internet, televisi, majalah dan bentuk media massa lainnya yang dijadikan sebagai sumber informasi, untuk memenuhi rasa keingintahuan remaja tentang reproduksi atau seksualitas. oleh karena itu remaja memerlukan informasi tentang kesehatan reproduksi dengan benar sehingga diharapkan remaja akan memiliki sikap dan tingkah laku yang bertanggung jawab mengenai organ dan proses reproduksinya sendiri (bkkbn, 2008). pada fase pubertas terjadi perubahan fisik sehingga pada akhirnya seorang anak akan memiliki kemampuan bereproduksi. terdapat lima perubahan khusus yang terjadi pada pubertas, yaitu pertambahan tinggi badan yang cepat, perkembangan seks sekunder, perkembangan organ-organ reproduksi, perubahan komposisi tubuh serta perubahan sistem sirkulasi dan sistem respirasi yang berhubungan dengan kekuatan dan stamina tubuh (jose, 2010). masa remaja adalah waktu yang kritis dalam perkembangan seksualitas. seksualitas mencakup pemikiran, perasaan, dan perilaku yang terkait dengan identitas seksual remaja. ketertarikan terhadap lawan jenis terjadi selama masa remaja. beberapa alasan yang dinyatakan untuk pengembangan ketertarikan ini adalah perkembangan fisik, dan perubahan tubuh, tekanan dari teman sebaya, dan rasa ingin tahu / penasaran (kyle& carman, 2014) berdasarkan hasil dari studi pendahuluan yang telah dilakukan, siswa mengetahui informasi tentang kesehatan reproduksi hanya dari guru ipa. menurut paparan dari kepala sekolah, belum pernah diadakan penyuluhan atau pendidikan kesehatan tentang kesehatan reproduksi remaja di lingkungan sekolah. wawancara singkat dilakukan terhadap 3 siswa, hasilnya mereka belum mengetahui tentang kesehatan reproduksi. siswa juga indonesian journal of nursing practices 118 merasa malu bila membicarakan tentang kesehatan reproduksi. berdasarkan uraian latar belakang diatas, dapat diambil rumusan masalah yaitu “bagaimana gambaran tingkat pengetahuan tentang kesehatan reproduksi remaja pada siswa smp di yogyakarta?. metode penelitian ini adalah penelitian deskriptif kuantitatif dengan pendekatan cross sectional yaitu untuk melihat gambaran tingkat pengetahuan (nursalam, 2013). populasi dalam penelitian ini 450 siswa smp, di suatu smp swasta di yogyakarta. pengambilan sampel menggunakan tehnik consecutive sampling dengan jumlah 90 siswa sebagai responden. sampel harus memenuhi kriteria: bersedia menjadi responden dan mengisi kuesioner dengan lengkap. penelitian dilakukan di sekolah pada jam pelajaran olah raga dan kesehatan, pengambilan data dilakukan di beberapa kelas yang telah disetujui oleh guru. instrument yang digunakan adalah kuesioner yang telah diadopsi dari winarni (2003) dalam utama (2013), dengan nilai dari uji validitas (p= 0,0333) dan reliabilitas (r = 0.8385). pertanyaan kuisioner penelitian meliputi empat aspek yaitu; aspek pertumbuhan dan perkembangan; anatomi dan fisiologi alat reproduksi; kehilangan dan masa subur pada wanita, serta aspek penyakit menular seksual. siswa harus mengisi kuesioner secara mandiri. kuesioner yang dikerjakan secara kolektif tidak dimasukkan dalam pengolahan data. data yang diperoleh diolah dengan program spss dengan distribusi frekuensi. hasil hasil penelitian yang ditampilkan meliputi data demograf dan tingkat pengetahuan terkait aspek kesehatan reproduksi. tabel 1 menampilkan karakteristik demografi pelajar. pada karakteristik umur, rata-rata umur responden adalah 13 tahun yaitu 44 anak (48,9%). pada karakteristik kelas menunjukkan 49 anak (54,6%) kelas viii. sumber informasi yang didapat oleh responden, terbanyak adalah sumber informasi dari guru yaitu 72 anak (80%). pada tabel 2, data menunjukkan secara umum responden memiliki pengetahuan cukup yaitu sebanyak 71 anak (78,9%). pada karakteristik kelas yang memiliki kategori pengetahuan cukup yaitu kelas viii sebanyak 41 anak (45,6%). tingkat pengetahuan berdasarkan jenis kelamin yang memiliki pengetahuan dalam kategori cukup yaitu laki-laki sebanyak 49 anak (54,4%). pada tabel 3 diketahui bahwa pengetahuan siswa berdasarkan pada aspek-aspek tentang pengetahuan kesehatan reproduksi remaja, pengetahuan remaja dalam kategori baik yaitu pada aspek pertumbuhan dan perkembangan sebanyak 52 responden (57,8%). untuk aspek penyakit menular seksual, hiv/aids kebanyakan responden memiliki pengetahuan yang kurang yaitu sebanyak 54 responden (60%). vol. 1 no. 3 desember 2017 119 tabel 1. gambaran data demografi responden tingkat pengetahuan remaja tentang kesehatan reproduksi pada siswa smp di yogyakarta (n=90) data demografi frekuens i (f) pros entas e % jeni s kel ami n laki -l aki perempuan umur 11 12 13 14 16 kel as vii viii sumber informas i tel evi s i radi o internet vcd / fi l m maj al ah buku petugas kes ehatan orang tua guru teman 58 32 2 25 44 18 1 41 49 42 8 41 13 22 53 46 61 72 47 64,4% 35,6% 2,2% 27,8% 48,9% 20% 1,1% 45,6% 54,4% 53,3% 8,9% 45,6% 14,4% 24,4% 58,9% 51,1% 67,8% 80% 47,8% sumber : data primer, 2017 tabel 2. gambaran karakteristik responden dan tingkat pengetahuan tentang kesehatan reproduksi remaja pada siswa smp di yogyakarta (n=90) karakteri s ti k res ponden ti ngkat pengetahuan bai k % cukup % kurang % sel uruh res ponden kel as vii viii jeni s kel ami n laki -l aki perempuan 15 (16,7%) 11 (12,3%) 4 (4,4%) 7 (7,8%) 8 (8,9%) 71 (78,9%) 30 (33,3%) 41 (45,6%) 49 (54,4%) 22 (24,4%) 4 (4,4%) 0 (0%) 4 (4,4%) 2 (2,2%) 2 (2,2%) sumber : data primer, 2017 indonesian journal of nursing practices 120 tabel 3. gambaran tingkat pengetahuan berdasarkan aspek-aspek tentang kesehatan reproduksi remaja pada siswa smp di yogyakarta (n=90) as pekas pek kes ehatan reproduks i ti ngkat pengetahuan bai k (%) cukup (%) kurang (%) pertumbuhan dan perkembangan anatomi dan fi s i ologi al at reproduks i kehami l an dan mas a subur pada wani ta penyaki t menul ar seks ual , hiv / aids 52 (57,8%) 38 (42,2%) 19 (21,1%) 13 (14,4%) 35 (38,9%) 46 (51,1%) 37 (41,1%) 23 (25,6%) 3 (3,3%) 6 (6,7%) 34 (37,8%) 54 (60%) sumber : data pri mer, 2017 pembahasan pengetahuan merupakan hasi l tahu dan terjadi setelah seseorang melakukan penginderaan terhadap suatu objek tertentu. sebagian besar pengetahuan manusia diperoleh melalui mata dan telinga (notoadmodjo, 2010). berdasarkan hasil penelitian, secara umum tingkat pengetahuan tentang kesehatan reproduksi remaja pada siswa smp di yogyakarta adalah cukup. menurut peneliti, hal ini dikarenakan informasi yang didapatkan siswa tentang kesehatan reproduksi remaja masih belum maksimal dan responden memiliki daya serap pengetahuan yang berbeda-beda. sebuah penelitian kualitatif yang dilakukan talib et all (2011), menunjukkan bahwa guru biologi adalah sumber informasi siswa yang mengajarkan tentang proses kehamilan, pencegahan kehamilan, dan penyakit yang terjadi akibat hubungan seks pranikah. selain itu guru juga menjelaskan tentang menstruasi wanita dan masa subur wanita. menurut mubarak (2007 terdapat banyak faktor yang mempengaruhi pengetahuan yaitu sumber informasi, pengalaman, minat, pekerjaan, umur, dan pendidikan. pengetahuan pada penelitian ini terbagi menjadi empat aspek yaitu dari aspek pertumbuhan dan perkembangan, aspek anatomi dan fisiologi alat reproduksi, aspek kehamilan dan masa subur pada wanita, dan aspek penyakit menular seksual, hiv/aids. pada aspek pertumbuhan dan perkembangan siswa memliki pengetahuan yang baik yaitu 57,8%, peneliti berpendapat hasil ini diperoleh karena siswa sudah mengalaminya dan telah mendapatkan informasi yaitu guru dan buku. hal ini didukung oleh data bahwa sebagian besar siswa mendapatkan sumber informasi dari guru (80%) dan lebih dari setengah responden memperoleh informasi dari buku (58,9%). hal ini sejalan dengan hasil penelitian (freehary, 2009 dalam mukhsinah, 2014) yang dilakukan pada siswa smp di semarang, menunjukkan hasil sebanyak 70,92% remaja mengetahui bahwa seorang laki-laki dikatakan matang secara seksual bila sudah mengalami mimpi basah, dan pada perempuan 80,4% remaja tahu bahwa ciri kematangan seksual perempuan ditandai dengan terjadinya menstruasi. pada aspek anatomi dan fisiologi alat reproduksi, responden yang memiliki pengetahuan yang cukup sebanyak 46%. vol. 1 no. 3 desember 2017 121 hasil ini sesuai dengan penelitian yang dilakukan misirah (2011) dalam mukhsinah (2014) yang menyebutkan bahwa tingkat pengetahuan siswa tentang perubahan fisiologis masa pubertas tergolong cukup yaitu 64,1%. hasil penelitian lain (winarni, 2012 dalam mukhsinah, 2014), menunjukkan bahwa tingkat pengetahuan siswa tentang perkembangan organ seks sekunder pada masa pubertas tergolong cukup yaitu 57,5%. siswa yang memiliki pengetahuan kurang tentang penyakit menular seksual, hiv/aids, sebanyak 60%. hal ini disebabkan karena pada kelas vii dan viii belum mendapatkan materi pelajaran tentang penyakit menular seksual dan hiv/aids. mengacu pada kurikulum smp, khususnya pada pelajaran biologi, materi tentang penyakit menular seksual diberikan pada siswa kelas ix. topiktopik yaang diajarkan kepada siswa kelas ix meliputi sistem reproduksi pada pria, sistem reproduksi pada wanita, perkembangan embrio, hormon reproduksi, dan penyakit menular seksual (pms). pada siswa kelas vii dan viii informasi tentang sistem reproduksi yang didapatkan siswa sama dengan materi yang diberikan pada siswa kelas 6 sekolah dasar (sd), meliputi pertumbuhan dan perkembangan manusia, perubahan fisik tubuh manusia pada masa pubertas, dan perkembangbiakan manusia. menurut peneliti siswa juga kurang memanfaatkan media sebagai sumber informasi, baik media cetak maupun media elektronik seperti yang tercantum pada tabel 3. hasil penelitian menunjukkan bahwa tingkat pengetahuan siswa tentang kesehatan reproduksi remaja kelas vii lebih baik dari pada kelas viii, menurut peneliti tingkatan atau kelas tidak mempengaruhi pengetahuan tetapi dipengaruhi oleh sumber informasi yang didapatkan masing-masing siswa dan penyerapan pengetahuan yang diterima oleh masing-masing siswa. selain sumber informasi masih banyak faktor yang mempengaruhi pengetahuan, sesuai pendapat notoadmojo (2007 )dalam utama (2013) yang menyebutkan faktor-faktor yang dapat mempengaruhi pengetahuan yaitu : sosial ekonomi, kultur budaya, agama, pendidikan, dan pengalaman pada tabel 6 menunjukkan bahwa siswa perempuan yang memiliki pengetahuan baik sejumlah 8 orang (8,9%), sedangkan pada siswa laki-laki yang memiliki pengetahuan baik sebanyak 7 orang (7,8%). artinya dalam penelitian ini siswa perempuan memiliki pengetahuan yang lebih baik dibandingkan siswa lakilaki, dikarenakan kebiasaan anak perempuan yang lebih rajin dalam mencari informasi dibandingkan dengan anak laki-laki (notoadmodjo, 2007). hasil penelitian ini sejalan dengan hasil penelitian irawan (2016) dan mukhsinah (2014), yang menunjukkan bahwa perempuan memiliki pengetahuan yang lebih baik dari laki-laki. hasil penelitian ini tidak sejalan dengan hasil penelitian yang dilakukan oleh (hadiana, 2004 dalam dewi, 2012) bahwa perempuan memiliki pengetahuan tentang perkembangan seksualitas lebih rendah dibanding lakilaki. perempuan lebih mudah merasa malu sehingga cenderung membatasi diri untuk memperoleh informasi terkait perkembangan seksualitas. kesimpulan berdasarkan hasil penelitian diatas bahwa secara umum siswa smp di indonesian journal of nursing practices 122 yogyakarta memiliki pengetahuan yang cukup tentang kesehatan reproduksi, sedangkan hasil berdasarkan karakteristik kelas diketahui bahwa siswa kelas vii memiliki pengetahuan yang lebih baik dibandingkan dengan sisawa kelas viii, dan dari hasil berdasarkan karakteristik jenis kelamin diketahui bahwa siswa perempuan memiliki pengetahuan yang lebih baik daripada siswa laki-laki. referensi arikuto, s. (2010). prosedur penelitian suatu pendekatan praktik. jakarta : rineka cipta. badan kependudukan dan keluarga berencana nasional. (2008). kurikulum dan model pelatihan pengelolaan pusat informasi dan konseling kesehatan reproduksi remaja (pik-krr). jakarta : badan koordinasi keluarga berencana nasional badan kependudukan dan keluarga berencana nasional.(2012). survei demografi dan kesehatan indonesia. jakarta : kementrian kesehatan dewi, n.a.k. (2012). gambaran tingkat pengetahuan tentang perkembangan seksualitas pada remaja awal smpit anugerah insani bogor. kti. universitas indonesia. irawan, e. (2016). gambaran pengetahuan remaja tentang kesehatan reproduksi di desa kertajaya. jurnal ilmu keperawatan, vol. iv, no. 1. diakses 20 agustus 2017 jose, r. l. (2010). perkembagan remaja. jurnal sari pediatri.volume 12 nomor 1. hal. 21-29. kementerian kesehatan ri. (2013). laporan situasi perkembangan hiv & aids di indonesia. jakarta : kkri kyle, t & carman, s. alih bahasa yulianti d. (2014). buku ajar keperawatan pediatri. jakarta : egc. mahfudli.(2009). keperawatan kesehatan komunitas teori dan praktek dalam keperawatan. jakarta : salemba medika. mubarak et all. (2007). buku ajar ilmu komunitas 2, teori dan aplikasi dalam praktek dengan asuhan keperawatan komunitas, keluarga, dan gerontik. jakarta : cv agung seto mukhsinah, s.m. (2014). gambaran tingkat pengetahuan seksual santri kelas viii madrasah tsanawiyah persatuan islam 69 matraman. kti. uin syarif hidayatullah jakarta notoatmodjo, s. (2010). ilmu perilaku kesehatan. jakarta : rineka cipta. notoatmodjo, s. (2011). kesehatan masyarakat ilmu & seni. jakarta : rineka cipta nursalam. (2013). metodologi penelitian ilmu keperawatan. jakarta : salemba medika. nursalam.(2008). konsep dan penerapan metodologi penelitian ilmu keperawatan. jakarta : salemba medika omobuwa, o., et all. (2012). knowledge and perception of reproductive health servicec among in-school adolescents in lle-lfe, osun state, nigeria. journal of medicine and medical science. vol 3 (7) pp. 481-488. available online http://www.interestjournals.org /jmms. http://www.interestjournals.org/jmms http://www.interestjournals.org/jmms vol. 1 no. 3 desember 2017 123 potter & perry. (2009). fundamental keperawatan (edisi 7). (adrina ferderika nggie dan marina albar, penerjemah). jakarta : salemba medika. pusat studi kependudukan dan kebijakan universitas gajah mada. (2010). keluarga berencana dan kesehatan reproduksi. yogyakarta : pustaka pelajar. puspita, s. p. m et all. (2012). pengetahuan, sikap, peran orang tua perilaku seks remaja siswa smk negeri 4 jaeponto. putro, g. (2009). alternatif pengembangan model kesehatan reproduksi remaja.jurnal kesehatan reproduksi. volume 1 nomor 1. hal. 23-31. talib, j., mamat, m, ibrahim m, mohamad, z. (2012). analisis on sex education in school across malaysia. procediasocial and behavioral science 59. hal. 340348. triwibowo, c & pusphandani, m. e. (2015).pengantar dasar ilmu kesehatan masyarakat. yogyakarta : nuha medika utama, i.b. (2013). gambaran tingkat pengetahuan tentang kesehatan reproduksi pada siswa di sma n 1 imogiri. kti program studi ilmu keperawatan. universitas muhammadiyah yogyakarta. who. (2007). education and treatment in adolescent sexuality : the training of health professional. geneva : who who. (2011). the sexsual and reproductive health of younger adolescent. geneva : who 30 vol. 1 no. 1 desember 2016 wulan noviani1 1 program studi ilmu keperawatan, fakultas kedokteran dan ilmu kesehatan universitas muhammadiyah yogyakarta jl. lingkar selatan, kasihan, bantul yogyakarta 55183 email: wulan.n@umy.ac.id persepsi mahasiswa profesi ners tentang kode etik keperawatan indonesia di rumah sakit pendidikan universitas muhammadiyah yogyakarta abstrak kode etik keperawatan profesional merupakan dasar bagi praktik keperawatan. mahasiswa profesi ners merupakan calon tenaga profesional yang rentan mengalami dilema etik selama menjalani praktik profesi, oleh karena itu diperlukan pengetahuan tentang kode etik keperawatan. penelitian ini bertujuan untuk mengetahui persepsi mahasiswa profesi ners tentang kode etik keperawatan indonesia di rumah sakit pendidikan universitas muhammadiyah yogyakarta. jenis penelitian ini adalah deskriptif kualitatif. jumlah informan dalam penelitian ini sebanyak 26 orang. kriteria inklusi penelitian ini mahasiswa profesi ners yang sedang menjalani pendidikan profesi ners di rumah sakit pendidikan umy. pengumpulan data menggunakan focus group discussion (fgd) dan indepth interview. validitas data menggunakan keabsahan konstruk melalui proses triangulasi, keabsahan internal dan eksternal serta reliabilitas. metode analisa data dalam penelitian ini menggunakan content analysis. hasil penelitian menunjukan bahwa persepsi mahasiswa profesi ners dalam kategori baik. mereka menganggap bahwa kode etik sebagai pedoman perilaku baik perawat indonesia dalam memberikan asuhan keperawatan. fungsi kode etik sebagai pedoman, pengatur dan pembatas tindakan perawat. isi kode etik keperawatan indonesia mencakup hubungan perawat dengan pasien, praktik, masyarakat, teman sejawat dan profesi berlandaskan prinsip-prinsip etik. faktor yang menghambat pelaksanaan kode etik antara lain diri sendiri, lingkungan, role model, sarana dan prasarana. persepsi mahasiswa profesi ners tentang kode etik keperawatan indonesia dalam kategori baik. keywords: kode etik, mahasiswa keperawatan, persepsi, perawat indonesia, info artikel: masuk : 4 september 2016 revisi : 23 november 2016 diterima : 1 desember 2016 doi number : 10.18196/ijnp.1148 31 vol. 1 no. 1 desember 2016 abstract professional ethic code of nurses’ are the fundamental in nursing practice. nursing students profession as a professional candidate in health care system are commonly faced the dillema ethics during their clinical experiences. this study was conducted to explore the perception of nursing student profession about indonesian nurses’codes of ethics in academic hospital universitas muhammadiyah yogyakarta. the research was used desccriptive qualitative. the total informan this study was 26 people. the inclusion criterias were as a nursing student in nursing profession program in umy teaching hospitals. it was collected using fgd and indepth interview. the validity of data were used construct validity through triangulation process, internal and external validity, then realiability. data was analyzed using content analysis. the research result showed that perception of nursing student profession was good categorized. nursing student regarded that indonesian nurses’ ethics codes as a behaviour guidance for indonesian nurses’ to giving nursing care. the function of its are for guidance, regulator and controller for nursing intervention. the content of indonesian ethic codes for nurses included the relationship among nurses and patient, practice, society and profession based on ethical principles. all of the nursing student have been practicing indonesian ethic codes of nurses’ but it have several obstacles in their practice such as themselves, environment, role model, and facilities in hospitals. the perception of nursing student profession about indonesian ethic codes was good. keywords: ethic codes, indonesian nurses, perception, nursing student pendahuluan keperawatan profesional didefinisikan sebagai upaya promotif, preventif serta advokasi pada perawatan individu, keluarga dan komunitas (ana, 2010). perawat profesional memiliki tanggung jawab dan tanggung gugat dalam menyediakan pelayanan berkualitas tinggi bagi pasien, keluarga maupun masyarakat. perawat memiliki berbagai pengalaman etik dalam melakukan praktik profesional dan mereka seharusnya kenal dengan kode etik dan dapat membuat keputusan dengan baik (zahedi et al, 2013). perawat profesional rentan melakukan malpraktik atau kelalaian dalam bentuk pelayanan medis. berdasarkan laporan dari institute of medicine (iom) diperkirakan bahwa sekitar 44.000 – 98.000 pasien meninggal setiap tahunnya karena kesalahan medis, serta mengalami kerugian finansial sebesar us $17 – 29 milyar (dietz et al, 2010). menurut reising (2012), malpaktik yang dilakukan perawat profesional di amerika serikat antara lain gagal dalam berkomunikasi, mengikuti standar praktik, menggunakan peralatan, pendokumentasian data, melakukan pengkajian dan monitoring. data dari persatuan perawat nasional indonesia, pada tahun 2010-2015 diperkirakan terdapat sekitar 485 kasus malpraktik profesi keperawatan di indonesia yang terdiri dari 357 kasus malpraktik administratif, 82 kasus malpraktik sipil, dan 46 kasus malpraktik kriminal dengan unsur kelalaian. setiap perawat yang telah melaksanakan tugasnya secara kompeten dan penuh integritas seharusnya memiliki beberapa elemen kunci yang digunakan sebagai pedoman profesi seperti akreditasi dalam pendidikan, sistem lisensi dan sertifikasi, dan kode etik yang relevan (epstein & turner, 2015). kode etik profesional merupakan elemen dasar dari pengetahuan etik perawat yang berasal dari pendidikan etik. kode etik perawat merupakan hal yang sangat penting sehingga diperlukan pendekatan dalam mengajarkan etik keperawatan yang dimasukan dalam kurikulum pendidikan keperawatan (numminen et al, 2009). kode etik keperawatan sebagai bagian dari pengetahuan dasar etik berisi bagaimana perawat seharusnya berperilaku etik sebagai sebuah profesi, dan bagaimana seharusnya membuat keputusan saat mengalami hambatan dan mencegah terjadinya permasalahan etik serta berusaha memenuhi kewajiban profesional sesuai tujuan, nilai dan standar keperawatan (numminen et al, 2009; zahedi et al, 2013; shahriari et al, 2013). mahasiswa profesi ners merupakan calon perawat profesional di masa depan yang rentang menghadapi dilema etik selama menjalani praktik klinik di profesi. 32 mereka memerlukan pengetahuan tentang kode etik keperawatan indonesia untuk dijadikan pedoman dalam memberikan perawatan yang aman dan sesuai dengan etik legal saat ini. penelitian ini bertujuan untuk mengetahui persepsi mahasiswa profesi ners tentang kode etik keperawatan indonesia di rumah sakit pendidikan universitas muhammadiyah yogyakarta. metode jenis penelitian ini adalah deskriptif kualitatif. jumlah informan dalam penelitian ini sebanyak 26 orang. kriteria inklusi penelitian ini antara lain mahasiswa profesi ners yang menjalani pendidikan profesi ners di rumah sakit pendidikan umy. pengumpulan data menggunakan focus group discussion (fgd) dan indepth interview menggunakan pedoman fgd dan panduan wawancara semi terstruktur. validitas data menggunakan keabsahan konstruk melalui proses triangulasi dengan metode fgd dan wawancara mendalam. keabsahan internal mengacu pada gambaran keadaan yang sesungguhnya melalui proses analisis dan interpretasi yang tepat. keabsahan eksternal mengacu pada hasil penelitian yang dapat digeneralisasikan untuk kasus lain serta reliabilitas mengacu pencapaian hasil yang sama apabila dilakukan penelitian ulang yang sama sekali lagi. metode analisa data yang digunakan adalah content analysis. hasil penelitian 1. karakteristik informan karakteristik informan dalam penelitian ini adalah mahasiswa profesi ners umy. gambaran umum karakteristik informan berdasarkan umur, jenis kelamin dan budaya dapat dilihat pada tabel 1. berdasarkan tabel 1 dapat diketahui bahwa karakteristik informan menurut jenis kelamin, mayoritas perempuan sebanyak 18 orang (69,24%). sebagian besar reponden berusia 22 tahun sebanyak 20 orang (76,93%). mayoritas informan berasal dari budaya jawa sebanyak 13 orang (50%). tabel 1. karakteristik informan berdasarkan umur, jenis kelamin dan budaya (n=26) vol. 1 no. 1 januari 2017 31 etik selama menjalani praktik klinik di profesi. mereka memerlukan pengetahuan tentang kode etik keperawatan indonesia untuk dijadikan pedoman dalam memberikan perawatan yang aman dan sesuai dengan etik legal saat ini. penelitian ini bertujuan untuk mengetahui persepsi mahasiswa profesi ners tentang kode etik keperawatan indonesia di rumah sakit pendidikan universitas muhammadiyah yogyakarta. metode jenis penelitian ini adalah deskriptif kualitatif. jumlah informan dalam penelitian ini sebanyak 26 orang. kriteria inklusi penelitian ini antara lain mahasiswa profesi ners yang menjalani pendidikan profesi ners di rumah sakit pendidikan umy. pengumpulan data menggunakan focus group discussion (fgd) dan indepth interview menggunakan pedoman fgd dan panduan wawancara semi terstruktur. validitas data menggunakan keabsahan konstruk melalui proses triangulasi dengan metode fgd dan wawancara mendalam. keabsahan internal mengacu pada gambaran keadaan yang sesungguhnya melalui proses analisis dan interpretasi yang tepat. keabsahan eksternal mengacu pada hasil penelitian yang dapat digeneralisasikan untuk kasus lain serta reliabilitas mengacu pencapaian hasil yang sama apabila dilakukan penelitian ulang yang sama sekali lagi. metode analisa data yang digunakan adalah content analysis. hasil penelitian 1. karakteristik informan karakteristik informan dalam penelitian ini adalah mahasiswa profesi ners umy. gambaran umum karakteristik informan berdasarkan umur, jenis kelamin dan budaya dapat dilihat pada tabel 1. berdasarkan tabel 1 dapat diketahui bahwa karakteristik informan menurut jenis kelamin, mayoritas perempuan sebanyak 18 orang (69,24%). sebagian besar reponden berusia 22 tahun sebanyak 20 orang (76,93%). mayoritas informan berasal dari budaya jawa sebanyak 13 orang (50%). tabel 1. karakteristik informan berdasarkan umur, jenis kelamin dan budaya (n=26) no. karakteristik frekuensi persentase 1. jenis kelamin a. laki-laki b. perempuan 8 18 30,76% 69,24% 2. umur a. 21 tahun b. 22 tahun c. 23 tahun d. 25 tahun 3 20 2 1 11,53% 76,93% 7,70% 3,84% 3. budaya a. jawa b. sunda c. dayak d. melayu e. bima f. sasak g. minang h. banjar i. maluku 13 1 3 4 1 1 1 1 1 50% 3,84% 11,53% 15,38% 3,84% 3,84% 3,84% 3,84% 3,84% sumber: data primer, 2016 persepsi kode etik keperawatan indonesia isi pelaksanaan dan hambatan perawat dan klien perawat dan praktik perawat dan masyarakat perawat dan teman sejawat perawat dan profesi pengertian gambar 1. persepsi kode etik keperawatan indonesia sumber: data primer, 2016 vol. 1 no. 1 januari 2017 31 etik selama menjalani praktik klinik di profesi. mereka memerlukan pengetahuan tentang kode etik keperawatan indonesia untuk dijadikan pedoman dalam memberikan perawatan yang aman dan sesuai dengan etik legal saat ini. penelitian ini bertujuan untuk mengetahui persepsi mahasiswa profesi ners tentang kode etik keperawatan indonesia di rumah sakit pendidikan universitas muhammadiyah yogyakarta. metode jenis penelitian ini adalah deskriptif kualitatif. jumlah informan dalam penelitian ini sebanyak 26 orang. kriteria inklusi penelitian ini antara lain mahasiswa profesi ners yang menjalani pendidikan profesi ners di rumah sakit pendidikan umy. pengumpulan data menggunakan focus group discussion (fgd) dan indepth interview menggunakan pedoman fgd dan panduan wawancara semi terstruktur. validitas data menggunakan keabsahan konstruk melalui proses triangulasi dengan metode fgd dan wawancara mendalam. keabsahan internal mengacu pada gambaran keadaan yang sesungguhnya melalui proses analisis dan interpretasi yang tepat. keabsahan eksternal mengacu pada hasil penelitian yang dapat digeneralisasikan untuk kasus lain serta reliabilitas mengacu pencapaian hasil yang sama apabila dilakukan penelitian ulang yang sama sekali lagi. metode analisa data yang digunakan adalah content analysis. hasil penelitian 1. karakteristik informan karakteristik informan dalam penelitian ini adalah mahasiswa profesi ners umy. gambaran umum karakteristik informan berdasarkan umur, jenis kelamin dan budaya dapat dilihat pada tabel 1. berdasarkan tabel 1 dapat diketahui bahwa karakteristik informan menurut jenis kelamin, mayoritas perempuan sebanyak 18 orang (69,24%). sebagian besar reponden berusia 22 tahun sebanyak 20 orang (76,93%). mayoritas informan berasal dari budaya jawa sebanyak 13 orang (50%). tabel 1. karakteristik informan berdasarkan umur, jenis kelamin dan budaya (n=26) no. karakteristik frekuensi persentase 1. jenis kelamin a. laki-laki b. perempuan 8 18 30,76% 69,24% 2. umur a. 21 tahun b. 22 tahun c. 23 tahun d. 25 tahun 3 20 2 1 11,53% 76,93% 7,70% 3,84% 3. budaya a. jawa b. sunda c. dayak d. melayu e. bima f. sasak g. minang h. banjar i. maluku 13 1 3 4 1 1 1 1 1 50% 3,84% 11,53% 15,38% 3,84% 3,84% 3,84% 3,84% 3,84% sumber: data primer, 2016 persepsi kode etik keperawatan indonesia isi pelaksanaan dan hambatan perawat dan klien perawat dan praktik perawat dan masyarakat perawat dan teman sejawat perawat dan profesi pengertian gambar 1. persepsi kode etik keperawatan indonesiagambar 1. persepsi kode etik keperawatan indonesia 2. persepsi tentang kode etik keperawatan indonesia hasil penelitian menunjukan bahwa persepsi mahasiswa profesi ners tentang kode etik keperawatan dapat dilihat dari pandangan atau tanggapan mahasiswa 33 vol. 1 no. 1 desember 2016 tentang definisi, fungsi, isi, pelaksanaan dan hambatan pelaksanaan kode etik keperawatan indonesia. tema dalam penelitian ini adalah pada gambar 1. a. persepsi tentang pengertian kode etik keperawatan persepsi tentang pengertian kode etik keperawatan indonesia adalah tanggapan tentang definisi kode etik keperawatan yang ada di indonesia. hasil penelitian menunjukan bahwa informan mendefinisikan kode etik keperawatan indonesia sebagai peraturan yang berisi hak, kewajiban dan ruang lingkup perawat dalam melakukan tindakan keperawatan yang harus ditaati oleh seluruh perawat di indonesia. hal ini didukung dengan pernyataan informan sebagai berikut: “ kode etik itu suatu aturan, nilai-nilai atau etika yang mengatur perawat indonesia berisi kewenangan atau batasan perawat...”. (fgd4) ..”kode etik itu melekat dalam perilaku perawat, suatu peraturan berisi ruang lingkup, tindakan keperawatan apa saja, yang perawat wajib tahu, acuan untuk berperilaku bagi perawat yang berisi batasan-batasan yang harus dilakukan dan dijaga perawat (fgd3). b . p e r s e p s i t e n t a n g f u n g s i k o d e e t i k keperawatan persepsi tentang fungsi kode etik keperawatan adalah tanggapan mahasiswa tentang fungsi kode etik keperawatan yang mereka ketahui. hasil penelitian menunjukan bahwa mahasiswa mengganggap fungsi kode etik keperawatan indonesia adalah sebagai pedoman, pelindung, pengatur perilaku perawat dan pembatas tindakan. hal ini didukung dengan pernyataan sebagai berikut: ..” fungsi kode etik adalah sebagai pedoman yang berisi batasan-batasan, wewenang, hak dan kewajiban perawat”. (fgd4) ..”fungsi kode etik sebagai pengatur dan pedoman”. (informan1, 21 th) ..” fungsi kode etik untuk keselamatan pasien, pedoman bagi perawat dalam melakukan tindakan keperawatan, fungsinya memperjelas pekerjaan perawat dan sebagai pelindung bagi perawat.” (fgd2) c. persepsi tentang isi kode etik keperawatan mahasiswa profesi ners menganggap isi kode etik terdiri dari beberapa hal. hasil penelitian menunjukan bahwa sebagian besar dapat menyebutkan isi kode etik dengan baik. isi kode etik keperawatan yang disampaikan informan melalui meliputi perawat dan pasien, perawat dan praktik, perawat dan masyarakat, perawat dan teman sejawat serta perawat dan profesi. hal ini didukung oleh pernyataan sebagai berikut: 1. perawat dan pasien informan mengganggap bahwa perawat saat berhubu ngan dengan pasien harus menerapkan prinsiprinsip etik seperti beneficience/ memberikan manfaat, non malefi cien ce/ tidak menciderai , justice/ berlaku adil tidak membeda-bedakan, autonomy/ kebebasan berpendapat, veracity/ berkata jujur, fidelity/ menepati janji, confidentiality/ menjaga kerahasiaan pasien. informan menganggap perawat bertanggung jawab dalam pemberian asuhan keperawatan pada pasien sesuai dengan standar prosedur operasional (spo), perawat harus menghargai hak-hak pasien, semua tindakan berfokus pada pasien, memberikan asuhan keperawatan yang kompre hensif meliputi aspek biopsikososiokultural dan spiritual. informan juga beranggapan bahwa perawat harus bersikap terbuka, care pada pasien, menjaga komunikasi dan hubungan saling percaya, berperan sebagai edukator, konselor dan advokator bagi pasien dan menghargai hak-hak pasien. informan menganggap perawat harus mengetahui apa saja kebutuhan pasien, selalu dekat dengan pasien dan keluarga, serta dapat memfasilitasi semua kebutuhan pasien dan keluarga. hal ini didukung oleh pernyataan sebagai berikut: “...perawat harus menjaga kerahasiaan, menjaga hubungan baik dengan pasien, harus menegakan prinsip etik seperti tidak menimbulkan masalah, tidak mencederai, otonomi, tidak memaksakan kehendak, tanggung jawab memberikan asuhan keperawatan kepada pasien dengan baik sesuai 34 dengan spo dan urutan...” (informan 1, 21 th) “ perawat harus berkata jujur, terbuka, tindakan untuk pasien harus aman, tidak menciderai pasien, tidak pilih kasih, harus memiliki otonomi, menjaga privacy klien, perawat harus berfokus pada pasien tidak membedakan suku, agama, ras, kedudukan. (diam sesaat). tanggung jawab perawat adalah pemberi pelayanan pada semua aspek biopsikososiokultural spiritual.” (fgd 3) “..perawat harus menjaga komunikasi, membina hubungan saling percaya, tanggung jawab perawat memberikan asuhan keperawatan, berperan sebagai edukator, konselor, advokator, perawat menjaga rahasia pasien, dalam memberikan tindakan keperawatan memandang semua pasien sama, menghormati hak-hak pasien, kebudayaan, kepercayaan.” (fgd 2). 2. perawat dan praktik mahasiswa menganggap konsil keperawatan merupakan hal penting dalam pengaturan praktik keperawatan sehingga dapat memperjelas tugas dan tanggung jawabnya sesuai ranah profesi. informan beranggapan bahwa perawat harus melakukan praktik sesuai dengan protap atau aturan yang ada, meningkatkan kualitas diri dengan meningkatkan pengetahuan, keterampilan dan sikap melalui pendidikan, seminar, pelatihan, workshop. informan berpendapat perawat harus up date ilmu, tidak boleh resisten dan dapat mengaplikasikan ilmu yang diperoleh dalam praktik keperawatan. informan juga beranggapan bahwa perawat dapat membuat inovasi dalam praktik keperawatan yang bertujuan untuk meningkatkan kualitas pelayanan dan memberikan kepuasan pasien pada pasien dan keluarga. hal ini didukung oleh pernyataan sebagai berikut: “perawat harus memiliki konsil keperawatan untuk mengatur tindakan-tindakan keperawatan, perawat harus paham tugas dan tanggung jawabnya sesuai ranah profesi, harus berpikir kritis, diperlukan up grade ilmu melalui pendidikan formal atau non formal, meningkatkan skill dan sikap”. (fgd3) ..” perawat dalam melakukan praktik harus sesuai protap atau aturan yang ada, perawat harus meningkatkan kualitas diri serta up date ilmu melalui sekolah, seminar,pelatihan, workshop, supaya dalam menangani pasien dapat sesuai penelitian terbaru dan rumah sakit harus mewajibkan perawat untuk up date ilmu”. (fgd4) “perawat menjunjung nama baik profesi keperawatan, perawat dalam praktik memfasilitasi kebutuhan holistik pasien melalui biopsikososiospiritual kultural, meningkatkan keterampilan dalam praktik melalui pelatihan.(hmm tujuan praktik untuk kepuasan pasien dan meningkatkan kualitas pelayanan” (fgd1). 3. perawat dan masyarakat mahasiswa profesi ners menilai perawat berfokus pada pemberian asuhan keperawatan bagi komunitas dan keluarga melalui kegiatan yang dapat meningkatkan kesehatan melalui upaya promosi kesehatan, preventif/ pencegahan penyakit, kuratif/ pengobatan, rehabilitatif/ pemulihan. informan beranggapan bahwa seharusnya perawat berguna bagi masyarakat dalam berbagai, dalam memberikan pelayanan berfokus pada pemberdayaan masyarakat melalui informan mengganggap bahwa perawat memiliki peran sebagai edukator/ pemberi pendidikan bagi masyarakat, dengan melakukan tindakan keperawatan yang meliputi edukasi/ pendidikan, pemberdayaan, peningkatan status kesehatan serta kesiapsiagaan dalam memberikan pertolongan dalam menghadapi bencana. hal ini didukung oleh pernyataan sebagai berikut: “paradigmanya perawat tidak hanya merawat orang sakit tetapi perawat melakukan upaya promotif dan preventif, perawat berperan sebagai pendidik bagi masyarakat, sebagai pemberi informasi untuk menjaga kesehatan, memberdayakan masyarakat.” (fgd 3) “perawat sebagai edukator dalam pemberian pendidikan kesehatan melalui upaya promotif, preventif, kuratif, berperan aktif dalam kegiatan masyarakat dengan pemben tukan kader dan pemberdayaan masyarakat.” (fgd 2) 35 vol. 1 no. 1 desember 2016 4. perawat dan teman sejawat mahasiswa menilai hubungan perawat dengan teman sejawat diwujudkan dalam bentuk kolaborasi dengan saling melengkapi satu sama lain yang berpusat pada pasien. informan beranggapan bahwa perawat harus dapat membina hubungan yang baik, berkomunikasi yang baik dan menerapkan prinsip etik. informan menganggap bahwa perawat harus dapat menghargai, menjunjung tinggi profesionalisme dan saling berbagi informasi. hal ini didukung oleh pernyataan sebagai berikut: ..” sistemnya saling kolaborasi, saling membutuhkan, berpusat pada pasien bagi semua tenaga kesehatan, saling menghargai, tanpa memasuki ranah profesi lain, saling memberikan informasi.” (fgd ) “membina hubungan baik dengan teman sejawat, komunikasi dengan baik dan melaksanakan prinsip etik.”(informan 1, 21 th) “perawat sebagai sumber informasi untuk profesi lain, perawat saling melengkapi dengan profesi lain. perawat menunjukan profesionalitasnya, dan saling menghargai.” (fgd2) 5. perawat dan profesi informan menilai profesi keperawatan memiliki jenjang karir keperawatan sebagai indikator dari profesionalisme perawat untuk meningkatkan mutu pelayanan keperawatan. informan beranggapan bahwa perawat harus menjaga nama baik profesi, meningkatkan profesionalisme diri dengan cara meningkatkan level pendidikan minimal sarjana keperawatan ners. informan juga berpendapat bahwa tingkat pendidikan keperawatan yang bervariasi dapat diperjelas standar, wewenang, kompetensi dan harus disosialisasikan, standar pendidikan keperawatan minimal s1 keperawatan ners. hal ini dukung pertanyaan sebagai berikut: “profesi itu memiliki tingkatan dalam jenjang karir keperawatan, perawat meningkatkan level pendidikan dan profesionalismenya “ (informan1, 21 th) “perawat menjaga nama baik profesi, meningkatkan profesionalisme diri”. (fgd2) “kode etik perlu ditinjau ulang, apakah sudah sesuai dengan profesi keperawatan lalu disosialisasikan. (fgd1) “ level pendidikan keperawatan indonesia yang bervariasi perlu dibuat standarnya, wewenang klinis, kompetensi harus diperjelas serta disosialisasikan. standar pendidikan keperawatan minimal sebaiknya s1 keperawatan ners supaya dapat meningkatkan mutu pelayanan dan memberikan informasi kepada pasien saat memberikan tindakan keperawatan.” (fgd4) d. persepsi tentang pelaksanaan kode etik keperawatan mahasiswa profesi ners menilai bahwa sudah melaksanakan kode etik keperawatan saat menjalani praktik profesi. informan beranggapan bahwa pelaksanaan kode etik pada mahasiswa bervariasi, mayoritas sudah melakukan sesuai dengan prinsip etik tetapi implementasinya tergantung kondisi. hal ini didukung pernyataan sebagai berikut: ..”insyaallah sudah melaksanakan kode etik (informan23, 21 th) ..sudah melakukan kode etik keperawatan saat praktik tapi tergantung kondisi... (informan8, 22th) ...ada beberapa yang sudah saya lakukan dalam kode etik keperawatan tapi ada beberapa terbawa lingkungan, saya berusaha berkomunikasi secara terapeutik dengan pasien dan keluarga tanpa membedakan latar belakang mereka..” (informan13, 21 th) e. persepsi tentang hambatan pelaksanaan kode etik keperawatan mahasiswa profesi ners menilai bahwa hambatan pelaksanaan dari diri sendiri kurang pengetahuan tentang kode etik butuh sosialisasi, role model diperlukan untuk mengajarkan implementasi kode etik dalam praktik keperawatan. hal ini didukung pernyataan sebagai berikut: ..”hambatan dari pelaksanaan kode etik dari diri saya sendiri karena kurang pengetahuan tentang 36 kode etik meskipun sebenarnya saya yakin sudah menjalankan tapi teorinya masih kurang, diperlukan role model dari dosen, supervisor, preseptor atau perawat (informan1, 21 th) ..”hambatan dari perawat yang disana mungkin juga dari diri saya sendiri karena pengetahuannya minim terkait praktiknya karena selama ini hanya dapat teori (informan6,22 th) ..”hambatan dari fasilitas di rumah sakit, diri sendiri, sama lingkungan (informan11,22 th) pembahasan 1. persepsi tentang pengertian kode etik keperawatan indonesia hasil penelitian menunjukan bahwa persepsi mahasiswa profesi ners tentang kode etik keperawatan tergolong baik. mahasiswa mengetahui tentang definisi kode etik keperawatan indonesia dan aplikasinya. manusia dalam mempersepsikan sesuatu memiliki perbedaan dalam sudut pandang penginderaan termasuk mempersepsikan sesuatu yang baik atau positif maupun persepsi buruk atau negatif (sugihartono, 2007). faktor-faktor yang mempengaruhi perbedaan persepsi antara lain pengetahuan, pengalaman dan sudut pandangnya (waidi, 2006). pengetahuan seseorang dipengaruhi oleh umur, jenis kelamin, pekerjaan, pendidikan dan sumber informasi (notoatmodjo, 2010). hasil penelitian menunjukan bahwa mahasiswa mengetahui definisi kode etik keperawatan berdasarkan sumber informasi yang pernah mereka peroleh saat perkuliahan di tingkat pendidikan sarjana keperawatan melalui blok professional nurse dan manajemen keperawatan. hal ini berbeda dengan penelitian yang dilakukan oleh tahmine et al (2010) menunjukkan yang bahwa konsep etika profesional keperawatan yang diberikan di sekolah atau kampus keperawatan hanya sebatas formalitas dan cenderung mengabaikan sehingga membuat banyak mahasiswa keperawatan menjadi tidak sensitif terhadap issue sehari hari dalam bekerja dibidang keperawatan. berdasarkan karakteristik informan dan informan dalam penelitian ini juga dapat dilihat bahwa semua memiliki tingkat pendidikan yang sama yaitu sarjana keperawatan dengan usia rata-rata 22 tahun, jenis kelamin terbanyak adalah perempuan dan budayanya bervariasi dari pulau jawa, sumatera, kalimantan, sulawesi, dan nusa tenggara, sehingga persepsi mahasiswa profesi ners umy relatif sama satu dengan yang lain. 2. persepsi mahasiswa profesi ners tentang fungsi kode etik keperawatan indonesia hasil penelitian menunjukan bahwa mahasiswa profesi ners mengetahui fungsi dari kode etik keperawatan indonesia dengan baik. hal ini didukung oleh penelitian dari numminen et al, (2009) yang menunjukan bahwa kode etik profesional dipandang sebagai elemen dasar dari pengetahuan etik perawat dan merupakan dampak dari pendidikan etik. kode etik dipandang sebagai bagian dari pengetahuan dasar etik perawat yang tidak dapat dibandingkan yang memiliki fungsi untuk membantu perawat dalam membuat keputusan etik, menjadi pedoman dalam menyediakan perawatan yang berkualitas secara etik, dan memberikan informasi kepada masyarakat tentang tujuan, nilai dan standar keperawatan. 3. persepsi mahasiswa profesi ners tentang isi kode etik keperawatan indonesia hasil penelitian menunjukan bahwa pengetahuan mahasiswa profesi ners umy tentang isi kode etik dalam kategori baik. informan dan informan menganggap bahwa isi kode etik keperawatan indonesia terdiri dari yaitu hubungan perawat dengan klien, perawat dengan praktik, perawat dengan masyarakat, perawat dengan teman sejawat dan perawat dengan profesi. perawat profesional melakukan asuhan keperawatan kepada pasien berlandaskan kode etik keperawatan dalam berbagai setting baik di klinik, pendidikan maupun komunitas. kode etik keperawatan berisi pedoman-pedoman yang digunakan sebagai dasar praktik keperawatan yang berisi hubungan perawat dan klien, perawat dan praktik, perawat dan masyarakat, perawat dan teman sejawat serta perawat dan profesi (www.inna-ppni.or.id). 37 vol. 1 no. 1 desember 2016 perawat merupakan salah satu pemberi pelayanan dalam sistem kesehatan yang memiliki tanggung jawab dalam memberikan pelayanan kepada klien berdasarkan isu etik. mereka memerlukan pengetahuan untuk menjadi pedoman dalam memberikan perawatan yang aman dan sesuai dengan etik legal saat ini (shahriari et all, 2013). pengetahuan akan kode etik keperawatan merupakan suatu landasan utama bagi perawat untuk memberikan asuhan keperawatan karena kode etik keperawatan adalah salah satu ciri/persyaratan profesi perawat dalam menentukan, mempertahankan dan meningkatkan standar profesi serta mencerminkan semua perawat dalam penilaian moral bagi klien atau masyarakat yang ada disekitarnya termasuk tenaga medis lainnya (nasrullah, 2014). menurut kozier (2010), kode etik perawat merupakan tanggung jawab seorang perawat dalam melaksanakan asuhan keperawatan karena tanggung jawab selain berhubungan dengan peran perawat sendiri, perawat juga harus tetap berkompeten dalam pengetahuan, sikap dan bekerja sesuai kode etik keperawatan sehingga kemampuan, keterampilan dan pengetahuan yang relevan dengan disiplin ilmu dapat meningkatkan tingkat kepercayaan pasien, keyakinan akan asuhan dan kenyamanan pasien selama menjalani perawatan. hasil penelitian ini sesuai dengan penelitian numminen et al (2009) yang menunjukkan bahwa kode etik perawat diperlukan untuk menyediakan pengetahuan dasar etik dan dasar nilai bagi perawat yang didukung beberapa literature, tetapi relevansi kode etik juga perlu didiskusikan dalam literatur keperawatan. hal ini sesuai dengan penelitian adhikari et al (2016), perawat memiliki pengetahuan etika kesehatan yang signifikan namun pengetahuan tentang kode etik inti pada praktik klinik perawat masih rendah. hal ini disebabkan oleh responden kurang mengenal kode etik yang digunakan. 4. persepsi mahasiswa profesi ners tentang pelaksanaan dan hambatan hasil penelitian menunjukan bahwa mahasiswa p r o f e s i n e r s u m y t e l a h m e l a k s a n a k a n k o d e etik keperawatan selama praktik profesi, dapat mengidentifikasi prinsip etik namun dalam aplikasinya masih tergantung diri sendiri dan kondisi. penghambat dalam pelaksanaan kode etik antara lain diri sendiri karena pengetahuan terbatas, role model perawat maupun pendidik akademik dan klinik, sarana dan prasarana. hal ini tidak sesuai dengan penelitian noviani dan abrori (2016), dimana pengetahuan mahasiswa keperawatan profesi ners angkatan 23 umy tentang kode etik keperawatan baik melalui analisis kuantitatif dan kualitatif. namun, dalam penelitian ini hanya berfokus pada pengetahuan saja, tidak sampai pada perilaku dalam mengimplementasikan kode etik keperawatan. hal ini berbeda dengan hasil penelitian sheresta & jose (2014), dimana pengetahuan tentang hukum lebih besar dibandingkan dengan pengetahuan etik. semua responden tidak puas dengan pengetahuannya tentang etika dan hukum, dan hanya 50% yang dapat melakukan praktik dengan baik. pengetahuan individu, etik, empiris dan estetik yang didapat dari pendidikan keperawatan ditambah lagi dari pengetahuan mentorship, role model, anekdot dan tradisi mempengaruhi persepsi profesionalisme pada mahasiswa keperawatan (june and jenni, 2012; scrout, 2012 ). perilaku yang diamati pada perawat profesional secara signifikan mempengaruhi mahasiswa keperawatan untuk belajar mengembangkan kepekaan identitas profesional melalui role model positif dan negatif secara konstruktif (june and jenni, 2013). institusi pendidikan memiliki peran dalam menyiapkan mahasiswa profesi keperawatan untuk dapat melaksanakan praktik keperawatan secara etis dan legal. hal ini juga terkait tersedianya role model yang dapat dijadikan contoh dalam melaksanakan kode etik keperawatan. institusi pendidikan juga harus dapat mengintegrasikan pendidikan etik ke dalam kurikulum selama pendidikan keperawatan baik tahap akademik dan profesi, supaya mahasiswa dapat memahami konsep etik dengan baik. 38 hal ini sesuai dengan penelitian numminen et al (2009), yang menunjukan bahwa kode etik profesional dianggap informan sebagai elemen dasar dari pengetahuan etik perawat yang berasal dari pendidikan etik, karena hal ini sangat penting sehingga diperlukan pendekatan dalam mengajarkan etik keperawatan yang dimasukan dalam kurikulum pendidikan keperawatan. hal ini juga sesuai dengan penelitian adhikari et al (2016), pengajaran etika pada institusi keperawatan memerlukan penggabungan segera untuk menjamin bahwa etika keperawatan masuk dalam kurikulum. kesimpulan persepsi mahasiswa profesi ners tentang kode etik keperawatan indonesia dalam kategori baik. pengetahuan tentang definisi, fungsi, isi, serta hambatan dalam pelaksanaan kode etik keperawatan indonesia dalam kategori baik. daftar pustaka adhikari, s., paudel, k., aro, a. r., adhikari, t. b., adhikari, b., mishra, s. r. 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(2012). an exploratory study: student nurses’ perceptions of professionalism. nurse education in practice 13(1) · may 2012, www.researchgate.net/ publication/225087618_an_exploratory_study_ student_nurses’_perceptions_of_professionalism per satuan perawat nasional indonesia. kode etik keperawatan indonesia. diakses pada 16 januari 2017 dari www.inna-ppni.or.id. persatuan perawat nasional indonesia. malpraktik perawat. diakses pada 16 januari 2017 dari www.ppni.or.id panduan penulisan indonesian journal of nursing practice (ijnp). nasrullah, d. (2014). etika dan hukum keperawatan untuk mahasiswa dan praktisi keperawatan. jakarta: tim. notoatmodjo, s. (2012). etika dan hukum kesehatan. jakarta: rineka cipta. notoatmodjo, soekodjo. 2010. ilmu perilaku kesehatan. jakarta: rineka cipta notoatmodjo, s. (2010). pendidikan dan perilaku kesehatan. jakarta: rineka cipta. noviani, w., abrori, f. (2016). indonesian nurses’ codes of ethics perspectives on nursing student at universitas muhammadiyah yogyakarta teaching hospitals. proceeding: 6th international nursing conference 2016. cebu university, phillipines. nursalam. (2013). metodologi penelitian ilmu keperawatan. jakarta: salemba medika. numminen, o, leino-kilpi, h, van der arend, a, & katajisto, j. (2011). comparison of nurse educators’ and nursing students’ descriptions of teaching codes of ethics. nursing ethics, cinahl complete, ebscohost. diakses pada 16 juni 2016 dari http://web.a.ebscohost. com/ehost/ numminen, o, van der arend, a, & leino-kilpi, h. (2009). nurse educators and nursing students perspectives on teaching codes of ethics. nursing ethics cinahl complete, ebscohost. diakses pada 16 juni 2016 dari http://web.a.ebscohost.com/ehost/ numminen, o, van der arend, a, & leino-kilpi, h. (2009). nurses codes of ethics in practice and education: a review of the literature. scandinavian journal of caring sciences cinahl complete, ebscohost. diakses pada 16 juni 2016 dari http://web.a.ebscohost.com/ehost/ nursing malpractice statistics. diakses pada 1 desember 2016 dari www.rightdiagnosis.com. reising, d, l. (2012). top 5 claims, prevention tips and reference material provided through:” make your 39 vol. 1 no. 1 desember 2016 nursing care malpractice proof. american nurse today, volume 7,number 1, january 2012. rosenkoetter, m, & milstead, j. (2010). a code of ethics for nurse educators: revised, nursing ethics, cinahl complete, ebscohost. diakses pada 1 april 2016 dari http://web.a.ebscohost.com/ehost/ salehi, t. dehghn nayeri,n. nagarendah, r. (2010). ethics : patients rights and the code of nursing ethics in iran. ojin: the online journal of issue in nursing , vol.15/ no.3. diakses pada 1 november 2016 dari http://www. nursingworld.org/ shahriari, m., mohammadi, e., abbasadeh, a., bahrami, m. (2013). nursing ethical values and definitions: a literature review. iranian journal of nursing midwifery research. diakses pada 1 november 2016 dari https:// www.ncbi.nlm.nih.gov/pubmed/23983720 shrestha, s and jose p. (2014). knowledge and practice of nursing ethics and laws. journal of universal collage of medical sciences , vol 02/no.03. zahedi, f., sanjari, m., aala, m., peymani, m., aramesh, k., parsapour, a., dastgerdi, m. v. (2013). the code of ethics for nurses. iranian journal of public health, 42(1), 1-8. diakses pada 2 juni 2016 http://search.proquest. com/docview/1347622579?accountid=38628. 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. 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 16 vol. 1 no. 2 juni 2017 remaja bisa mencegah gizi lebih dengan meningkatkan self-efficacy dan konsumsi sayur-buah fauzan widianto1, sigit mulyono2, poppy fitriyani2 1 departemen keperawatan akper setih setio, muara bungo, 37211 indonesia 2 departemen keperawatan komunitas fakultas ilmu keperawatan universitas indonesia, depok, 16424, indonesia email: fauzanwidianto31@gmail.com abstrak prevalensi gizi lebih pada remaja setiap tahunnya mengalami peningkatan. gizi lebih merupakan suatu masalah yang kompleks yang dipengaruhi oleh banyak faktor, salah satunya kurangnya konsumsi sayuran dan buah. kurangnya konsumsi sayuran dan buah di asumsikan tidak adanya keyakinan (self-efficacy) pada remaja untuk mengonsumsi sayuran dan buah karena beberapa hal. tujuan dari penelitian ini adalah untuk mengetahui hubungan self-efficacy dengan konsumsi sayuran-buah dan kejadian gizi lebih. metode yang digunakan adalah crossectional. jumlah sampel yang digunakan adalah 156 remaja kelas 7 dan 8. tekhnik pengambilan sample yang digunakan adalah stritified propotional random sampling. kuesioner yang digunakan adalah selfefficacy for fruit, vegetable and water intake dan food recall. penelitian ini menunjukan bahwa self-efficacy berhubungan dengan konsumsi sayuran dan buah dan kejadian gizi lebih (or=9,467, 2,093). hasil regersi logistik menunjukan preferensi merupakan variabel confounding pada konsumsi sayuran dan buah. sedangkan jenis kelamin, genetik dan konsumsi sayuran dan buah merupakan variabel confounding dari gizi lebih. kata kunci:, gizi lebih, konsumsi sayuran dan buah, obesitas, remaja, self-efficacy abstract the prevalence of overweight in adolescents each year has increased. overweight is a complex issue that is influenced by many factors, one of the cautions is the lack of consumption vegetables and fruit. lack of consumption vegetables and fruit in the adolescents is assumed to info artikel: masuk : 4 januari 2017 revisi : 12 mei 2017 diterima : 22 mei 2017 doi number : 10.18196/ijnp.1257 17 vol. 1 no. 2 juni 2017 be absence of confidence (self-efficacy) in adolescents to eat vegetables and fruit for several reasons. the purpose of this study was to determine the relationship self-efficacy with vegetable-fruit consumption and the incidence of overweight. the method of research used way cross sectional. a total samples of 156 teenagers grade 7 and 8 in junior high schools was involved in this study. using stratified proportional random sampling. the questionnaires used are self-efficacy for fruit, vegetable and water intake and food recall. this study showed that self-efficacy associated with the consumption of vegetables and fruit and the incidence of overwight (or=9,467, 2,093).. the results of regresion logistic showed preferences had confounding variable in the consumption of vegetables and fruit. whereas gender, genetics and consumption of vegetables and fruit is a confounding variable of nutrition keywords : adolescents, obese, overwight, selfefficacy, vegetables fruits intakes pendahuluan permasalahan gizi remaja di beberapa negara seperti di negara maju dan berkembang tidak jauh berbeda. di negara maju terjadi pergeseran permasalahan gizi, dimana terjadi penurunan gizi kurang dan meningkatnya gizi lebih. hal tersebut merupakan fenomena di beberapa tiga dekade ahir ini. berdasarkan riskesdas (2013) angka kejadian gizi kurang pada remaja umur 13-15 tahun mengalami penurunan. pada tahun 2007 angka kejadian gizi kurang pada remaja umur 13-15 tahun sebanyak 11,5 % turun menjadi 7,8% pada tahun 2013. penurunan kejadian gizi kurang berbanding terbalik dengan kejadian gizi lebih yaitu 2,4% pada tahun 2007 naik menjadi 10,8% pada tahun 2013. prevalensi gizi lebih setiap tahun mengalami peningkatan, rosner (2002) menyatakan lebih dari setengah milyar dari total 6,2 milyar jiwa penduduk di dunia mengalami gizi lebih. world health organitation (2000) telah mendeklarasikan obesitas sebagai epidemi global. pada tahun 2008 cdc melaporkan bahwa 20% anak usia sekolah (6 – 17 tahun) di amerika serikat mengalami overweight dan lebih dari 40% mengalami obesitas (cdc, 2010). prevalensi obesitas di eropa juga mengalami peningkatan dua kali lipat setiap tahunnya terutama di eropa barat dan selatan (lobstein, 2003). meningkatnya prevalensi gizi lebih pada remaja di indonesia disebabkan oleh perubahan gaya hidup pada remaja. sekarang ini terjadi perubahan pola makan dimana remaja lebih suka makan-makanan yang berlemak, manis dan cepat saji dari pada makan sayuran dan buah. pola aktivitas remaja seperti jalan kaki, bersepeda, melakukan permainan yang mengeluarkan keringat, dan berolahraga sangat minim dan kebanyakan remaja lebih suka menonton televisi dan bermain gadget. menurut riska (2010) faktor seseorang yang menyebabkan gizi lebih pada remaja diantaranya ketidak-seimbangan asupan makan dan aktifitas fisik serta kurang memperhatikan faktor-faktor lain yang secara terintegrasi seperti aspek psikologis (body image), aspek psikiatrik (depresi), dan aspek gender. maurer dan smith (2011) dalam penelitiannya mengatakan remaja yang berjam-jam di depan komputer, televisi dan mengkonsumsi makanan yang tinggi lemak dan gula merupakan faktor penyebab obesitas. gizi lebih pada remaja harus segera ditangani karena mempunyai banyak dampak yang sangat merugikan. akibat gizi lebih negara maju seperti amerika serikat mengalami permasalahan financial sebesar us$ 146 milyar (trogdon, 2012). dampak selanjutnya menurut palilingan (2010), masalah kesehatan yang dapat terjadi pada remaja yang mengalami gizi lebih seperti penyakit hipertensi, diabetes melitus (dm tipe ii), kardiovaskuler, dan gangguan fungsi hati (displidemia). intervensi promosi kesehatan di sekolah seperti konsumsi sayuran dan buah merupakan upaya yang dapat dilakukan oleh perawat komunitas dalam mengatasi permasalahan status gizi, sehingga remaja dengan gizi lebih terhindar dari permasalahan penyakit kronik lainnya. kecenderungan dampak negatif yang ditimbulkan oleh gizi lebih menyebabkan remaja dengan gizi lebih termasuk dalam populasi berisiko (at risk populations) 18 chong dan hoer (2005) dalam penelitiannya menjelaskan bahwa remaja yang mengonsumsi sayuran dan buah-buahan 5 porsi dalam sehari mengalami penurunan berat badan. selain itu, konsumsi sayuran dan buah dikaitkan dengan penurunan resiko penyakit kardiovaskuler dan serebrovaskuler (dauchet et al, 2006; guillanie, 2012). sayuran dan buah mencegah resiko kanker tertentu, terutama dari sistem pencernaan (boffetta et al, 2007; guillanie, 2012). promosi kesehatan melalui edukasi merupakan proses interaktif yang mendorong terjadinya pembelajaran, dan pembelajaran merupakan cara untuk menambah pengetahuan, sikap, dan keterampilan melalui sebuah praktik dan pengalaman tertentu (smeltzer & bare, 2008; potter & perry, 2009). edukasi mengenai gizi adalah metode yang paling umum digunakan untuk mempromosikan perilaku makan akan tetapi hasilnya sangat kurang (mann et al, 2007; annesi, 2011). meta-analisis juga menunjukan bahwa program edukasi kelompok biasanya membawa dampak positif terhadap konsumsi sayuran dan buah akan tetapi dampak klinis seperti perilaku dianggap marginal (gullianie, 2012). selain itu sebagian besar edukasi tidak secara teoritis mengidentifikasi perubahan perilaku dan variabel psikososial yang memediasi perubahan perilaku. kurang efektifnya edukasi kesehatan untuk mengubah perilaku makan di dukung beberapa penelitian yang menunjukan bahwa keterampilan dalam pengaturan diri (self-regulatory) diterapkan untuk mengendalikan perilaku makan. hal tersebut merupakan faktor yang jauh lebih penting daripada pengetahuan tentang nutrisi dalam mengubah perilaku diet pada remaja dengan obesitas (powell et al., 2007; annesi, 2011). lippke dan ziegelmann (2008) menyatakan untuk mengubah perilaku diet seseorang, tidak bisa dilakukan hanya dengan memberikan pengetahuan dasar tentang gizi saja, tetapi juga perlu adanya motivasi dan kehendak dari individu tersebut yang kemudian memandu sebuah proses dalam mengontrol perilaku (self-regulatory). kemampuan seseorang dalam mengontrol sebuah perilaku atau self-regulatory tergantung pada keyakinan seseorang dalam melakukan sebuah tindakan tertentu. faktor motivasi dan kehendak dalam mengontrol perilaku sangat dipengaruhi oleh self-efficacy. tinjauan sistematis akhir-akhir ini mengidentifikasikan bahwa selain kebiasaan dan niat, self-efficacy juga merupakan faktor yang konsisten dalam perubahan perilaku konsumsi sayuran dan buah pada remaja (guillaume, godin & vezina im, 2010). metode penelitian ini menggunakan desain crossectional. populasi dalam penelitan ini adalah seluruh remaja yang bersekolah di smpn di jagakarsa. jumlah sample dalam penelitian ini berjumlah 164 remaja kelas 7 dan 8.. kriteria eksklusi dari penelitian ini adalah remaja dengan status imt < 1 sd (gizi kurang). tekhnik sampling yang digunakan adalah multistage stratified propotional random sampling. penilaian self-efficacy menggunakan quesioner selfefficacy for fruit, vegetable and water intake. penilain imt dengan microtois dan timbangan berat badan. pengukuran intake makanan dan aktifitas fisik pada remaja menggunakan food recall dan adolescent phisycal activity recall quesiober. pengkategorian self-efficacy dinyatakan dengan cutt of point dari skor mean self-efficacy (baik: ≥ 85; kurang : ˂ 85). selanjutnya pengkategorian konsumsi sayur-buah menggunakan jumlah porsi konsumsi sayur-buah setiap hari berdasarkan standar who. dikategorikan kurang apabila jumlah konsumsi sayur buah pada remaja < 4 porsi/hari. dikategorikan cukup apabila jumlah konsumsi sayur-buah ≥ 4 porsi/hari. pengkategorian indeks masa tubuh berdasarkan standar who yaitu sangat kurus (< -3sd), kurus (-2 sd sampai -3sd), normal (-2 sd sampai + 1sd), overweight (+ 1 sd sampai +2 sd), obesitas (> +2sd). pada penelitian ini imt dikategorikan menjadi dua yaitu gizi lebih (jika imt/u > + 1sd) dan normal (jika imt/u -2 1 sd). sedangkan gizi kurang dalam penelitian ini dieksklusikan. penelitian ini sudah mendapatkan persetujuan dari komite etik universitas indonesia. analisis bivariat 19 vol. 1 no. 2 juni 2017 dalam penelitian ini menggunakan uji kai kuadrat dan untuk multivariatnya menggunakan regresi logistik. hasil dari 164 remaja hanya 154 yang menjadi responden. delapan responden dikeluarkan dari penelitiann ini dikarenakan tidak lengkap dalam pengisian kuesioner. dari jumlah tersebut jenis kelamin responden perempuan lebih banyak dari pada laki-laki yaitu 92 (59%). penghasilan keluarga responden lebih banyak di atas umr yaitu 86 (55,1%). lebih banyak responden tidak ada riwayat keturunan kegemukan dari orang tuanya 96 (61,5%). rata-rata berat badan remaja adalah 50,62 kg (sd:10,579), tinggi badan remaja rata-rata 155,55 cm (sd:6,977) dan jumlah anggota dari keluarga adalah 4,74 (sd:1,153). remaja mayoritas menyukai sayuran dan buah 131 (84%). orang tua mayoritas menyediakan sayuran dan buah sebanyak 139 (89,1%). aktifitas fisik remaja lebih banyak kurang yaitu 94 (60,3%). self-efficacy remaja lebih banyak baik yaitu 80 (51,3%) dan jumlah konsumsi sayurannya lebih banyak kurang yaitu 119 (76,3%). status imt remaja lebih banyak normal yaitu 92 (59%). analisis bivariat self-efficacy dengan konsumsi sayuran dan buah ditunjukan dalam tabel 1 berikut ini. tabel 1. distribusi responden menurut self-efficacy dan konsumsi sayuran-buah pada remaja di smpn jagakarsa (n=156) selfefficacy konsumsi sayuran dan buah total or (95% ci p value kurang cukup n % n % n % kurang 71 93,4 5 6,6 76 100 9,467 3,44426,022 0,000 baik 48 60,0 32 40 80 100 jumlah 119 76,3 37 23,7 156 100 hasil analisis dari hubungan antara self-efficacy dengan konsumsi sayuran dan buah diperoleh bahwa sebanyak 71 (93,4%) remaja dengan self-efficacy yang kurang jumlah konsumsi sayuran dan buahnya kurang. remaja dengan kategori self-efficacy baik yang jumlah konsumsi sayurannya baik sebanyak 32 (40,0%). hasil uji statistik diperoleh bahwa ada hubungan yang signifikan antara self-efficacy dengan konsumsi sayuran dan buah. hasil analisis diperoleh nilai or=9,467, artinya remaja yang memiliki self-efficacy yang baik mempunyai peluang 9,467 kali untuk mengonsumsi sayuran dan buah dibanding remaja yang self-efficacynya kurang. adanya hubungan antara self-efficacy dengan konsumsi sayuran dan buah menggambarkan semakin tinggi self-efficacy remaja maka semakin tinggi konsumsi sayuran dan buah. selanjutnya hubungan dari self-efficacy dengan kejadian gizi lebih ditunjukan pada tebel 2 berikut ini. tabel 2. distribusi responden menurut self-efficacy dan kejadian gizi lebih pada remaja di smpn jagakarsa (n=156) self-efficacy kejadian gizi lebih total or (95% ci) p value gizi lebih normal n % n % n % kurang 41 53,9 35 46,1 76 100 2,903 1,4985,627 0,002 baik 23 28,8 57 71,3 80 100 jumlah 64 41,0 92 59,0 156 100 hasil analisis tersebut adalah remaja dengan tingkat selfefficacy yang kurang mengalami kejadian gizi lebih sebanyak 41 (53,9%). selanjutnya remaja dengan tingkat self-efficacy yang baik yang berstatus gizi normal sebanyak 57 (71,3%). hasil uji statistik diperoleh bahwa ada ada hubungan yang signifikan antara self-efficacy dengan kejadian gizi lebih. dari hasil analisis diperoleh nilai or=2,903, artinya remaja yang memiliki self-efficacy yang baik mempunyai peluang 2,903 kali untuk memiliki berat badan normal dibanding remaja yang self-efficacy-nya kurang. uji multivariat menggunakan regresi logistik dilakukan untuk mengetahui faktor yang paling berpengaruh setelah dikontrol variabel counfounding. hasil uji multivariat ditunjukan pada tabel 3 dan 4. hasil uji multivariat yang pertama didapatkan persamaan regresinya adalah zself-efficacy= 19,34 + ß konsumsi sayur-buah + ßpreferensi. didapatkan hasil bahwa remaja yang self-efficacy-nya baik mempunyai peluang 8,97 kali konsumsi sayuran dan buahnya cukup 20 dibandingkan remaja yang self-efficacy-nya kurang setelah dikontrol variabel preferensi. tabel 3. pemodelan akhir analisis multivariat faktor risiko yang mempengaruhi konsumsi sayuran dan buah pada remaja di smpn jagakarsa (n=156) no variabel koefisien b p value 1 self-efficacy 8,970 0,000 2 preferensi 3,412 0,123 hasil uji multivariat kedua didapatkan persamaan regresinya adalah zself-efficacy= 19,34 + ßgizi lebih + ßselfefficacy + ßjenis kelamin + ßkons sayur-buah + ß genetik. hasilnya adalah remaja yang self-efficacy-nya baik mempunyai peluang status gizi normal sebanyak 2,327 kali dibandingkan remaja yang self-efficacy-nya kurang setelah dikontrol variabel jenis kelamin, konsumsi sayuran-buah dan genetik. tabel 4 pemodelan akhir analisis multivariat faktor risiko yang mempengaruhi kejadian gizi lebih pada remaja di smpn jagakarsa (n=156) no variabel koefisien b p value 1 self-efficacy 2,327 0,032 2 jenis kelamin 0,581 0,153 3 konsumsi sayuran-buah 2,053 0,009 4 genetik 4,662 0,000 pembahasan adanya hubungan self-efficacy dengan konsumsi sayuran dan buah bisa dijadikan dasar untuk intervensi guna meningkatkan sayuran dan buah pada remaja. lizaur (2008) menjelaskan self-efficacy merupakan salah satu faktor utama untuk memodifikasi perilaku dan meningkatkan konsumsi sayuran dan buah. annesi (2011) menjelaskan dengan meningkatkan keterampilan self-regulatory seperti self-efficacy konsumsi sayuran dan buah seseorang akan meningkat hal ini dikarenakan self-efficacy membuat seseorang cenderung berfokus pada pengaturan diri seperti pengaturan diit yang tinggi sayuran dan buah serta pengendalian perilaku makan makanan yang kurang sehat. pengaturan diri menurut kreausukon (2012) akan lebih efektif jika ada perencanaan (planning) pada setiap individu sehingga dalam penelitiannya kreausukon menggunakan planning disamping self-efficacy untuk meningkatkan konsumsi sayuran dan buah. kefektifitasan dari penelitian kreasukon dapat meningkatkan jumlah konsumsi sayuran sebanyak 1,5 – 2 porsi perhari. tidak hanya penelitian dari kreausukon penelitian dari schwarzer (2012) menghasilkan bahwa untuk mengubah perilaku seseorang pertama kali yang dilakukan adalah mempunyai niat untuk berubah dan niat tersebut dibentuk dari keyakinan diri (self-efficacy ) yang sudah direncanakan terlebih dahulu sebelum di implementasikan untuk mencapai target tertentu. perilaku dalam mengonsumsi sayuran dan buah pada remaja bisa ditingkatkan dengan cara pencapaian prestasi, pengalaman orang lain, persuasi verbal, umpan balik fisiologis dan kondisi emosional. (bandura, 1997). cara tersebut tentunya akan lebih efektif apabila dikombinasikan dengan program pemerintah yang ada yaitu program gizi seimbang (pgs) dimana edukasi dalam program tersebut bisa dimasukan intervensi seperti peningkatan self-efficacy guna meningkatkan konsumsi sayuran dan buah. selama ini kejadian gizi lebih memang lebih diidentikan dengan faktor genetik aktifitas fisik dan konsumsi sayuran dan buah. pada penelitian ini faktor genetik sangat dominan mempengaruhi status gizi pada remaja. menurut maglaya (2009) genetik merupakan faktor penting terhadap terjadinya gizi lebih. remaja yang mempunyai salah satu orang tua yang mengalami kegemukan maka berpeluang besar untuk mengalami kegemukan. menurut penelitian ogden (1996) jika salah satu orang tua tergolong dalam gemuk atau obesitas, maka kemungkinan 40% remaja akan memiliki berat badan berlebih dan apabila kedua orang tuanya mengalami overweight atau obese maka 80% remaja memiliki peluang terjadinya berat badan berlebih. sebaliknya, orang tua dengan berat badan yang kurus memiliki peluang 7% memiliki anak remaja yang kelebihan berat badan. menurut annesi (2012) dan moreno (2014) self-efficacy berhubungan dengan penurunan gizi lebih setelah dicontrol variabel konsumsi sayuran dan aktifitas fisik (p< 0,0001; r2 : 0,12). pada penelitian tersebut annesi (2012) menekankan pada peningkatan konsumi sayuran dengan cara meningkatkan self-efficacy, akan tetapi tidak hanya melalui self-efficacy annesi menggunakan aktifitas fisik untuk mengurangi rasa kejenuhan 21 vol. 1 no. 2 juni 2017 dan mengurangi dampak droop out dari responden. hasil penelitian dari linde et al (2004) menjelaskan bahwa tingkat self-efficacy berbanding terbalik dengan berat badan, seseorang yang memiliki self-efficacy rendah maka mempunyai berat badan yang tinggi atau dengan kata lain mengalami kegemukan (p<0,001; or:4,82). adanya hubungan antara self-efficacy dalam mengonsumsi sayuran dan buah secara langsung dengan kejadian gizi lebih membuat self-efficacy menjadi hal yang penting untuk intervensi pencegahan gizi lebih. self-efficacy tidak hanya menjadi prekdiktor utama dari konsumsi sayuran dan buah akan tetapi secara langsung berhubungan dengan kejadian gizi lebih. kesimpulan penelitian ini menunjukan bahwa ada hubungan antara self-efficacy dan konsumsi sayuran dan buah setelah dikontrol preferensi serta adanya hubungan antara self-efficacy dengan kejadian gizi lebih setelah dikontrol jenis kelamin, konsumsi sayuran dan buah dan geneitik pada remaja di smpn jagakarsa. berdasarkan hasil tersebut perlunya pengembangan program promosi kesehatan dengan menggunakan intervensi selfefficacy yang dimasukan dalam edukasi kesehatan. intevensi tersebut seperti: pengalaman akan keberhasilan sebelumnya (enactive mastery experience), pengalaman orang lain (vicarious experience), keadaaan fisiologis atau emosional (physichological and emotional states) dan dukungan sosial dari orang lain (social persuasion). intervensi tersebut bisa menggunakan beberapa pendekatan salah satunya adalah konseling. daftar pustaka annesi, james j. (2011). relationship of initial self-regulatory ability with changes in self-regulation and associated fruit and vegetable consumption in severely obese women initiating an exercise and nutrition treatment: moderation of mood and self-efficacy. journal of sports science and medicine (2011) 10, 643-648 cdc (2010). healthty youth, coordinate scholl health. http// www.cdc.gov/healthtyyouth/cshpp. diakses tanggal 10 februari 2016. chung, s. j., & hoerr, s. l. (2005). predictors of fruit and vegetable intakes in young adults by gender. nutrition research, 25, 453–463 guillaumie, l., godin, g., & vezina im, l.a. (2010). psychosocial determinants of fruit and vegetable intake in adult population: a systematic review. international journal of behavioral nutrition and physical activity, 7, 1–12 guillaumie, laurence., gaston., jeans-claude m., elisabeth s., laurent m. 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(2005). community public health nursing practice: health for family and populations. third editions. st. louis ogden, j. 1996. health psyckology: a text book. open university press: buckhingham-philadelphia pingkan, palilingan. (2010). apakah anak anda obesitas?. betterhealth tahun ii/ edisi 3/ triwulan/ september 2010 online. avaible at http://www.ekahospital.com/ uploads/bulletins/final/%/20/draf.pdf\. [accesed 01/10/2015] rizka, ruhul aflah, rahayu indiya lestari, yustini (2010). hubungan pola makan dengan kejadianobesitas pada remaja di sma katholik cendrawasih. tesis: program studi ilmu gizi fakultas kesehatan masyarakat universitas hasanuddin rossner s. (2002). obesity. the disease of the twenty -first century. internat. j. obesity & related metabolic disorders 2002; 2 6(suppl 4):s2-4. 22 smeltzer, bare. 2001. buku ajar keperawatan medikal bedah : brunner & suddarth. jakarta : egc trogdon, j. g., finkelstein, e. a., feagan, c. w., & cohen, j. w.(2012). stateand payer-specific estimates of annual medial expenditures attributable to obesity. obesity, 20, 214–22 who (2000). report of a who consultation, report no.894. obesity: preventing and managing the global epidemic. who: geneva, switzerland. 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. (2013) . gambaran sikap mahasiswa unpad terhadap kawasan tanpa rokok di kampus unpad. karya tulis ilmiah strata satu universitas padjadjaran. jamal, h., leida, m., thaha., & ansariadi. (2012). kepatuhan mahasiswa terhadap penerapan kawasan bebas asap rokok di kampus universitas hasanuddin. kementrian kesehatan ri (2011). informasi tentang penanggulangan masalah merokok melalui radio . jakarta. kementrian kesehatan ri (2013). riset kesehatan dasar (riskesdas) 2013. jakarta. rahmadi, a., lesatari, y., & yenita (2013). hubungan pengetahuan dan sikap terhadap rokok dengan kebiasaan merokok siswa smp di kota padang. jurnal kesehatan andalas. diakses 5 november 2015, dari htt p://jurnal.fk .unand.ac.id/ index.php/jka/article/view/62. robaka, y., rimawati, e., & nurjanah. (2013). kepatuhan mahasiswa terhadap kawasan tanpa rokok (ktr) di universitas dian nuswantoro semarang. karya tulis ilmiah strata satu universitas dian nuswantoro semarang. semarang. salawati & amalia. (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. 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. 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(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. 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 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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(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 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 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. 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(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. 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 knowledge towards cupping therapy (hijamah) are still insufficient in some aspects. acknowledgement the author would like to thank the nursing students of universitas muhammadiyah yogyakarta for their participation in this study and universitas muhammadiyah yogyakarta for this project's financial support. references al-balawi, a. m., almutairi, a. h., alawad, a. o., & merghani, t. h. 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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" 32 vol. 1 no. 2 juni 2017 pengalaman seksual pasangan penderita hiv dalam mempertahankan status hiv negatif di rspi prof. dr. sulianti saroso widia astuti. aw1 , fitrian rayasari2 1 rs penyakit infeksi prof. dr. sulianti saroso, jakarta utara. 2 fakultas ilmu keperawatan universitas muhammadiyah jakarta, cempaka putih, jakarta pusat. e-mail: waaw_nurse@yahoo.com abstrak hiv/aids masih menjadi masalah di indonesia dengan faktor risiko tertinggi penularan melalui hubungan heteroseksual. meskipun hubungan heteroseksual merupakan faktor penyebab utama penularan hiv, masih ada pasangan odha hiv positifhiv negatif dapat hidup dengan normal tanpa tertular hiv meski bertahun – tahun tetap melakukan hubungan seksual. pasangan ini disebut serodiskordan. studi fenomenologi ini dilakukan untuk mengeksplorasi berbagai pengalaman seksual serodiskordan dalam mempertahankan status hiv negatif di rspi prof. dr. sulianti saroso. sebanyak 6 serodiskordan berpartisipasi dalam studi ini. data dikumpulkan dengan wawancara mendalam. empat tema utama teridentifikasi dalam studi ini : (1) pengetahuan tentang hiv/aids, cara penularan dan penyebab suami terinfeksi, (2) kebutuhan seksual, (3) pencegahan penularan hiv, (4) pandangan tentang seksualitas. pengetahuan yang baik mengenai pencegahan penularan hiv sangat berdampak pada kemampuan serodiskordan dalam mempertahankan status hiv negatifnya selama ini dengan cara penggunaan kontrasepsi dan memberikan dukungan dalam kepatuhan mengkonsumsi arv. diperlukan edukasi dan konseling yang berkelanjutan pada serodiskordan dalam meningkatkan pengetahuannya mengenai hiv/aids sehingga dapat mengurangi terjadinya kasus baru hiv. kata kunci: pengalaman seksual, serodiskordan, mempertahankan status hiv negatif. abstract hiv/aids is still a problem in indonesia with the highest risk factors for transmission through heterosexual relations. although heterosexual info artikel: masuk : 28 januari 2017 revisi : 10 mei 2017 diterima : 28 mei 2017 doi number : 10.18196/ijnp.1259 33 vol. 1 no. 2 juni 2017 intercourse is the main cause of hiv transmission factors, there are still a couple people living with hiv can live normally without being infected with hiv even though many – year fixed sexual intercourse. the couple called serodiscordant. phenomenology study was conducted to explore various sexual experience serodiscordant in maintaining negative hiv status at rspi, prof. dr. sulianti saroso. as many as 6 serodiscordant participated in this study. data collected by in-depth interviews. the four main themes identified in this study: (1) knowledge of hiv/ aids, transmission method and causes the infected husband, (2) sexual needs, (3) the prevention of hiv transmission, (4) views about sexuality. a good knowledge about the prevention of hiv serodiscordant ability badly in maintaining its negative hiv status during this time by means of the use of contraceptives and provide support in compliance to consume arvs. required education and ongoing counseling on improving his knowledge in serodiscordant about hiv/aids so as to reduce the occurrence of new cases of hiv. keywords: sexual experience, serodiscordant, maintaining a negative hiv status pendahuluan hiv/aids masih menjadi masalah di dunia, diperkirakan sebanyak 5,1 juta orang hidup dengan hiv/aids. dengan urutan tertinggi terdapat di china, india, dan indonesia (unaids, 2016). di indonesia, jumlah klien dengan hiv/aids menurut data ditjen pengendalian penyakit dan pengendalian lingkungan departemen kesehatan (pp & pl depkes) pada tahun 2015 sebanyak 735.256 orang dengan jumlah infeksi baru sebesar 85.532 orang. dki jakarta menempati urutan ketiga provinsi yang memiliki penderita hiv/aids yaitu sebesar 8.093, setelah provinsi jawa timur dan provinsi papua (kemenkes ri ,2016). faktor risiko tertinggi penularan virus hiv adalah pada hubungan heteroseksual yaitu sebesar 82,8%, serta homoseksual sebesar 7,4% (kemenkes, 2016). di pokja hiv/aids rs prof. dr. sulianti saroso yang merupakan rumah sakit rujukan kasus hiv/aids, terjadi peningkatan kasus baru pada tahun 2016 yaitu sebanyak 271 kasus dibanding tahun sebelumnya. dari 217 penderita baru 25% penderita hiv ditularkan oleh pasangannya (suami atau istri). peningkatan jumlah kasus baru karena tertular pasangan seksual kemungkinan karena ketidaktahuan pasangan mengenai pencegahan penularan hiv/aids. hubungan seksual sangat beresiko tinggi menularkan virus hiv, tetapi ada pasangan seksual penderita hiv yang tidak tertular virus hiv, mereka biasa di sebut serodiskordan. pasangan odha serodiskordan adalah jalinan hubungan pasangan odha (suami atau istri) dengan status salah satu dari pasangan terinfeksi hiv (hiv positif) dan pasangan lainnya tidak terinfeksi hiv (hiv negatif). pasangan serodiskordan mempunyai harapan untuk dapat hidup normal layaknya pasangan lainnya yang tidak menderita hiv. mereka tetap ingin memenuhi kebutuhan biologisnya terutama kebutuhan seksual meski dengan pasangan yang menderita hiv. menurut syafar (2014), serodiskordan (pasangan odha negatif hiv) memiliki sikap pasrah menghadapi risiko infeksi, demi keinginan memiliki anak dan keinginan merasakan seks tanpa pembatas. kebutuhan seksual tetap harus terpenuhi karena kebutuhan seksual berfungsi untuk pembuktian akan kesuburan, merasakan kesenangan atau kenikmatan, mempererat ikatan suami istri, menegaskan maskulinitas atau feminitas, meningkatkan harga diri, dan mengurangi ansietas atau ketegangan. dalam memenuhi kebutuhan biologisnya sebagian pasangan serodiskordan tetap menggunakan kondom untuk mencegah penularan baik itu pada pasangan heteroseksual maupun homoseksual (pebody, 2015). penggunaan kondom merupakan salah satu cara mencegah penularan virus hiv. meskipun kondom tidak 100% memberikan perlindungan untuk setiap infeksi, namun bila digunakan dengan tepat akan sangat mengurangi risiko infeksi (kemenkes, 2011). seperti dalam penelitiannya chaterine (2014), penggunaan kondom pada pasangan heteroseksual dan patuh mengkonsumsi arv (antiretroviral) mempunyai resiko yang paling rendah untuk penularan hiv ( 0,5%) dibandingkan hanya menggunakan kondom (76%). menurut kemenkes 2013, kepatuhan dalam penggunaan obat arv akan meningkatkan dampak positif pada tingkat kesehatan individu maupun di tingkat masyarakat, yaitu meningkatnya kualitas hidup odha (orang dengan hiv/ aids) dan terjadinya penurunan penularan hiv di masyarakat. 34 maka semakin banyak odha yang diobati maka semakin besar pula dampak manfaatnya dan akan menuju “3 zero”, yaitu zero infeksi baru, zero kematian terkait aids, zero stigma dan diskriminasi. bagi serodiskordan, penggunaan arv oleh pasangan seropositif menurunkan kekhawatiran terhadap penularan hiv ( stratena, 2000). pasangan serodiskordan merupakan kelompok beresiko penularan hiv, yang bisa berdampak pada peningkatan kasus infeksi baru. di indonesia masih sedikit penelitian yang membahas tentang serodiskordan, baik mengenai jumlah maupun pengalamannya. begitupun di rspi prof. dr. sulianti saroso, juga masih sangat minim data mengenai pasangan serodiskordan. berdasarkan fenomena diatas pengalaman serodiskordan dalam mempertahankan status hiv negatifnya tersebut perlu digali secara mendalam. tujuannya agar dapat teridentifikasi dan diperoleh informasi mengenai bagaimana aktivitas seksualnya, frekuensi melakukan hubungan seksual maupun alat kontrasepsi yang digunakan sehingga mereka tidak tertular hiv. selain itu diharapkan juga dapat tergali faktorfaktor apa saja yang mendukung seperti kepatuhan arv pasangan hiv positif, riwayat ims, dan profilaksis pada serodiskordan. dengan diperolehnya informasi tersebut diharapkan dapat menjadi pengetahuan bagi penderita hiv bagaimana mengurangi atau meminimalkan penularan pada pasangan seksualnya sehingga dapat berdampak pada pengurangan kasus infeksi baru tujuan penelitian penelitian ini bertujuan untuk mengeksplorasi berbagai pengalaman seksual serodiskordan dalam mempertahankan status hiv negatif di rspi prof. dr. sulianti saroso. metode penelitian penelitian ini merupakan penelitian kualitatif dengan pendekatan fenomenologi. pada penelitian ini berfokus pada pengalaman serodiskordan dalam mempertahankan status hiv negatif. kriteria inklusi informan dalam penelitian ini adalah pasangan odha yang memiliki status hiv negatif, memiliki suami yang memiliki status hiv positif dan sudah sudah menjalani pengobatan arv. informan sudah melakukan pemeriksaan anti hiv 2 sampai 3 kali berturut-turut, terakhir melakukan pemeriksaan anti hiv dalam waktu 3 bulan terakhir dan hasil hiv negatif. jumlah informan pada penelitian ini sebanyak 6 orang dan key informan dalam penelitian ini adalah suami informan dengan status hiv positif. pengumpulan data didapatkan dengan menggunakan tekhnik wawancara mendalam (in depth interview) dengan alat pengumpulan data yang digunakan adalah panduan pertanyaan, buku catatan lapangan, alat tulis dan alat perekam. selama penelitian, peneliti selalu meyakinkan informan bahwa informan terlindungi dengan memperhatikan aspek kebebasan untuk menentukan apakah informan bersedia atau tidak untuk meberikan informasi yang dibutuhkan dan secara sukarela menadatangani lembar persetujuan (self determination). informan juga dijaga kerahasiaan identitas dan alamatnya selama dan sesudah penelitian (anonimity) dan data yang digunakan hanya untuk kegiatan penelitian (privacy & dignity), lalu setiap kerahasiaan informan dijaga dengan memberikan kode informan inf 01, inf 02 dan seterusnya (confidentialy) dan penelitipun memberi kebebasan informan untuk memilih waktu dan tempat dilakukannya wawancara (protection from discomfort). setelah data sudah dirasa lengkap peneliti mulai melakukan prngolahan data. proses pengolahan data yang dilakukan peneliti dimulai dari membuat transkripsi yaitu merubah rekaman suara menjadi bentuk tertulis secara verbatim berserta dengan catatan lapangan. berikutnya peneliti membaca transkripsi berulangulang untuk memahami setiap pernyataan informan sehingga didapat kata kunci dari setiap informan kemudian dikelompokkan menjadi berbagai kategori lalu selanjutnya kategori dipahami untuk menentukan tematema utama yang muncul. adapun uji validitas data yang peneliti gunakan dalam penelitian ini yaitu dengan uji kreadibilitas data atau kepercayaan terhadap data hasil penelitian, yang meliputi: dengan merekam hasil wawancara dan mendengarkannya berulangulang, wawancara lagi dengan sumber data yang telah ditemui dengan tujuan mengecek kembali data yang peneliti peroleh benar atau tidak dengan cara mengklarifikasi jawaban dari informan sebelumnya, dengan triangulasi pengecekan data dari suami informan. 35 vol. 1 no. 2 juni 2017 hasil penelitian a. karakteristik informan tabel 4.1 karakteristik data sosiodemografi informan kode informan umur jenis kelamin agama pendi dikan pekerjaan usia pernikahan lama suami terdiagnosa hiv inf.01 39 thn perempuan katolik smea wiraswasta 11 thn 9 thn inf.02 45 thn perempuan islam slta irt 7 thn 3 thn inf.03 44 thn perempuan islam sd wiraswasta 19 thn 3 thn inf.04 35 thn perempuan islam slta irt 3 thn 1 thn inf.05 38 thn perempuan kristen pt wiraswasta 8 thn 8 thn inf.06 38 thn perempuan islam sd irt 15 thn 7 thn informan dalam penelitian ini berjumlah enam orang yang semuanya berjenis kelamin perempuan, sesuai dengan kriteria inklusi bahwa informan adalah istri dari penderita hiv positif dengan status hiv negatif, berusia antara 35 45 tahun, dan agama terdiri dari agama kristen dan islam. tingkat pendidikan informan juga beragam, mulai dari lulusan sekolah dasar (sd), sekolah lanjutan tingkat atas (slta/ smea) dan perguruan tinggi (pt). jenis pekerjaan informan terdiri dari ibu rumah tangga (irt) dan dan wiraswasta. adapun usia pernikahan informan bervariasi dari 3 tahun hingga 19 tahun dan lamanya suami terdiagnosa hiv pun bervariasi dari 1 tahun hingga 9 tahun. b. analisis tematik tema-tema yang teridentifikasi setelah dilakukan wawancara mendalam dan dilakukan analisa terdapat 4 tema yang teridentifikasi yaitu: 1) pengetahuan tentang hiv/aids skema tema pengetahuan tentang hiv/ aids kategori sub tema tema penyakit karena hubungan seksual penyakit karena jarum suntik cara penularan hiv/aids penyakit karena cairan tubuh pengetahuan tentang hiv/aids pengertian hiv/aids melalui hubungan sex melalui cairan tubuh melalui jarum suntik penyebab suami tertular hiv free sex narkoba suntik tidak tahu 36 2) kebutuhan seksual skema tema 2 kebutuhan seksual kategori sub tema tema kebutuhan biologis kewajiban melayani suami tanpa penetrasi hubungan sex bukan prioritas frekuensi hubungan seksual hubungan sex mempererat pernikahan pengetahuan hubungan seksual kebutuhan seksual normal : 3-4x seminggu tidak normal: dari november sampai sekarang cuma 3x sebulan 23x tidak pernah 1 thn tidak pernah 7 tahun alat kontrasepsi sexual role tidak pernah coitus coitus interuptus 3) pencegahan penularan hiv/aids skema 3 tema pencegahan penularan hiv kategori sub tema tema pencegahan penularan hiv kontrasepsi dukungan kepatuhan arv profilaksis pada serodiskordan kondom coitus interuptus histerektomi alarm mengingatkan menyiapkan arv tidak mendapatkan profilaksis 4) pandangan tentang seksualitas. skema tema 4 pandangan tentang seksualitas kategori sub tema tema pandangan tentang seksualitas agama biologis ibadah istri kewajiban kebutuhan manusia berkembang biak pembahasan tema 1: pengetahuan tentang hiv/aids. pada tema ini menekankan bagaimana gambaran pengetahuan informan mengenai hiv/aids yang tengah diderita oleh suami informan. dari wawancara mendalam didapat beberapa kategori pada pengetahuan informan mengenai hiv/aids yaitu penyakit yang disebabkan oleh hubungan seksual, penyakit karena cairan tubuh, penyakit karena jarum suntik, menular melalui hubungan sex, melalui cairan tubuh, melalui jarum suntik, sex bebas, narkoba suntik, dan tidak tahu. dari beberapa kategori-kategori tersebut muncul 3 sub tem yaitu pengertian hiv/aids, cara penularan hiv/aids dan penyebab suami tertular hiv/aids. berikut penjelasan dari tema yang diperoleh: a. pengertian hiv/aids dari hasil wawancara mendalam, enam informan mempunyai pengetahuan beragam mengenai pengertian hiv/ aids. semua informan tidak ada yang mampu menyebutkan pengertian hiv/aids secara teoritis, semua informan menjawab berdasarkan cara penularannya. semua informan menjawab bahwa hiv/aids adalah penyakit yang disebabkan oleh hubungan seksual. selain itu ada beberapa informan yang menjawab bahwa hiv/aids adalah penyakit yang disebabkan oleh cairan tubuh dan jarum suntik. padahal secara teoritis, 37 vol. 1 no. 2 juni 2017 pengertian hiv adalah virus yang menyebabkan aids dan aids sendiri adalah sekumpulan gejala atau penyakit yang disebabkan oleh menurunnya kekebalan tubuh akibat infeksi oleh virus hiv (sudoyo aru, dkk 2009). tingkat pendidikan informan yang beragam kemungkinan besar mempengaruhi tingkat pengetahuan informan. ini dirujuk dari hasil penelitian oktarina,dkk (2009), bahwa terdapat hubungan antara pendidikan dan tingkat pengetahuan tentang hiv/aids. hasil ini menggambarkan semakin tinggi tingkat pendidikan semakin baik pula tingkat pengetahuannya. responden yang mempunyai tingkat pendidikan tinggi cenderung mempunyai pengetahuan yang lebih baik, demikian juga sebaliknya. berdasarkan hasil wawancara, semua informan mendapatkan informasi mengenai hiv/aids ketika mereka konseling pertama kali saat suami terdiagnosa hiv/aids. masingmasing informan berbeda dalam waktu mendapatkan konseling pertama kali, ada yang 1 tahun terakhir hingga 9 tahun terakhir, sehingga sangat dimaklumi ketika pengetahuan informan tidak terlalu baik mengenai pengertian hiv/ aids. konseling yang berkelanjutan dan terus menerus sangat dibutuhkan oleh serodiskordan untuk meningkatkan pengetahuan serodiskordan. penularan hiv/aids dapat terjadi walau istri hanya berhubungan seks dengan suami, sehingga dalam upaya melindungi diri dari ancaman hiv dan aids maka pasangan dan perempuan usia subur perlu memiliki informasi, pengetahuan/ pemahaman mengenai kesehatan reproduksi, ims, serta hiv dan aids. perbaikan akses dan sumber informasi harus selalu ada untuk meningkatkan pengetahuan, kepedulian dan perlindungan suami serta anggota keluarga lainnya, termasuk dalam hal ini adalah kemampuan perempuan untuk memutuskan mengenai kebutuhan hubungan seksualnya (kemenpppa, 2008). b. cara penularan hiv/aids berdasarkan hasil wawancara mendalam mengenai pengetahuan informan tentang cara penularan hiv/aids, semua informan mengetahui bahwa hiv/aids ditularkan melalui hubungan seksual, melalui cairan tubuh (darah, asi) dan jarum suntik yang di gunakan bergantian. menurut nursalam (2007), penularan hiv & aids dapat ditularkan melalui 6 cara yaitu melalui hubungan seksual tanpa kondom dengan pengidap hiv/aids baik secara vaginal, oral dan anal ; melalui proses kelahiran dan menyusui; melalui transfusi darah, produk darah dan organ donor; pemakaian alat kesehatan yang tidak steril; alat-alat untuk menoreh kulit; dan menggunakan jarum suntik tidak steril bergantian. c. penyebab suami tertular hiv/aids berdasarkan penelitian yang sudah dilakukan peneliti dengan wawancara mendalam sebagian informan mengatakan bahwa suaminya tertular hiv/aids karena riwayat melakukan sex bebas baik saat sudah menikah maupun sebelum menikah dengan informan. ini sesuai dengan hasil penelitan megawati (2014), bahwa cara penularan hiv terbanyak adalah melalui hubungan seksual dengan lawan jenis, dengan aktivitas seksual yang sering dilakukan adalah vaginal seks dan anal seks, 84,2% perempuan tertular hiv dari vaginal seks, 30,8% lakilaki tertular hiv karena penerima anal seks, 21,1% perempuan tertular hiv karena penerima anal seks. dan menurut hoffman (2015) resiko penularan hiv melalui vaginal intercourse yang tidak aman bersiko menularkan hiv sebanyak 0,05% 0,15 % setiap satu kali kontak (coitus). dan sebagian kecil informan mengatakan bahwa suaminya tertular hiv/aids akibat menggunakan narkoba suntik yang dipakai bergantian dengan temannya. penggunaan narkoba suntik merupakan faktor resiko penyebaran hiv, di indonesia pada tahun 2015 jumlah kasus baru hiv disebabkan oleh penasun (pengguna narkoba suntik) sebanyak 2,6% (kemenkes, 2016). dua informan berikutnya mengatakan bahwa informan tidak tahu dari mana suami mendapatkan virus hiv tersebut, informan terkesan menutupi dan tidak ingin membuka riwayat suaminya. informan akan berusaha menerima kekurangan dan kelebihan suami mereka. sikap informan tersebut merupakan bentuk dukungan informan terhadap suaminya, dan merupakan bentuk support kepada suami agar tetap semangat menjalani hidup. dukungan dari orang terdekat (keluarga) sangat berarti bagi odha seperti hasil penelitian payuk (2012) bahwa terdapat hubungan antara dukungan keluarga (p=0,000), dukungan teman (p=0,001), dan dukungan petugas kesehatan (p=0,023) dengan dukungan sosial orang dengan hiv&aids. penelitian ini menyarankan keluarga dan teman untuk memberikan dukungan penuh kepada odha sehingga odha mampu untuk meningkatkan kepatuhan dalam menjalani art (antiretroviral theraphy). 38 tema 2: kebutuhan seksual tema ini menjelaskan bagaimana pengalaman informan mengenai kebutuhan seksual, frekuensi hubungan seksual serodiskordan dan suami, dan bagaimana tekhnik hubungan seksual (sexual role) sehingga serodiskordan tidak tertular hiv/ aids, meskipun masih aktif melakukan hubungan seksual. kebutuhan seksual merupakan salah satu kebutuhan dasar manusia, begitupun pada penderita hiv/aids keinginan untuk memenuhi kebutuhan seksualnya pasti tetap ada. meski keinginan untuk berhubungan seksual selalu ada, tapi mereka cenderung menjaga pasangannya agar tidak tertular hiv, hal ini sesuai dengan hasil penelitian maspiah (2008) yang menunjukkan bahwa sebagian besar subyek penelitian tidak melakukan hubungan seksual berisiko karena melindungi diri dan pasangan, serta sebagai sarana kb. a. pengetahuan tentang hubungan seksual berdasarkan hasil wawancara mendalam pada keenam informan, pengetahuan informan mengenai konsep kebutuhan seksual khususnya mengenai pengertian hubungan seksual sangat beragam. beberapa informan mengatakan bahwa hubungan seksual adalah kebutuhan biologis baik pada wanita maupun pria. informan meyakini bahwa mereka wajib memenuhi kebutuhan suami dan melayani suami meski suami mereka menderita hiv/aids. keyakinan tersebut sesuai dengan keyakinan yang dianut informan yang berdasarkan dalam suatu hadits, diriwayatkan abdurrahman bin auf menjelaskan bahwa rasulullah saw. bersabda: ِهِتْأَت ْمَلَف ِهِشاَرِف ىَلِإ ُهَتَأَرْما ُلُجَّرلا اَعَد اَذِإ ىَّتَح ُةَكِئَالَمْلا اَهْتَنَعَل اَهْيَلَع َناَبْضَغ َتاَبَف َحِبْصُت artinya : “apabila seorang laki-laki mengajak istrinya ke ranjangnya, lalu sang istri tidak mendatanginya, hingga dia (suaminya) bermalam dalam keadaan marah kepadanya, maka malaikat melaknatnya hingga pagi tiba.” (hr. bukhari dan muslim). dan didalam al quran allah swt berfirman: ُهَّللٱ َلَّضَف اَمِب ِءٓاَسِّنلٱ ىَلَع َنوُمَّٰوَق ُلاَجِّرلٱ ۚۡمِهِلَٰوۡمَأ ۡنِم ْاوُقَفنَأ ٓاَمِبَو ٖضۡعَب ٰىَلَع ۡمُهَضۡعَب اَمِب ِبۡيَغۡلِّل ٖتَٰظِفَٰح ٌتَٰتِنَٰق ُتَٰحِلَّٰصلٱَف َّنُهوُظِعَف َّنُهَزوُشُن َنوُفاَخَت يِتَّٰلٱَو ُۚهَّللٱ َظِفَح ۡمُكَنۡعَطَأ ۡنِإَف َّۖنُهوُبِرۡضٱَو ِعِجاَضَمۡلٱ يِف َّنُهوُرُجۡهٱَو اّٖيِلَع َناَك َهَّللٱ َّنِإ ۗاًليِبَس َّنِهۡيَلَع ْاوُغۡبَت اَلَف ٣٤ اٖريِبَك artinya:“kaum pria adalah pemimpin bagi kaum wanita, karena allah telah melebihkan sebagian mereka (pria) atas sebagian yang lain (wanita), dan karena mereka (pria) telah menafkahkan sebagian dari harta mereka. maka dari itu, wanita yang salihah ialah yang taat kepada allah subhanahu wa ta’alaagi memelihara diri ketika suaminya tidak ada, karena allah telah memelihara (mereka). wanita-wanita yang kalian khawatirkan nusyuznya, maka nasihatilah mereka, dan jauhilah mereka di tempat tidur, dan pukullah mereka. jika mereka menaati kalian, janganlah kalian mencari-cari jalan untuk menyusahkan mereka. sesungguhnya allah mahatinggi lagi mahabesar.” (q.s. an nisa: 34). selain menjawab bahwa kebutuhan seksual adalah kebutuhan biologis dan merupakan kewajiban dalam melayani suami, ada juga informan yang mengatakan bahwa kebutuhan seksual berfungsi untuk mempererat pernikahan, dan menjaga keharmonisan rumah tangga sehingga memang harus dijaga. berbagai kondisi kesehatan suami informanpun mempengaruhi pasangan serodiskordan dalam memenuhi kebutuhan seksual masingmasing pasangan. b. frekuensi hubungan seksual dari hasil wawancara mendalam, jawaban mengenai frekuensi hubungan seksual serodiskordan bervariasi. sejak suami mereka terdiagnosa hiv sebagian besar informan (5 informan) mengatakan bahwa ada perubahan frekuensi dalam melakukan hubungan seksual, ini dikarenakan masalah kesehatan suami. dua informan mengatakan bahwa frekuensi hubungan seksual yang biasanya bisa dilakukan 2 sampai 3 kali dalam seminggu, tetapi sejak suami mereka sakit hubungan seksual dilakukan hanya 3 sampai 4 kali dalam sebulan. informan lainnya mengatakan bahwa dia dan suami hanya melakukan hubungan seksual sebanyak 3 kali dalam 8 bulan terakhir, 39 vol. 1 no. 2 juni 2017 ini dikarenakan kesehatan suami yang selalu menurun. frekuensi hubungan seksual kelima pasangan serodiskordan ini dikategorikan tidak normal, menurut boyke (2011) meski tidak ada pola baku dalam frekuansi hubungan sex suami istri, sangat dianjurkan suami istri berhubungan intim secara teratur 1-4 kali seminggu. pertimbangannya, frekuensi tersebut sesuai ritme tubuh atau kondisi fisiologis pria maupun wanita karena produksi sperma oleh testis sudah memenuhi kuota penampungan dalam waktu tiga hari, jika bisa mengikuti ritme fisiologis tersebut akan lebih baik. bahkan ada dua informan yang mengaku bahwa sejak suami terdiagnosa hiv, mereka tidak pernah lagi melakukan hubungan seksual dengan alasan bahwa suami tidak mau menularkan penyakit ini kepada istrinya. selain itu ada juga yang disebabkan karena disfungsi seksual, salah satu informan mengatakan bahwa sejak menderita hiv suami sudah tidak bisa lagi ereksi. ini sesuai dengan hasil penelitian mao (2009) kemungkinan laki-laki hiv positif mengalami bentuk disfungsi seksual dibandingkan dengan laki-laki hiv negatif: masalah ereksi (52% dibanding 39%), kesulitan ejakulasi (31% banding 22%), ejakulasi dini (21% banding 17%), kehilangan libido (60% banding 40%), ketiadaan kenikmatan seks (32% banding 26%), cemas terhadap kemampuan secara seksual (47% banding 42%) dan nyeri saat berhubungan seks (8% banding 7%). begitupun pada hasil penelitian zona md (2012), studi ini menunjukkan hubungan yang jelas antara erectile dysfunction (ed) dan hiv, setelah disesuaikan dengan usia dan bmi. selain infeksi hiv, hipogonadisme dikaitkan dengan ed. selain itu, prevalensi ed lebih tinggi pada laki-laki yang terinfeksi hiv dibandingkan laki-laki yang tidak terinfeksi hiv, di semua umur. tetapi masih ada pasangan serodiskordan (informan ke 5) yang tidak merasa ada perubahan frekuensi hubungan seksual, mereka masih melakukan 3 sampai 4 kali dalam seminggu. c. tekhnik hubungan seksual (sexual role) dari hasil penelitian beragam jawaban informan mengenai tekhnik dalam melakukan hubungan seks agar tidak tertular hiv, sebagian besar informan mengaku menggunakan pengaman (kondom) saat melakukan hubungan seksual, waktu penggunaannya pun berbeda-beda sebagian besar informan mengatakan bahwa mereka menggunakan kondom sejak memulai aktivitas seksual bersama suami, tetapi ada satu informan yang mengatakan menggunakan kondom saat akan orgasme saja. dengan menggunakan kondom informan merasa lebih aman karena tidak terpapar langsung dengan cairan tubuh suami, dan ini mengurangi resiko penularan. ini merujuk pada penelitiannya chaterine (2014), bahwa penggunaan kondom pada pasangan heteroseksual dan patuh mengkonsumsi arv (antiretroviral) mempunyai resiko yang paling rendah untuk penularan hiv ( 0,5%). satu orang informan mengatakan menggunakan cara coitus interuptus untuk menghindari penularan hiv, ini sesuai dengan penelitian higgins phd (2013) bahwa kurang dari 1% peserta survei kuantitatif secara spontan coitus interuptus sebagai metode keluarga berencana mereka saat ini, 48% responden wawancara kualitatif melaporkan menggunakan metode coitus interuptus seumur hidup. coitus interuptus sering digunakan sebagai alternatif kondom yang menyenangkan, bila kondom tidak tersedia, dan / atau sebagai metode “placeholder” sebelum mendapatkan kontrasepsi suntik dan beberapa responden menggambarkan penggunaan metode coitus interuptus untuk mengurangi risiko hiv. selain itu terdapat informan yang menggunakan tekhnik tanpa penetrasi dalam memenuhi kebutuhan seksual suami, itu dilakukan hanya sebagai pengganti atau selingan diantara penggunaan kondom. dua informan lainya bahkan mengatakan tidak pernah melakukan hubungan seksual dalam bentuk apapun sejak suami terdiagnosa hiv. tema 3: pencegahan penularan hiv tema ini menjelaskan tentang bagaimana pengalaman serodiskordan dalam mencegah penularan hiv terhadap diri mereka, yang terdiri dari kontrasepsi apa yang digunakan, bagaimana bentuk dukungan serodiskordan agar suami tetap patuh pada pengobatan arv, dan profilaksis apa yang didapat oleh serodiskordan agar mereka tidak tertular hiv. a. kontrasepsi berdasarkan hasil wawancara mendalam sebagian besar informan mengatakan menggunakan kondom saat berhubungan seksual, penggunaan kondom lebih dari satu lapis pun menjadi pilihan salah satu informan karena ketakutan akan tertular virus hiv. penggunaan kondom secara konsisten merupakan salah satu anjuran pemerintah untuk mencegah penularan hiv (permenkes, 2013). hal inipun sesuai dengan 40 penelitian c weller (2002) bahwa penggunaan kondom secara konsisten dapat mengurangi 80% dalam kejadian hiv. memang tidak ada jaminan bahwa kondom akan memberikan perlindungan 100%, namun bila digunakan dengan benar, kondom akan mengurangi risiko-risiko penularan ims dan hiv (bkkbn, 2014). selain penggunaan kondom, kontrasepsi pilihan informan adalah dengan cara coitus interuptus. metode ini digunakan hanya selingan ketika tidak menggunakan kondom. satu informan lainnya mengaku tidak pernah menggunakan kontrasepsi selama berumah tangga dikarenakan telah melakukan histerktomi akibat perdarahan post partum. dan sejak suami terdiagnosa hiv satu tahun yang lalu, informan mengaku tidak pernah lagi melakukan hubungan seksual dalam bentuk apapun. b. dukungan kepatuhan arv berbagai bentuk dukungan serodiskordan dalam meningkatkan kepatuhan arv suaminya, mulai dari menggunakan alarm agar tidak terlewat waktu minum obat, selalu mengingatkan suami setiap waktu minum obat, dan selalu menyiapkan arv tepat waktu, baik disiapkan sendiri oleh informan maupun dengan bantuan keluarga lainnya. kepatuhan dalam mengkonsumsi arv merupakan salah satu cara mengurangi resiko penularan hiv kepada pasangan, hal ini sesuai dengan panduan art dari kemenkes (2014), bahwa terapi arv adalah pencegahan penularan hiv paling efektif saat ini. orang dengan hiv yang mempunyai pasangan seksual non-hiv (pasangan serodiskordan) harus diinformasikan bahwa terapi arv juga bertujuan untuk mengurangi risiko penularan pada pasangannya. kepatuhan dalam mengkonsumsi arv sangat dipengaruhi oleh dukungan dari orang-orang terdekat penderita hiv, terutama istri. ini didukung oleh penelitian sugiharti (2012) dengan hasil sebanyak 9 dari 11 odha memiliki tingkat kepatuhan odha minum obat arv > 95%. faktor-faktor yang mendukung odha dalam minum obat arv adalah faktor keluarga, teman, forum wpa (warga peduli aids) dan faktor internal dalam diri odha. c. profilaksis bagi serodiskordan berdasarkan hasil wawancara mendalam, semua informan mengaku tidak pernah mendapatkan profilaksis arv. tahun 2015, who mengeluarkan rekomendasi kembali bahwa dari dua belas percobaan efektivitas profilaksis oral yang telah dilakukan di antara pasangan serodiskordan, pria heteroseksual, wanita, pria yang berhubungan seks dengan pria, orang yang menyuntikkan narkoba dan transgender wanita, dibuat kesimpulan bahwa profilaksis sangat dianjurkan untuk pria yang berhubungan seks dengan pria dengan pertimbangkan bahwa lelaki sex lelaki (lsl) adalah orangorang yang berisiko tinggi tertular hiv. di indonesia, profilaksis prapajanan pada serodiskordan pasangan heteroseksual tidak terlalu ditekankan begitupun pelaksanaannya di pokja hiv aids rspi sulianti saroso, di rspi yang lebih diutamakan diberikan profilaksis yaitu khusus pada pasangan lsl, penasun dan pasca pajanan sesuai dengan rekomendasi who 2015. tema 4: pandangan tentang seksualitas tema ini menjelaskan bagaimana pandangan serodiskordan tentang seksualitas. seksualitas adalah kebutuhan dasar manusia dalam manifestasi kehidupan yang berhubungan dengan alat reproduksi. (stevens: 1999). sedangkan menurut who dalam mardiana (2012) seksualitas adalah suatu aspek inti manusia sepanjang kehidupannya dan meliputi seks, identitas dan peran gender, orientasi seksual, erotisme, kenikmatan, kemesraan dan reproduksi. a. agama dari hasil wawancara mendalam sebagian informan mengatakan bahwa seksualitas adalah suatu bentuk ibadah istri terhadap suami, dan merupakan kewajiban dalam melayani suami. keyakinan bahwa melayani suami merupakan ibadah tertuang dalam sebuah hadist: rasulullah saw bersabda, “dalam kemaluanmu itu ada sedekah.” sahabat lalu bertanya, “wahai rasulullah, apakah kita mendapat pahala dengan menggauli istri kita?.” rasulullah menjawab, “bukankah jika kalian menyalurkan nafsu di jalan yang haram akan berdosa? maka begitu juga sebaliknya, bila disalurkan di jalan yang halal, kalian akan berpahala.” (hr. bukhari, abu dawud dan ibnu khuzaimah). dan dalam hal hubungan seksual, istri wajib melayani suami jika suami mengajaknya untuk berhubungan, maka istri tidak boleh menolaknya, ini merujuk pada hadist: 41 vol. 1 no. 2 juni 2017 ِّيِبَّنلا ِنَع : ُهْنَع ُهَّللا َيِضَر َةَرْيَرُه يِبَأ ُثيِدَح اَذِإ َلاَق َمَّلَسَو ِهْيَلَع ُهَّللا ىَّلَص اَهْتَنَعَل اَهِجْوَز َشاَرِف ًةَرِجاَه ُةَأْرَمْلا ِتَتاَب َحِبْصُت ىَّتَح ُةَكِئاَلَمْلا artinya: diceritakan dari abu hurairah bahwa rasulullah bersabda: etika suami mengajaknya berhubungan intim, kemudian ia menolaknya, sehingga suami tidur dengan penuh kegundahan, ia dilaknat oleh para malaikat sampai pagi. (hr. muslim). b. biologis berdasarkan hasil wawancara, beberapa informan mengatakan bahwa seksualitas itu merupakan kebutuhan manusia baik laki-laki ataupun perempuan dan merupakan cara manusia untuk memperoleh keturunan (berkembang biak). seperti firman allah swt: ْنِم ْمُكَقَلَخ يِذَّلا ُمُكَّبَر اوُقَّتا ُساَّنلا اَهُّيَأ اَي الاَجِر اَمُهْنِم َّثَبَو اَهَجْوَز اَهْنِم َقَلَخَو ٍةَدِحاَو ٍسْفَن َنوُلَءاَسَت يِذَّلا َهَّللا اوُقَّتاَو ًءاَسِنَو اًريِثَك اًبيِقَر ْمُكْيَلَع َناَك َهَّللا َّنِإ َماَحْرألاَو ِهِب artinya : “hai sekalian manusia, bertakwalah kepada tuhan-mu yang telah menciptakan kamu dari diri yang satu, dan daripadanya allah menciptakan istrinya; dan daripada keduanya allah memperkembang biakkan laki-laki dan perempuan yang banyak. dan bertakwalah kepada allah yang dengan (mempergunakan) nama-nya kamu saling meminta satu sama lain, dan (peliharalah) hubungan silaturahmi. sesungguhnya allah selalu menjaga dan mengawasi kamu “. (qs. an nisaa :1). kesimpulan berdasarkan dari hasil penelitian dapat disimpulkan pengalaman pengalaman serodiskordan dalam mempertahankan status hiv negatife: 1. diperoleh gambaran karakteristik informan, jumlah informan sebanyak 6 orang dengan usia antara 35 45 tahun, dan agama terdiri dari agama kristen dan islam. tingkat pendidikan informan sekolah dasar (sd), sekolah lanjutan tingkat atas (slta/ smea) dan perguruan tinggi (pt). jenis pekerjaan terdiri dari ibu rumah tangga (irt) dan dan wiraswasta. usia pernikahan dari 3 tahun hingga 19 tahun dan lamanya suami terdiagnosa hiv dari 1 tahun hingga 9 tahun. 2. diperoleh gambaran pengetahuan mengenai hiv/ aids, pengetahuan tentang hiv/aids tergambar dari pengetahuan informan mengenai pengertian hiv/aids, cara penularan dan penyebab suami tertular hiv. semua informan tidak dapat menjelaskan pengertian hiv/aids secara konsep, informan lebih banyak tahu mengenai cara penularan hiv/aids. ketakutan – ketakutan akan penularan hingga ada beberapa informan yang tidak melakukan hubungan seksual sama sekali karena kurang pengetahuan. perlu diberikan informasi yang terus menerus terutama informasi-informasi terbaru mengenai hiv/aids kepada serodiskordan. 3. diperoleh gambaran dan informasi mendalam mengenai kebutuhan seksual serodiskordan, ini tergambar dari pengetahuan tentang hubungan seksual, frekuensi hubungan seksual dan sexual role serodiskordan. pemenuhan kebutuhan seksual pasangan serodiskordan sangat dipengaruhi oleh kondisi kesehatan suami yang menderita hiv/aids sehingga mempengaruhi frekuensi melakukan hubungan seksual. sexual role pasangan serodiskordan bervariasi : menggunakan alat kontrasepsi, coitus interuptus, tanpa penetrasi dan tidak berhubungan sex sama sekali 4. diperoleh gambaran dan informasi mendalam mengenai alat kontrasepsi yang digunakan pasangan hivserodiskordan. kontrasepsi yang digunakan pasangan serodiskordan sebagian besar adalah kondom, coitus interuptus dilakukan hanya sebagai pengganti jika kondom tidak tersedia. 5. diperoleh gambaran dan informasi mendalam mengenai cara pencegahan penularan hiv yang dilakukan serodiskordan. serodiskordan melindungi dirinya dari penularan hiv/aids yaitu dengan penggunaan pengaman dan tidak berhubungan seksual sama sekali juga menjadi pilihan serodiskordan dalam melindungi dirinya agar tidak tertular hiv. 42 6. diperoleh gambaran dan informasi mendalam mengenai kepatuhan arv pasangan hiv dan profilaksis yang digunakan oleh serodiskordan dan lama penggunaanya. semua pasangan informan teratur dan patuh dalam mengkonsumsi arv dan semua informan tidak pernah mendapatkan profilaksis. 7. diperoleh gambaran dan informasi mendalam mengenai pandangan serodiskordan tentang seksualitas dilihat dari sisi agama yaitu merupakan bentuk ibadah istri, dan merupakan kewajiban istri dalam melayani kebutuhan seksual suami. dan pandangan seksualitas dari sisi biologis bahwa sex merupakan kebutuhan manusia dan cara memperbanyak keturunan. referensi yulianti, adiningtyas prima (2013). kerentanan perempuan terhadap penularan hiv/aids: studi pada ibu rumah tangga pengidap hiv/aids di kabupaten pati. palastren jurnal vol. 6, no. 1, juni 2013. van der straten, ariane (2010). sexual risk behaviors among heterosexual hiv serodiscordant couple in the era of postexposure prevention and viral suppresive therapy. california. aids 2010, vol 14 no 4. aru w, sudoyo (2009). buku ajar ilmu penyakit dalam, jilid ii, edisi v. jakarta. martin, catherine (2014). hiv prevention in serodiscordant cuoples. wits reproductive health and hiv institute. centre for disease control and prevention (2013). hiv testing and risk behaviors among gay, bisexual, and other men who have sex with men. united states. 2013 nov 29;62(47):958-62. rokhmah, dewi (2015). pola asuh dan pembentukan perilaku seksual berisiko terhadap hiv/aids pada waria. jurnal kesehatan masyarakat. http://journal. unnes.ac.id/nju/index.php/kemas megawati, dhita danny (2015). perilaku seksual pada orang dengan hiv di yogyakarta. skripsi : naskah publikasi ugm. martha, evi; kresno, sudarti (2016). metodologi penelitian kualitatif untuk bidang kesehatan. jakarta: raja grafindo persada. dalimoenthe, ikhlasiah (2011). perempuan dalam cengkeraman hiv/aids: kajian sosiologi feminis perempuan ibu rumah tangga. unj. komunitas vol 5 , nomor 1, juli 20111; 41-48. kemenkes (2011). pedoman nasional penanganan ims 2011. jakarta kemenkes (2013). pedoman penatalaksanaan hiv/aids. jakarta. kemenkes (2014). permenkes pedoman pemberian antiretroviral. jakarta. kemenkes (2016). profil kesehatan indonesia.jakarta kemenpppa (2008). pemberdayaan perempuan dalam pencegahan penyebaran hiv-aids. jakarta odendal, lesley (2009). increased risk of hiv transmission in serodiscordant coples wishing to conceives. https:// aidsmap.com. bukit, lidya mellisa (2015). dimensi budaya dan penyebaran hiv/aids di perkumpulan kasih rakyat. usu. perspektif sosiologi, vol 3, no 1, oktober 2015. lowdermilk, perry, cashion (2014). maternity nursing 8th edition. evolve saryono, mekar dwi anggraeni (2011). metodologi penelitian kualitatif dalam bidang kesehatan. yogyakarta: nuha medika. syafar, dkk (2014). analisis hambatan perilaku pencegahan hiv aids pada pasangan serodiskordan di kota makasar. unhas. http://repository.unhas.ac.id/ handle/123456789/11558 mardiana (2012). aktifitas seksual pra lansia dan lansia yang berkunjung ke poliklinik geriatric rs pusat angkatan udara dr. esanawati antariksa jakarta timur. skripsi: fkm ui. mao l et al (2009). self-reported sexual difficulties and their association with depression and other factors among gay men attending high hiv-caseload general practices in australia. j sex med 6: 1378-85, 2009. moleong, m.a (2014). metodologi penelitian kualitatif edisi revisi. bandung. remaja rosdakarya. n.p.diwyami, a.a.s. sawitri, d.n.wirawan (2011-2015). sexual role dan riwayat infeksi menular seksual sebagai risiko serokonversi hiv pada laki seks dengan laki yang berkunjung di klinik bali medika badung, bali. bali. 43 vol. 1 no. 2 juni 2017 nursalam (2007). asuhan keperawatan pada pasien terinfeksi hiv. jakarta. salemba medika. febriani, nurul (2010). pola penyakit saraf pada penderita hiv/aids di rsup dr. kariadi semarang. undip. becquet, renaud (2007). early mixed feeding and breastfeeding beyond 6 months increase the risk of postnatal hiv transmission. http://dx.doi. org/10.1016/j.ypmed.2007.11.014 heffron, r (2011). hormonal contraceptive use and risk of hiv-1 transmission: a prospective cohort analysis. 6th international aids society conference on hiv pathogenesis, treatment and prevention (ias 2011). rome, july 17-20, 2011. abstract weax0206. pebody, roger (2015). awarenes of treatment’s impact on transmission is transforming the lives of couple of mixed hiv status in australia. sociology of health and illness australia. http://spiritia.or.id/ price, sylvia a. (2007). patofisiologi konsep klinis dan proses-proses penyakit. dialih bahasa oleh brahm dr, dkk. jakarta. egc weller, susan c (2002). condom effectiveness in reducing heterosexual hiv transmission. chocrane library. http://onlinelibrary.wiley.com/ getidentitykey?redirectto susilowati, tuti (2012). faktor –faktor risiko yang berpengaruh terhadap kejadian hiv dan aids di semarang dan sekitarnya. jurnal komunikasi kesehatan http://e-journal.akbid-purworejo.ac.id/ index.php/jkk2/article/view/45 khatimah, umi khusnul (2013). hubungan seksual suami-istri dalam perspektif gender dan hukum islam. ahkam jurnal ilmu syariah. http://journal. uinjkt.ac.id/index.php/ahkam/article/view/936 unaids (2016). aids up date 2016. switzerland. raharjo, wahyu (2016). harga diri seksual , konvulsivitas seksual, dan perilaku seks beresiko pada orang dengan hiv/aids. universitas gunadarma: jurnal psikologi volume 43, nomor 1, 2016: 52 – 65 wall km (2016). hormonal contraception safe for women with hiv and may have important health benefit. australia who (2012). guidance on couples hiv testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples. switzerland. zona md, et al (2012). erectile dysfunction is more common in young to middle-aged hiv-infected men than in hiv-uninfected men. university of modena and reggio emilia. http://onlinelibrary.wiley.com/ doi/10.1111/j.1743-6109.2012.02750.x/full vol. 4 no. 1 june 2020 1 ijnp (indonesian journal of nursing practices) vol 4 no june 1, 2020 : 1-6 machmudah1, nikmatul khayati1, sri widodo1, elsi dwi hapsari2, fitri haryanti2 1universitas muhammadiyah semarang 2universitas gadjah mada corresponding author: machmudah email: machmudah@unimus.ac.id improvement of prolactin hormone levels on postpartum mothers taken by the oketani massage and pressure in gb-21 point article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.41101 abstract background: breastfeeding will provide a wide range of benefits for both mother and baby. breastfeeding is one of the physical adaptations and processes of changing maternal roles in postpartum mothers. not all mothers can go through this process correctly. a small amount of milk production on the first day of postpartum is one of the complaints that is often felt by mothers. the hormone prolactin is one of the factors that influence milk production. one way to stimulate the production of the hormone prolactin is by breast treatment. breast care will affect hypopise to release the hormone progesterone, estrogen, prolactin, and oxytocin more. objective: the purpose of this study was to identify the effect of pressure on the jianjing gb-21 acupressure point and oketani massage on the level of the hormone prolactin. method: the type of this research is a quasi-experiment with the design used is a pre-post-test design with the control group. prolactin hormone levels were examined before the intervention (on the first day) and on a ninth day. the examination was carried out using the elisa (enzym linked immunosorbent assay) technique. data obtained was analyzed using an independent sample t-test. result: the study showed that there was an increase in mean values of maternal prolactin levels after oketani massage intervention and pressure on gb-21 acupressure points. the administration of a combination of interventions, namely oketani massage and pressure at the gb-21 point, can increase the highest levels of the hormone prolactin, which is 3.41. whereas in the control group that did not get any intervention, had the lowest levels of the hormone prolactin that is equal to 2,925 conclusion: it can be concluded that oketani massage and applying pressure at the gb-21 point can increase the levels of the hormone prolactin, respectively. keywords: acupressure; jianjing gb-21; oketani massage; prolactin introduction infant mortality rate (imr) in indonesia is still quite high compared to countries in southeast asia, which is 24 per 1,000 live births, compared to malaysia (16/1000) and singapore (2/1000) live births. this figure is also far from the target sdgs of 12 per 1000 live births in 2030 (national population and family planning board bkkbn, statistics indonesia bps, ministry of health kemenkes, & icf, 2018). the most common causes of infant death are diarrhea and drinking problems (31.4%) and pneumonia (23.8%) (ministry of health, 2018). the high infant mortality rate can be overcome if the baby gets adequate nutrition through breastfeeding. unicef data states that 30,000 infant deaths in indonesia and 10 million 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/3478 indonesian journal of nursing practices 2 infant deaths in the world each year can be prevented through exclusive breastfeeding for six months from the date of birth, without having to provide additional food and drink to babies (flaherman, chan, desai, agung, hartati, & yelda, 2018). based on indonesia's health profile in 2017, the coverage of exclusive breastfeeding in indonesia reaches 35.73% or about one-third of babies who get exclusive breastfeeding from birth until the age of six months (ministry of health, 2017). while the coverage data for exclusive breastfeeding in central java in 2017 was 41.89%. data from the semarang city health office shows that the coverage of exclusive breastfeeding in semarang city in 2017 was 67.16%, reaching the target of the central java provincial health office at 65%. but there are still some areas in the city of semarang where coverage of exclusive breastfeeding is still below the target (central java provincial health department, 2017). exclusive breastfeeding is influenced by several factors, such as breastfeeding knowledge, attitude, subjective norm, practice control, and breastfeeding experience (huang, ouyang, & redding, 2019; zhang, zhu, zhang, & wan, 2018). breastfeeding experience is included the involvement of breastfeeding not coming out immediately on the first day after giving birth, mothers feel breast milk comes out a bit, difficulty in sucking the baby, the state of putting mother's milk, and the influence of the promotion of replacement milk (isytiaroh, 2019). field conditions indicate that early breastfeeding success is also influenced by the mother's and baby's health. post-cesarean section mothers need recovery time due to the effects of anesthesia and the pain of the cesarean section. the policy of several hospitals that do not implement rooming in with the reason that the mother still needs supervision is weak and cannot care for her baby will cause breastfeeding to experience a delay. the delayed breastfeeding will cause the mother to stop breastfeeding. research conducted by hobbs, mannion, mcdonald, s. brockway, & tough (2016) reveals that women who delivered by planned c-section had no intention to breastfeed or did not initiate breastfeeding. it makes them have a three times greater risk of stopping breastfeeding in the first month postpartum compared to mothers who gave birth normally. blushing and pumping breast milk for 10-20 minutes to overcome the delayed breastfeeding process until the baby can suckle. blushing and pumping breast milk can help maximize prolactin receptors and reduce the risk due to the absence of breastfeeding (jones, 2018). in addition to expressing milk, efforts to stimulate the hormones prolactin and oxytocin can also be made by breast care, breast massage, oxytocin massage, endorphin massage, and acupressure. massage can influence psychological factors, thereby increasing the relaxation and comfort level of the mother, reducing stress and making the mother more healthy and relaxed. oketani massage in postpartum mothers can cause breasts to become softer, the areola and nipples become elastic, increase the flow of milk because there is pressure on the alveoli, provide comfort and relieve pain in the breast (kabir & tasnim, 2009). stimulation to increase the reflex letdown can be done by acupressure massage at jianjing gb-21 point. the pressure at this point, can provide calm and relaxation during breastfeeding (moriarty, & sharp, 2013). research on the intervention of oketani massage and applying pressure at the jianjing gb-21 point has not been done much in indonesia, so it is necessary to conduct a study of the effect of oketani massage and acupressure at the gb-21 point in increasing the production of the hormone prolactin. the purpose of this study was to identify the effect of pressure on the jianjing gb-21 acupressure point and oketani massage on the level of the hormone prolactin. method this type of research is a quasi-experiment with the design used is the pre-post-test design with a control group. in this study, divided into two groups, namely the intervention group and the vol. 4 no. 1 june 2020 3 control group, measurements were made at the first and last time of the study. (sugiyono, 2001). the study was conducted from july to september 2017. the intervention group was divided into three interventions, the first group was given the intervention of oketani massage, the second group was given a pressure intervention at the point gb-21, and the third group was given the intervention of a combination of oketani massage and pressure at the point gb-21. prolactin hormone levels were examined before the intervention (on the first day) and on a ninth day. the examination was carried out using the elisa (enzym linked immunosorbent assay) technique. the sample was postpartum mothers in the mlati ii public health center in sleman. the inclusion criteria in this study were normal postpartum mothers in the mlati ii public health center in sleman, providing exclusive breastfeeding, healthy infants, infant weight of 2800 4000 grams. criteria for exclusion were mothers with postpartum complications, such as postpartum hemorrhage, postpartum infection, anemia. to describe the characteristics of respondents and the dependent variable using the frequency distribution while analyzing differences in the levels of the hormone prolactin in the intervention and control groups using the independent sample t-test. prior to the research, the proposal was carried out in a study at the medical / health research biotetics commission of fk unnisula semarang proven by certificate number 192 / v / 2017 / biotic commission. results the study result is shown in table 1. it explains that the youngest age is found in the oketani group, which is the age of 20 years, the oldest one is in the combination group (oketani and pressure at the point of gb-21), namely 42 years. the highest number of deliveries (parity) in all groups was three births. table 1. distribution of respondents based on age and parity variable group min max mean s.d age gb-21 24 40 30 6,058 oketani 20 38 32 7,162 combination 24 42 32 7,106 control 26 42 32 6,181 parity gb-21 1 6 3 1,92 oketani 1 3 2 0,836 combination 2 3 2 0.54 control 1 3 2 0.707 table 2 shows that the administration of a combination of interventions, namely oketani massage and pressure at the gb-21 point, can increase the highest levels of the hormone prolactin, which is 3.41. whereas in the control group that did not get any intervention, had the lowest levels of the hormone prolactin that is equal to 2,925. discussion the results of the study explained that the youngest age of the respondents was 20 years in the oketani group. respondents have a junior high school education background with p1a0 obstetric status, gives birth to the first child with a birth weight of 3200 grams. this respondent showed the lowest prolactin level on the first day compared to other respondents, which was 41 ng / ml. table 2. prolactin hormone levels in respondents before (day 1) after (day 9) group min max mean sd min max mean sd gb-21 2.65 3.3 2.95 0.26 1.82 3.08 2.47 0.53in oketani massage 2.22 3.13 2.84 0.325 0.593 3.13 2.92 0.98 combination 2.3 3.16 2.8 0.367 2.44 3.41 2.86 0.36 control 2.309 3.160 3.02 0.145 1.82 2.925 2.707 0.273 the oldest respondent age was 42 years in the combination group (oketani and pressure at point gb-21). respondents have a junior high school education background with p2a0 obstetrics status, giving birth to a baby with a birth weight of 2500 grams. respondents had prolactin levels on the first indonesian journal of nursing practices 4 day at 30.7 ng / ml (the lowest compared to respondents in the same group). prolactin hormone levels the results of this study showed that on a ninth day, an increase in prolactin was 3.41 in the intervention group combination of oketani massage and pressure at the gb-21 point, low prolactin levels occurred in the group without intervention. effective interventions reduce stress, increase relaxation, enhance the immune system so that people can feel healthier is with massage (yu, wells, wei, & fewtrell, 2019). massage is one way to release prolactin and oxytocin into the body. satomi oketani from japan was the first person to develop an oketani massage. the oketani massage is considered as a useful technique to build confidence and improved milk secretion among mothers facing difficulty during lactation (roy, tasnim, jahan, nazmeen, debnath, & islam, 2019). it is proven to provide comfort, provide a relaxed feeling, reduce pain in postpartum mothers, and load the breast feels softer, makes the mothers more feels elastic in their areola and nipples, makes it easier for babies to suckle because there is an emphasis on the alveoli so that the flow of milk is smoother. oketani massage is done for 15-20 minutes, by giving massage to the retro mammary (oketani massage steps the first technique to the seventh technique) and one massage technique on the right and left breast (the eighth technique) (kabir & tasnim, 2009). the results of this study indicate that the intervention of oketani massage on respondents can increase levels of the hormone prolactin by 3.13 on the ninth day. this research is in line with foda's theory (2004), which explains that the increase in the production of the hormone prolactin and oxytocin by the intervention of oketani massage. the production of breast milk in the alveoli is influenced by the hormone prolactin, while that which stimulates the breast glands for breast milk is the hormone oxytocin. prolactin hormone secretion can be stimulated by other interventions that put pressure on the jianjing gb-21 acupressure point (gall blader 21) (yelland, 2005). the results of this study showed an increase in the level of the prolactin hormone on the ninth day was 3.08 in the group of respondents with the intervention of the jianjing gb-21 acupressure point, whereas on the first day the level of the prolactin hormone level was 1.82. to stimulate an increased decrease in reflexes (flow reflexes), it can be with jianjing acupressure point gb-21 (gall blader 21). in breastfeeding mothers who experience muscle tension can be applied to pressure points, jianjing gb-21 acupressure to provide a sense of relaxation and calm during breastfeeding (moriarty, & sharp, 2013). prolactin hormone levels secreted during breastfeeding have a relaxing effect and euphoria that causes breastfeeding mothers to feel calm, so that high levels of the hormone prolactin during breastfeeding can prevent psychological disorders in postpartum mothers, including postpartum blues. (riordan & auerbach, 2010 in rahayu et al., 2015). the way to escalate milk production by increasing feelings of relaxation in postpartum mothers is the jianjing gb-21 acupressure point (rahayu, 2015). minimize the side effects of delays in breastfeeding babies and maximize prolactin receptors with jianjing gb-21 acupressure point techniques. through the acupressure meridian points according to the organ in question can increase the levels of endorphins in the blood and systemic, also reduce the discomfort that will suppress the production of the hormone prolactin (garret et al, 2003 in apriany, 2010: saputra, 2000). the gate control theory explains that large-diameter beta nerve fibers receive stimulation from the meridian acupressure points that are transmitted to the spinal cord, and the spinal cord contains gelatin as a control gate before the afferent nerve fibers send to cell transmission. then, cell transmission transmits to the central nervous system with reduced discomfort before (hakam, krisna & tutik, 2009 in rahayu et al., 2015). massage and pressure at the acupressure point can increase the body's endorphin levels, which is the body's natural morphine (haryanto, sriyono, vol. 4 no. 1 june 2020 5 rosyidi, & afandi, 2018). a comfortable, calm, and relaxed atmosphere will bring positive emotions that can increase the secretion of endorphin neurotransmitters through pomc, which functions as a painkiller and excessive control of crf secretion (lestari, rahmawati, & windarti, 2019). let down reflexes, levels of the hormones prolactin, and oxytocin can increase if the mother feels comfortable and relaxed (rahayu et al., 2015). producing the hormone prolactin from the brain can be stimulated by acupressure points for lactation (rahayu et al., 2015). the points which are the lactation peak stimulation points are st 17 (ruzhong), st 18 (rugen), and jianjing gb-21. conclusion it can be concluded that oketani massage and applying pressure at the gb-21 point can increase the levels of the hormone prolactin, respectively, by 3.08 and 3.13 on the ninth day. the highest increase in the prolactin hormone was found in respondents who received a combination intervention of oketani massage and pressure at the gb-21 point, which was 3.41. references apriany, d. 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(2018). what factors influence exclusive breastfeeding based on the theory of planned behaviour. midwifery, 62, 177-182. https://doi.org/10.1016/j.midw.2018.04.00 6 68 vol. 1 no. 1 desember 2016 efektifitas penggunaan cold pack dibandingkan relaksasi nafas dalam untuk mengatasi nyeri pasca open reduction internal fixation (orif) agung kristanto1, fitri arofiati2 1 program studi magister keperawatan, program pasca sarjana,universitas muhammadiyah yogyakarta 2 dosen , program studi magister keperawatan, program pasca sarjana, universitas muhammadiyah yogyakarta e-mail : arofiatifitri@gmail.com abstrak latar belakang : nyeri merupakan masalah utama pasien pada pasien post operasi yang penatalaksanaannya dapat dilakukan secara farmakologis dan non farmakologis. salah satu upaya non farmakologis yang dapat dilakukan adalah menggunakan cold pack sebagai salah satu inovasi kompres dingin. tujuan penelitian ini untuk mengetahui efektifitas kompres dingin cold pack dengan relaksasi nafas dalam untuk menurunkan nyeri pada pasien post orif (open reduction internal fixation) pada ekstermitas atas dan bawah metode: penelitian ini menggunakan rancangan quasi eksperimen pre-test-post-test with control group dengan subyek penelitian ditentukan menggunakan tehnik total sampling pada pasien post orif, yang dibagi menjadi 2 kelompok, perlakuan dan kontrol. pada kelompok perlakuan diberikan intervensi cold pack dan pada kelompok kontrol di berikan intervensi relaksasi nafas dalam, yang masing-masing dilakukan 4 kali. penggunaan uji statistik pada penelitian ini dengan uji independen t-test dan paired t-test. hasil : hasil uji independen t-test sebelum dan setelah dilakukan intervensi membuktikan bahwa terdapat penurunan skala nyari pada kedua intervensi dengan nilai p 0,000. meskipun secara bersamaan menunjukkan penurunan skala nyari, namun dari 4 kali pengukuran yang dilakukan pemberian cold pack memperlihatkan perbedaan penurunan skala nyeri sebesar 4,33 poin dengan nilai t 20,55 dibandingkan pemberian relaksasi nafas dalam.kesimpulan : penelitian ini membuktikan bahwa pemberian cold pack memiliki efektifitas lebih besar dibandingkan pemberian relaksasi nafas dalam.saran : penggunaan cold pack lebih ditingkatkan sebagai salah satu implementasi keperawatan mandiri, namun tetap memperhatikan perubahan kondisi fisik pasien. kata kunci: kompres dingin, cold pack, nyeri info artikel: masuk : 7 september 2016 revisi : 25 november 2016 diterima : 7 desember 2016 doi number : 10.18196/ijnp.1154 69 vol. 1 no. 1 desember 2016 abstrac background: pain is the main problem of patients post surgery. the reguler pain management are use pharmacological and non pharmacological therapy. one of the variety of non pharmacology therapy is cold compression, which is an innovation of cold pack. aim of research the purpose of this study was to compare the effectiveness of cold compress cold pack with deep breathing relaxation in reducing pain for patients with post orif (open reduction internal fixation). research methods: this study design was quasi-experiments pre-test post-test with control group. there were patients post orif in the third class ward dr soeradji tirtonegoro klaten consisting of 15 patients in the intervention cold compress with cold pack and 15 patients the control group in the deep breathing relaxation as respondents. the treatment was done 4 times post analgetic i and post analgetic ii. pain level was measured by vas pain scale and conducted in 2 times the first after analgesic 1, second measurement after analgesic 2. the statistical test for analysis data used independent test t-test and paired ttest.result: the results of independent t-test before the intervention is relatively the same. meanwhile, after intervention the level of pain from intervention group which was cold pack decreased 3 (three) point and from control group (deep breathing relaxation) decreased 1 (one) point. the statictical analysis measurement showed that p value was 0,00.conclusion: it is proved that the intervention of cold pack has more effective than deep breathing relaxation. suggestion: used cold pack further enhanced as one implementation of independent nursing, but still pays attention to changes in the patient’s physical condition. key words: cold compress, cold pack, pain pendahuluan pasien dengan diagnose fraktur di rsup dr soeradji tirtonegoro klaten umumnya dilakukan tindakan orif ataupun open reduction external fixation (oref) yang menimbulkan rasa nyeri. hal ini disebabkan oleh fraktur itu sendiri maupun karena tindakan pembedahan yang menjadi stimulus timbulnya nyeri. angka kejadian fraktur yang dilakukan tindakan orif ataupun oref di rsup dr soeradji tirtonegoro klaten pada tahun 2015 sebanyak 168 pasien dan fraktur ekstremitas sebanyak 844 yang mengalami peningkatan 5% dari tahun sebelumnya. meningkatnya angka kejadian ini diiringi dengan timbulnya nyeri yang merupakan masalah utama pada pasien pasca operasi sekaligus merupakan pengalaman multidimensi yang tidak menyenangkan akibat kerusakan jaringan1. pe r k e m b a n g a n i l m u k e d o k t e r a n t e n t a n g managemen nyeri cenderung lebih mengutamakan terapi farmakologis yaitu dengan memberikan obat opioid, non opioid dan analgetik2. terapi farmakologi dianggap lebih efektif dan efisien serta signifikan dalam mengatasi nyeri. hal ini dikarenakan efek yang langsung dirasakan secara fisik, dan kebijakan rumah sakit cenderung lebih memilih terapi farmakologi untuk mengatasi nyeri yang didukung perkembangan penelitian terkait. selain manajemen nyeri farmakologis saat ini juga dikembangkan manajemen nyeri non farmakologis, diantaranya berupa penggunaan teknik distraksi teknik relaksasi, hypnosis,transcutaneous electrical nerve stimulation (tens).pemijatan, tusuk jarum, aroma terapi, serta kompres hangat dan dingin3.efektifitas kompres dingin dengan menggunakan metode yang bervariasi telah banyak diteliti dan diaplikasikan dalam setting pelayanan keperawatan. beberapa penelitian sebelumnya menjelaskan bahwa cold packefektif megurangi nyeri pada kasus ortopaedi ringan, sedangkan pada kasus ortopaedi berat menggunakan perendaman air es, namun efisiensi penggunaan cold pack lebih dianjurkan4,5. penelitian lain menyatakan bahwa kompres dingin ini juga tidak mengganggu pembuluh darah perifer dan tidak menyebabkan kerusakan jaringan kulit apabila perendaman dilakukan sesuai prosedur6. kompres dingin sebagai alternatif penanganan nyeri pada pasien dengan nyeri ringan ataupun sedang tidak digunakan lagi dalam panduan penanganan nyeri. penanganan nyeri ringan lebih menggunakan tehnik relaksasi nafas dalam, sedangkan pada nyeri sedang dan berat menggunakan terapi obat dalam menangani nyeri7. berdasarkan best practice yang dilakukan di taiwan, tehnik kompres dingin menjadi salah satu penanganan yang sedang dikembangkan walaupun penelitian terkait dengan tehnik ini masih dilakukan. 70 dalam praktek klinik perawatan nyeri dengan kompres dingin cenderung menggunakan alat cryoterapi. kompres dingin cryoterapi menggunakan suhu sekitar 5-10°c yang diberikan setiap 15 menit sampai nyeri hilang. penggunaan diberikan segera setelah dilakukan operasi atau satu jam setelah operasi karena setelah satu jam post operasi pasien mulai merasakan nyeri akibat dari penurunan pengaruh obat analgetik yang diberikan saat di kamar operasi8,9. kompres dingin adalah suatu metode dalam penggunaan suhu rendah setempat yang dapat menimbulkan beberapa efek fisiologis10. terapi dingin diperkirakan menimbulkan efek analgetik dengan memperlambat kecepatan hantaran saraf sehingga impuls nyeri yang mencapai otak lebih sedikit. mekanisme lain yang bekerja adalah bahwa persepsi dingin menjadi dominan dan mengurangi persepsi nyeri. salah satu alasan kompres dingin tidak masuk dalam panduan penanganan nyeri karena kompres dingin tidak efisiensi waktu. faktor kenyamanan juga mempengaruhi proses pemberian kompres dingin karena pasien menjadi basah oleh es batu yang mencair. namun demikian pemberian perlakuan kompres dingin tidak mengganggu pembuluh darah perifer dan tidak menyebabkan kerusakan jaringan kulit apabila perendaman dilakukan sesuai prosedur. saat ini telah dikembangkan cold pack sebagai pengganti biang es (dry ice) atau es batu. cold pack mempunyai beberapa keunggulan dibanding dengan es batu. jika es batu digunakan ia akan habis dan berubah menjadi gas karbon diosida, sehingga hanya dapat digunakan sekali saja. cold pack dapat digunakan berkali-kali dengan hanya mendinginkan kembali kedalam lemari pembuat es (freezer).cold pack merupakan produk alternatif pengganti dry ice & es batu.ketahanan beku bisa mencapai 8-12 jam tergantung box yang digunakan.pemakaiannya dapat berulang-ulang selama kemasan tidak bocor (rusak). berdasarkan fakta banyak kelebihan cold pack dibandingkan dengan es batu sebagai bahan untuk kompres dingin, maka penulis berinovasi menggunakan cold pack sebagai alat untuk melakukan kompres dingin untuk mengurangi nyeri dengan memasukkan cold pack kedalam kantong berbahan kain sintetis tahan air dan menempatkan di sisi kanan dan kiri pada luka bekas operasi fraktur. penelitian ini bertujuan bertujuan untuk mengetahui efektifitas cold pack terhadap perubahan nyeri dibandingkan dengan penggunaan relaksasi nafas dalampada pasien pascaorif desain penelitian jenis penelitian yang digunakan dalam penelitian ini adalah penelitian kuantitatif dengan pesain penelitian quasi experimentdan rancangan pre-test-post-test with control group.sampel yang dipilih adalah pasien pasca orif pada ekstremitas atas ataupun bawah yang dirawat di rsup dr soeradji tirtonegoro klaten dan memenuhi kriteria inklusi berusia 20-60 tahun, pasca orif hari ke – 0, kesadaran compos mentis, memiliki skala nyeri 1 -6 (dinilai dengan skala vas). kriteria eksklusi pada penelitian ini adalah pasien dengan pasca operasi total knee replacement, mengalami multiple fraktur, mengalami komplikasi dan fraktur patologis. besar sampel dalam penelitian ini ditetapkan berjumlah 30 yang terbagi menjadi dua kelompok yaitu 15 responden kelompok intervensi dilakukan kompres dengan cold pack dan 15 orang lainnya menjadi responden kelompok kontrol yang diberikan relaksasi nafas dalam sesuai panduan penanganan nyeri di rsup soeradji tirtonegoro klaten. pengelompokan responden dilakukan dengan menggunakan tehnik random sampling. intervensi kompres dengan cold pack maupun relaksasi nafas dalam dilakukan terhadap pasien dengan skala nyeri ringan (1-3) dan nyeri sedang (46). pengukuran nyeri dilakukan dengan visual analogi scale (vas). sebelum digunakan alat terlebih dahulu di uji kenyamanan kepada pasien serta fungsi dan keamanan alat pada perawat. hasil uji menunjukkan alat layak digunakan untuk karena pasien menganggap bahwa alat tersebut tidak mengganggu kenyamanannya dan menurut pasien alat tersebut dapat berfungsi dan aman untuk digunakan. intervensi kompres dengan cold pack maupun relaksasi nafas dalam dilakukan 1 (satu) jam setelah pemberian obat analgetik i dan analgetik ii dari 71 vol. 1 no. 1 desember 2016 instalasi bedah sentral (ibs). intervensi kompres dengan cold pack dilakukan setelah pasien pulih kesadarannya pasca operasi dan diintervensi kompres dengan cold pack selama 15 menit dan kemudian dilepas selama 15 menit. sebelum kompres dilepas dilakukan pengukuran skala nyeri dengan skala vas.siklus pengompresan dengan cold pack diatas diulang sampai sampai 4 kali siklus pengompresan atau selama 2 jam.pengompresan dengan cold pack pada tahap analgetik ii dilakukan kurang lebih 3-4 jam setelah pemberian obat di bangsal. proses pengompresan dan pengukuran skala nyeri seperti pada siklus pertama. proses pemberian intervensi relaksasi nafas dalam juga dilakukan setelah pasien sadar kurang lebih 3-4 jam dan tidak dalam pengaruh obat anastesi (analgetik i) pasien diajari dan diminta untuk melakukan tehnik relaksasi nafas selama 15 menit kemudian setelah 15 menit dilakukan pengukuran skala nyeri dengan skala vas.siklus pemberian relaksasi nafas dalam diulang sampai sampai 4 kali siklus. relaksasi nafas dalam pada analgetk ii juga dilakukan 3-4 jam setelah pemberian obat analgetik di bangsal. hasil penelitian hasil penelitian yang menggambarkan data demografi responden ditampilkan pada tabel 1, yaitu: tabel 1. karakteristik responden berdasarkan demografi pasien karakteristik responden kelompok intervensi cold pack kelompok kontrol relaksasi nafas dalam total n % n % n % 1. jenis kelamin laki-laki perempuan 4 11 26,7 73,3 8 7 53,3 46,7 12 18 40,0 60,0 2. umur < 30 tahun 3140 tahun 4150 tahun > 50 tahun 2 3 4 6 13,3 20,0 26,7 40,0 3 4 3 5 20,0 26,7 20,0 33,3 5 7 7 11 16,7 23,3 23,3 36,7 3. pendidikan sd sltp 8 4 53,3 26,7 7 4 46,7 26,7 15 8 50,0 26,7 karakteristik responden kelompok intervensi cold pack kelompok kontrol relaksasi nafas dalam total n % n % n % slta 3 20,0 4 26,7 7 23,3 4. riwayat operasi belum pernah 12 3 80,0 20,0 11 4 73,3 26,7 23 7 76,7 23,3 5. pekerjaan buruh swasta pedagang petani ibu rumah tangga mahasiswa 6 2 2 3 1 1 40,0 13,3 13,3 20,0 6,7 6,7 5 1 4 2 3 0 33,3 6,7 26,7 13,3 20,0 0 11 3 6 5 4 1 36,7 10,0 20,0 16,7 13,3 3,3 6. letak fraktur ekstremitas atas ekstremitas bawah 10 5 66,7 33,3 9 6 60,0 40,0 19 11 63,3 36,7 tabel 1 menggambarkan bahwa sebanyak 73,3% pasien berjenis kelamin perempuan, sebagian besar (40%) berusia lebih dari 50 tahun, berlatar belakang pendidikan sd (53,%), sebanyak 80% belum pernah menjalani operasi sebelumnya, sebanyak 40% bekerja sebagai buruh dan sebagian besar mengalami faktur di ekstremitas atas (66,7%) perbandingan skala nyeri sebelum dan sesudah intervensi pos analgetik i hasil perbandingan rasa nyeri sebelum dan sesudah pemberian cold pack dan relaksasi nafas dalam postanalgetik i digambarkan sebagai berikut. gambar 1. skala nyeri post analgetik i sebelum dan sesudah intervensi tabel 1. karakteristik responden berdasarkan demografi pasien tabel 1 menggambarkan bahwa sebanyak 73,3% pasien berjenis kelamin perempuan, sebagian besar (40%) berusia lebih dari 50 tahun, berlatar belakang pendidikan sd (53,%), sebanyak 80% belum pernah menjalani operasi sebelumnya, sebanyak 40% bekerja sebagai buruh dan sebagian besar mengalami faktur di ekstremitas atas (66,7%) perbandingan skala nyeri sebelum dan sesudah intervensi pos analgetik i hasil perbandingan rasa nyeri sebelum dan sesudah pemberian cold pack dan relaksasi nafas dalam postanalgetik i digambarkan sebagai berikut. gambar 1. skala nyeri post analgetik i sebelum dan sesudah intervensi sebelum mendapat perlakuan, rasa nyeri kelompok cold pack maupun relaksasi nafas dalam relatif sama. setelah mendapat perlakukan kompres cold pack, pasien mengalami penurunan rasa nyeri sebesar 1,46 poin pada pengukuran pertama analgetik i. pada pengukuran kedua, rasa nyeri mengalami penurunan sebesar 1,73 poin. pada pengukuran ketiga mengalami penurunan rasa nyeri sebesar 2,20 poin. pada pengukuran keempat, mengalami penurunan rasa nyeri sebesar 2,13 poin. tabel 2. perbandingan skala nyeri post analgetik i sebelum dan sesudah pemberian cold pack post analgetik i mean sd selisih t p pengukuran 1 pre tes 5,33 0,9 0 1,4 6 6,2 05 0,00 0pos tes 3,87 1,0 6 pengukuran 2 pre tes 4,93 0,9 6 1,7 3 6,5 00 0,00 0pos tes 3,20 1,2 6 01 23 45 6 pre p1 p2 p3 p4 pre p1 p2 p3 p4 kompres cold pack 5.33 3.87 3.2 2.27 2.07 relaksasi nafas dalam 5.4 4.87 4.73 4.47 4.13 post analgetik i sk al a n ye ri karakteristik responden kelompok intervensi cold pack kelompok kontrol relaksasi nafas dalam total n % n % n % 1. jenis kelamin laki-laki perempuan 4 11 26,7 73,3 8 7 53,3 46,7 12 18 40,0 60,0 2. umur < 30 tahun 3140 tahun 4150 tahun > 50 tahun 2 3 4 6 13,3 20,0 26,7 40,0 3 4 3 5 20,0 26,7 20,0 33,3 5 7 7 11 16,7 23,3 23,3 36,7 3. pendidikan sd sltp slta 8 4 3 53,3 26,7 20,0 7 4 4 46,7 26,7 26,7 15 8 7 50,0 26,7 23,3 4. riwayat operasi belum pernah 12 3 80,0 20,0 11 4 73,3 26,7 23 7 76,7 23,3 5. pekerjaan buruh swasta pedagang petani ibu rumah tangga mahasiswa 6 2 2 3 1 1 40,0 13,3 13,3 20,0 6,7 6,7 5 1 4 2 3 0 33,3 6,7 26,7 13,3 20,0 0 11 3 6 5 4 1 36,7 10,0 20,0 16,7 13,3 3,3 6. letak fraktur ekstremitas atas ekstremitas bawah 10 5 66,7 33,3 9 6 60,0 40,0 19 11 63,3 36,7 72 sebelum mendapat perlakuan, rasa nyeri kelompok cold pack maupun relaksasi nafas dalam relatif sama. setelah mendapat perlakukan kompres cold pack, pasien mengalami penurunan rasa nyeri sebesar 1,46 poin pada pengukuran pertama analgetik i. pada pengukuran kedua, rasa nyeri mengalami penurunan sebesar 1,73 poin. pada pengukuran ketiga mengalami penurunan rasa nyeri sebesar 2,20 poin. pada pengukuran keempat, mengalami penurunan rasa nyeri sebesar 2,13 poin. tabel 2. perbandingan skala nyeri post analgetik i sebelum dan sesudah pemberian cold pack post analgetik i mean sd selisih t p pengukuran 1 pretes 5,33 0,90 1,46 6,205 0,000 postes 3,87 1,06 pengukuran 2 pretes 4,93 0,96 1,73 6,500 0,000 postes 3,20 1,26 pengukuran 3 pretes 4,47 0,91 2,20 9,054 0,000 postes 2,27 0,96 pengukuran 4 pretes 4,20 0,94 2,13 8,342 0,000 postes 2,07 0,88 pada kelompok relaksasi nafas dalam, rata-rata skala nyeri pasien mengalami penurunan rasa nyeri sebesar 0,53 poin pada pengukuran pertama analgetik i. pada pengukuran kedua, rasa nyeri mengalami penurunan sebesar 0,60 poin. pada pengukuran ketiga, rasa nyeri mengalami penurunan rasa nyeri sebesar 0,67 poin. pada pengukuran keempat, rasa nyeri mengalami penurunan rasa nyeri sebesar 0,83 poin. sebelum diintervensi tidak ada perbedaan rasa nyeri pada kedua kelompok. hal tersebut berarti kedua kelompok mempunyai rasa nyeri yang sama sebelum diintervensi. tabel 3. perbandingan skala nyeri post analgetik i sebelum dan sesudah pemberian relaksasi nafas dalam post analgetik i mean sd selisih t p pengukuran 1 pretes 5,40 0,63 0,53 4,000 0,001 postes 4,87 0,83 pengukuran 2 pretes 5,33 0,82 0,60 4,583 0,000 postes 4,73 0,80 post analgetik i mean sd selisih t p pengukuran 3 pretes 5,13 0,91 0,67 5,292 0,000 postes 4,47 0,83 pengukuran 4 pretes 5,00 0,84 0,87 9,539 0,000 postes 4,13 0,83 perbandingan skala nyeri sebelum dan sesudah intervensi pos analgetik ii intervensi kompers cold pack dan nafas dalam juga dilakukan setelah pasien di bangsal dan setelah diberi obat analgetik ii. sebelum mendapatkan perlakuan analgetik ii, rata-rata nyeri kedua kelompok relatif sama. pada pengukuran pertama analgetik ii, rata-rata rasa nyeri mengalami penurunan sebesar 1,40 poin setelah mendapat kompres cold pack. pada pengukuran kedua,rasa nyeri menurun menjadi 1,87 poin setelah pemberian cold pack atau mengalami penurunan rasa nyeri sebesar 1,60 poin. pada pengukuran ketiga, rasa nyeri menurun sebesar 1,93 poin. pada pengukuran keempat rasa nyeri menurun sebesar 1,93 poin. tabel 4. perbandingan skala nyeri post analgetik ii sebelum dan sesudah pemberian cold pack post analgetik ii mean sd selisih t p pengukuran 1 pretes 4,07 1,16 1,40 6,548 0,000 postes 2,67 1,29 pengukuran 2 pretes 3,47 1,06 1,60 9,798 0,000 postes 1,87 0,83 pengukuran 3 pretes 3,13 0,99 1,93 9,374 0,000 postes 1,20 0,86 pengukuran 4 pretes 2,93 0,96 1,93 10,640 0,000 postes 1,00 0,65 rata-rata skala nyeri pasien mengalami penurunan rasa nyeri sebesar 0,60 poin setelah mendapat perlakukan relaksasi nafas dalam post analgetik ii. pada pengukuran kedua, rata-rata skala nyeri pasien mengalami penurunan rasa nyeri sebesar 0,60 poin. pada pengukuran ketiga, rata-rata skala nyeri pasien 73 vol. 1 no. 1 desember 2016 mengalami penurunan rasa nyeri sebesar 0,80 poin. pada pengukuran keempat, rata-rata skala nyeri pasien mengalami penurunan rasa nyeri sebesar 1,00 poin setelah dilakukan relaksasi nafas dalam. tabel 5 perbandingan skala nyeri post analgetik ii sebelum dan sesudah pemberian relaksasi nafas dalam post analgetik ii mean sd selisih t p pengukuran 1 pretes 4,60 0,63 0,60 4,583 0,000 postes 4,00 0,65 pengukuran 2 pretes 4,33 0,72 0,60 4,583 0,000 postes 3,73 0,70 pengukuran 3 pretes 4,20 0,86 0,80 7,483 0,000 postes 3,40 0,63 pengukuran 4 pretes 4,27 0,80 1,00 10,247 0,000 postes 3,27 0,96 hasil perbandingan rasa nyeri sebelum dan sesudah pemberian cold pack dan relaksasi nafas dalam postanalgetik ii digambarkan sebagai berikut. nyeri sebesar 0,60 poin. pada pengukuran ketiga, rata-rata skala nyeri pasien mengalami penurunan rasa nyeri sebesar 0,80 poin. pada pengukuran keempat, rata-rata skala nyeri pasien mengalami penurunan rasa nyeri sebesar 1,00 poin setelah dilakukan relaksasi nafas dalam. tabel 5 perbandingan skala nyeri post analgetik ii sebelum dan sesudah pemberian relaksasi nafas dalam post analgetik ii mean sd selisih t p pengukuran 1 pre tes 4,60 0,63 0,60 4,583 0,0 00pos tes 4,00 0,65 pengukuran 2 pre tes 4,33 0,72 0,60 4,583 0,0 00pos tes 3,73 0,70 pengukuran 3 pre tes 4,20 0,86 0,80 7,483 0,0 00pos tes 3,40 0,63 pengukuran 4 pre tes 4,27 0,80 1,00 10, 24 7 0,0 00pos tes 3,27 0,96 hasil perbandingan rasa nyeri sebelum dan sesudah pemberian cold packdan relaksasi nafas dalam postanalgetik ii digambarkan sebagai berikut. gambar 2. skala nyeri post analgetik ii sebelum dan sesudah intervensi sebelum diintervensi tidak ada perbedaan rasa nyeri pada kedua kelompok. setelah mendapat intervensi terdapat selisih dari pengukuran 1-4 dan bermakna secara statistik (p<0,05). skor rata-rata skala nyeri pasien yang diberi intervensi dengan kompres cold pack lebih rendah dibanding skor rata-rata skala nyeri pasien yang diberi intervensi dengan relaksasi nafas dalam. hal tersebut menunjukkan bahwa cold pack lebih efektif menurunkan rasa nyeri postanalgetik ii dibandingkan relaksasi nafas dalam. pembahasan hasil uji independen t-test menunjukkan perbedaan yang kecil rasa nyeri post analgetik i antara kelompok cold pack (5,33 poin) dengan relaksasi nafas dalam (5,4 poin) sebelum dilakukan kompres dingin cold pack dan relaksasi 0 1 2 3 4 5 6 pre p1 p2 p3 p4 pre p1 p2 p3 p4 kompres cold pack 4.07 2.67 1.87 1.2 1 relaksasi nafas dalam 4.6 4 3.73 3.4 3.27 post analgetik ii sk al a n ye ri gambar 2. skala nyeri post analgetik ii sebelum dan sesudah intervensi sebelum diintervensi tidak ada perbedaan rasa nyeri pada kedua kelompok. setelah mendapat intervensi terdapat selisih dari pengukuran 1-4 dan bermakna secara statistik (p<0,05). skor rata-rata skala nyeri pasien yang diberi intervensi dengan kompres cold pack lebih rendah dibanding skor rata-rata skala nyeri pasien yang diberi intervensi dengan relaksasi nafas dalam. hal tersebut menunjukkan bahwa cold pack lebih efektif menurunkan rasa nyeri postanalgetik ii dibandingkan relaksasi nafas dalam. pembahasan hasil uji independen t-test menunjukkan perbedaan yang kecil rasa nyeri post analgetik i antara kelompok cold pack (5,33 poin) dengan relaksasi nafas dalam (5,4 poin) sebelum dilakukan kompres dingin cold pack dan relaksasi nafas dalam. hal tersebut berati sebelum mendapat intervensi baik dengan cold pack maupun relaksasi nafas dalam, kondisi nyeri pasien hampir sama. setelah diintervensi, terdapat selisih dari pengukuran 1 4yang bermakna secara statistik (p<0,05). hal tersebut menunjukkan bahwa cold pack lebih efektif menurunkan rasa nyeri postanalgetik. hasil penelitian ini sesuai sebelumnya menyatakan bahwa kompres dingin efektif dalam menurunkan nyeri pasca operasi pada fraktur ataupun masalah dalam musculoskeletal11. penelitian terkait yang menggunakan media es yang mirip dengan penelitian ini menyatakan bahwa perendaman air dingin lebih efektif dibandingkan ice pack dan pemijatan dengan es12. penelitian lain juga menyatakan perendaman air es efektif dalam menurunkan nyeri pada kasus fraktur radius ulna dan perendaman ini dilakukan dalam suhu 10°c selama 15 menit tidak mengganggu dalam peredaran darah pasien12. hasil pengukuran skala nyeri dengan vas menunjukkan skala nyeri pada pemberian kompres dingin dan tehnik relaksasi nafas dalam ada penurunan angka skala nyeri antara pengukuran setelah pembedahan dan analgetik i dan pengukuran setelah diberikan analgetik ii. hal ini dapat dijelaskan karena nyeri pembedahan sedikitnya mengalami dua perubahan, pertama akibat pembedahan itu sendiri yang menyebabkan rangsangan nosiseptif dan yang kedua setelah proses pembedahan terjadi respon inflamasi pada daerah 74 sekitar operasi, dimana terjadi pelepasan zat-zat kimia (prostaglandin, histamin, serotonin, bradikinin, substansi p dan lekotrein) oleh jaringan yang rusak dan sel-sel inflamasi. zat-zat kimia yang dilepaskan inilah yang berperan pada proses transduksi dari nyeri pada pasca pembedahan13. berjalannya waktu maka proses inflamasi akan berkurang dan akan menurunkan intensitas nyeri pada paisen post operasi pembedahan pada umumnya termasuk orif. hasil penelitian lain menekankan bahwa pemberian kompres dingin akan mempengaruhi proses hemodinamik tubuh dengan vasokonstriksi, mengurangi aliran darah ke daerah luka sehingga menurunkan oedema, mematikan sensasi nyeri dan ,e,perlambat proses inflamasi14. hasil pengukuran skala nyeri pada pasien post operasi fraktur ekstermitas didapatkan hasil dimana pada pengukuran pertama dan pengukuran yang ke 4 mempunyai pola semakin menurun skala nyerinya baik pada pasien kelompok intervensi dengan kompres dingin cold pack maupun pada kelompok kontrol dengan relaksasi nafas dalam. skala nyeri pada post analgetik i mempunyai nilai yg lebih tinggi dibanding dengan nilai skala nyeri pada pasien post analgetik ii. hal ini disebabkan proses pengukuran skala nyeri paska analgesik i dilakukan pada akhir reaksi analgesik, sementara pada pengukuran ii dilakukan pada awal reaksi analgesik. sensitifitas akan meningkat, sehingga stimulus non noksius atau noksius ringan yang mengenai bagian yang meradang akan menyebabkan nyeri. nyeri inflamasi akan menurunkan derajat kerusakan dan menghilangkan respon inflamasi dan nyeri akan menurun intensitasnya. adanya proses inflamasi yang akan semakin berkurang dan intensitas nyeri juga akan berkurang menyebabkan hasil pengukuran skala nyeri pada 3 sampai 4 jam pasca operasi akan lebih tinggii pada skala nyeri 7-8 jam setelah tindakan operasi. kompres dingin dengan cold pack memberikan efek yang lebih baik dari tehnik relaksasi nafas. penurunan skala nyeri pada pemberian kompres dingin dengan cold pack mempunyai penurunan skala nyeri secara spesifik tiap pengompresan sekitar 2 point dan dapat dibuktikan dengan melihat keseluruhan proses pengompresan dengan cold pack dari pengompresan yang ke 1 sampai pengompresan yang ke 4 terjadi penurunan 3 point baik pada post analgetik i maupun pada post analgetik ii. sedangkan pada pemberian relaksasi nafas dalam secara spesifik tiap perlakuan menurunkan 1 point dan secara keseluruhan pemberian relaksasi nafas dalam dari perlakuan yang ke 1 sampai ke 4 juga menunjukkan penurunan yang tidak begitu besar yaitu 1 point baik post analgetik i dan post analgetik ii. prinsip yang mendasari penurunan nyeri oleh teknik relaksasi terletak pada fisiologi sistem syaraf otonom yang merupakan bagian dari sistem syaraf perifer yang mempertahankan homeostatis lingkungan internal individu. pada saat terjadi pelepasan mediator kimia seperti bradikinin, prostaglandin dan substansi p, akan merangsang syaraf simpatis sehingga menyebabkan vasokostriksi yang akhirnya meningkatkan tonus otot yang menimbulkan berbagai efek seperti spasme otot yang akhirnya menekan pembuluh darah, mengurangi aliran darah dan meningkatkan kecepatan metabolisme otot yang menimbulkan pengiriman impuls nyeri dari medulla spinalis ke otak dan dipersepsikan sebagai nyeri.15. pa d a s a a t r e l a k s a s i n a f a s d a l a m t e r s e b u t menghambat adanya pelepasan mediator kimia tersebut diatas sehingga vasokonstriksi dihambat, spasme otot berkurang, penekanan pembuluh darah berkurang sehingga nyeri berkurang. kompres dingin menstimulasi permukaan kulit untuk mengontrol nyeri, terapi kompres dingin yang diberikan akan mempengaruhi impuls yang dibawa oleh serabut taktil a-beta untuk lebih mendominasi sehingga gerbang akan menutup dan impuls nyeri terhalangi sehingga nyeri yang dirasakan akan berkurang atau hilang untuk sementara16. perbandingan proses mekanisme hambatan nyeri pada tehnik relaksasi dan kompres dingin dapat dilihat bahwa pada kompres dingin mempunyai alur yang lebih singkat dibanding relaksasi nafas dalam karena pada kompres dingin pencapaian pada sasaran pengatur nyeri atau pada “gerbang control“ pada teori nyeri lebih singkat dan lebih cepat sedangkan tehnik relaksasi nafas dalam mengurangi nyeri memerlukan proses 75 vol. 1 no. 1 desember 2016 metabolisme hormone yang memerlukan konsentarsi dan kesungguhan pada pasien dalam melakukan relaksasi nafas dalam untuk dapat menurunkan nyeri. kesimpulan tidak ada perbedaan skala nyeri pada kedua kelompok, sebelum dilakukan intervensi yaitu berada di level 4-5 dengan menggunakan pengukuran skala nyeri vas. setelah dilakukan intervensi, pemberian cold pack terbukti memberikan efek penurunan nyeri yang lebih banyak yaitu 2-3 poin, sementara relaksasi nafas dalam memberikan efek penurunan nyeri sebesar 1 poin. dengan demikian intervensi cold pack dapat dijadikan alternatif penatalaksanaan nyeri non farmakologi. saran 1. perawat di rumah sakit a. perawat dapat mengimplementasikan kompres dingin cold pack sebagai alternatif untuk penatalaksanaan nyeri non farmakologi di rumah sakit. b. meninjau kembali panduan dan kebijakan penatalaksanaan nyeri post operasi yang ada di rumah sakit dan menambah cold pack sebagai alternatif untuk mengurangi rasa nyeri post operasi fraktur. 2. bagi peneliti selanjutnya. peneliti lain diharapkan dapat mengembangkan penelitian ini dengan meneliti efektifitas penggunaan cold pack untuk menurunkan intensitas nyeri pada post operasi selain fraktur ataupun nyeri lain. daftar pustaka rizaldiy pinzon (2014) esesmen nyeri yogyakarta betha grafika l. tarau & m.burst .(2011) nyeri kronis jakarta egc pamela,et al. (2010) acut pain management : scientific evidence thirt edition australian and new zealand college of anaesthethists and faculty of pain medicine. australia krista lewis & kevin miller,(2008)ice bag application induced numbness in uninjured ankles with less discomfort than cold water immersionan honors thesis (honrs 499) ball state university muncie, indiana jon e block.(2010). cold and compression in the management of musculoskeletal injuries and o r t h o p e d i c o p e r a t i v e procedures: a narrative reviewopen access journal of sports medicine shaik, macdermid, birmingham & grewal (2015) short term sensory and cutaneous vascular responses to cold water immersion in patients with distal radius fracture (drf)sm j orthop. 2015;1(1):1003. tim nyeri rsst (2015) buku panduan penatalaksanaan nyeri di ruamh sakit dr soeradji tirtonegoro klaten. , indonesia elia purnamasari (2014) efektifitas kompres dingin terhadap penurunan intensitas nyeri pada pasien fraktur di rsud ungaran jurnal ilmu keperawatan dan kebidanan (jikk) krista lewis & kevin miller,(2008) ice bag application induced numbness in uninjured ankles with less discomfort than cold water immersion an honors thesis (honrs 499) ball state university muncie, indiana lane, elaine;latham, tracy (2009). managing pain using heat and cold therapy paediatric nursing;jul 2009; 21, 6; proquest nursing & allied health source pg. 142 devi mediarti, rosnani & sosya, (2015) pengaruh pemeberian kompres dingin terhadap nyeri pada pasien fraktur ekstremitas tertutup di igd rsmh pa l e m b a n g ta h u n 2012, jurnal kedokteran dan kesehatan volume 2 no 3 oktober 2015 : 253-260 andi nurchairiah1.(2013). efektifitas kompres dingin terhadap intensitas nyeri pada pasien fraktur tertutup di ruang dahlia rsud arifin achmad universitas riau manuela, angela,philipp,& reto (2014) effective treatment of posttraumatic and postoperative edema in patients with ankle and hindfoot fractures,a randomized controlled trial comparing multilayer compression therapy and intermittent impulse compression with t h e s t a n d a r d treatment with ice,the journal of bone and joint surgery, incorporated2014;96:1263-71 hegner, barbara j. (2003). asisten keperawatan suatu pendekatan proses keperawatan. jakarta : egc. 76 esperanza, maria, sandoval, diana & tania, (2010) motor and sensory nerve conduction are effected differently by ice pack, ice massage and cold water immersion research report physical therapy journal vol. 90 number 4 brunner & suddarth (2002). buku ajar medical bedah edisi 8 jakarta egc priharjo, r. (2003). perawatan nyeri. jakarta. egc. 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. 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. 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 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 44 vol. 1 no. 2 juni 2017 pengaruh active cycle of breathing technique terhadap peningkatan nilai vep1, jumlah sputum, dan mobilisasi sangkar thoraks pasien ppok abstrak salah satu bagian integral dari manajemen copd adalah membersihkan jalan nafas untuk mengatasi gejala klinis seperti produksi sputum dan sesak napas yang menyebabkan penurunan vep1, produksi sputum yang berlebihan, dan terganggunya mobilisasi toraks. perawat dapat membantu pasien ppok untuk memulihkan kondisi fisiknya dan memperbaiki pola nafasnya dengan memutus mata rantai keluhan yang ada dengan active cycle of breathing technique (acbt). tujuan penelitian ini untuk mengetahui pengaruh acbt terhadap peningkatan nilai vep 1 , pengurangan jumlah volume sputum, dan peningkatan mobilisasi sangkar toraks pada penderita ppok. penelitian ini merupakan penelitian quasi experiment dengan rancangan pre–post test with control group design. sebanyak 30 orang pasien dibagi kedalam 2 kelompok yaitu 15 responden untuk kelompok intervensi dan 15 responden untuk kelompok kontrol dengan menggunakan teknik quota sampling. analisis yang digunakan adalah uji t-test. kelompok intervensi diberikan terapi acbt dan farmakologi dan kelompok kontrol hanya diberikan terapi farmakologi. acbt memberikan pengaruh yang bermakna terhadap jumlah sputum dan ekspansi toraks pada kelompok intervensi daripada kelompok kontrol dengan nilai p = 0,026 untuk jumlah sputum dan p = 0,004 untuk ekspansi toraks, sedangkan pada nilai vep 1 , acbt tidak memberikan pengaruh yang bermakna dengan nilai p = 0,058. active cycle of breathing technique (acbt) efektif dalam membantu pengeluaran sputum dan meningkatkan ekspansi toraks pasien ppok, tetapi kurang efektif dalam meningkatkan nilai vep 1 . kata kunci: active cycle of breathing technique (acbt), penyakit paru obstruksi kronik, bersihan jalan napas, ekspansi toraks, vep 1 . titih huriah1, dwi wulandari ningtias 1 magister keperawatan, program pasca sarjana, universitas muhammadiyah yogyakarta email : titih.huriah@umy.ac.id info artikel: masuk : 21 januari 2017 revisi : 19 mei 2017 diterima : 11 juni 2017 doi number : 10.18196/ijnp.1260 45 vol. 1 no. 2 juni 2017 abstract airway clearance is an integral part of the management of copd to cope clinical symptoms such as sputum production and shortness of breath that causes impairment vep 1 , excessive sputum production, and impaired toraks mobilization. nurses can help copd patients to break the chain of the existing complaint with the active cycle of breathing technique (acbt). the purpose of this study was to determine the effect of acbt in increasing vep 1 , reducing amount of sputum, and increasing mobilization of the thoracic cage in copd patients. this is a quasi experimental study with pre-post test with control group design. the 30 participants were divided into experimental group (15 subjects) and control group (15 subjects) by using quota sampling. the experimental group received acbt and pharmacological therapy and the control group just received pharmacological therapy. result findings show that acbt give a significant effect on the amount of sputum and thoracic expansion in the intervention group than the control group, with p = 0.026 and p = 0.004 respectively, while for the value of vep 1 , acbt not provide significant effect with p = 0.058. acbt effective in helping expenditures sputum and increasing thoracic expansion copd patients, but less effective in enhancing the vep 1 . keywords: active cycle of breathing technique (acbt), chronic obstructive pulmonary disease, airway clearance, thoracic expansion, vep 1 . pendahuluan world health organization (who) pada tahun 2015, menyatakan bahwa ppok merupakan penyebab utama keempat morbiditas kronis dan kematian di amerika serikat, dan diproyeksikan akan menjadi peringkat ke-lima pada tahun 2020 sebagai beban penyakit di seluruh dunia. pada tahun 2020, diperkirakan 65 juta penduduk dunia menderita ppok sedang sampai berat, dimana lebih dari 3 juta orang meninggal karena ppok, dan menyumbang 6% dari seluruh penyebab kematian (dipiro, et al, 2015). indonesia dalam riskesdas tahun 2013, menyebutkan bahwa prevalensi ppok sebesar 3,7 persen per mil, dengan prevalensi lebih tinggi pada laki-laki yaitu sebesar 4,2% (kemenkes ri, 2013). propinsi daerah istimewa yogyakarta berada pada urutan ke-23 berdasarkan jumlah penderita ppok di indonesia, dengan prevalensi sebesar 3,0% (kemenkes ri, 2015). berdasarkan data dari rumah sakit paru respira yogyakarta pada tahun 2015, ppok menempati urutan pertama dari 10 besar penyakit pasien rawat inap maupun rawat jalan. jumlah pasien rawat inap sebanyak 104 orang, sedangkan pasien rawat jalan sebanyak 402 orang (respira, 2015). rabe et al (2007) menyatakan bahwa ppok adalah penyakit kronis saluran napas yang ditandai dengan hambatan aliran udara khususnya udara ekspirasi dan bersifat progresif lambat, disebabkan oleh pajanan faktor resiko seperti merokok, polusi udara di dalam maupun di luar ruangan (kemenkes ri, 2013). onset biasanya pada usia pertengahan dan tidak hilang dengan pengobatan (lestari, 2015). perhimpunan dokter paru indonesia (2011) menyatakan bahwa inflamasi dan air trapping adalah dasar dari ppok yang menyebabkan penurunan vep1 dan penyempitan saluran napas periferal. besarnya inflamasi, fibrosis, dan eksudat pada saluran napas kecil berhubungan dengan penurunan vep1 dan rasio vep1/fvc. ikalius (2007) menyatakan bahwa untuk memperbaiki ventilasi dan menyelaraskan kerja otot abdomen dan thoraks dengan teknik latihan yang meliputi latihan pernafasan. tujuan latihan pernafasan pada pasien ppok adalah untuk mengatur frekuensi dan pola pernafasan sehingga mengurangi air trapping, memperbaiki fungsi diafragma, memperbaiki ventilasi alveoli untuk memperbaiki pertukaran gas tanpa meningkatkan kerja pernafasan, memperbaiki mobilitas sangkar thoraks, mengatur dan mengkoordinasi kecepatan pernafasan sehingga sesak nafas berkurang (khotimah, 2013). perawat dapat membantu pasien ppok untuk memulihkan kondisi fisiknya dan memperbaiki pola nafasnya, untuk memutus mata rantai keluhan yang ada dengan active cycle of breathing technique (acbt) yang bertujuan untuk membersihkan jalan nafas dari sputum agar diperoleh hasil pengurangan sesak nafas, pengurangan batuk, dan perbaikan pola nafas yang terdiri dari breathing control (bc), thoracic expansion exercise (tee), dan forced expiration technique (fet). metode penelitian penelitian ini menggunakan metode quasi experiment dengan rancangan pre–post test design with control group, 46 yang akan mengungkapkan hubungan sebab akibat pemberian intervensi active cycle of breathing technique (acbt) terhadap nilai vep 1 , jumlah volume sputum, dan mobilisasi sangkar toraks pada penderita ppok. besar sampel dihitung dengan menggunakan rumus uji hipotesis dua kelompok independen beda rerata (mean). hasil perhitungan didapatkan masingmasing kelompok adalah 13 orang. peneliti menambahkan 2 responden pada masing-masing kelompok untuk antisipasi drop out sehingga jumlah masing-masing kelompok adalah 15 orang. teknik sampling yang digunakan adalah kuota sampling. kuota sampling diterapkan karena keterbatasan pasien rawat inap yang sesuai dengan kriteria inklusi dan eksklusi. sampel diambil dari populasi yang mempunyai ciri-ciri sesuai kriteria inklusi dan eksklusi sampai memenuhi jumlah (kuota) yang diinginkan. pembagian antara kelompok intervensi dan kelompok kontrol dilakukan dengan cara purposive sampling dimana kelompok intervensi dan kelompok kontrol berbeda ruangan. kriteria inklusi yang ditetapkan adalah pasien sesak nafas grade 0 sampai 3. kriteria eksklusi adalah pasien ppok dengan komplikasi kardiovaskuler, pasien ppok dengan gangguan jiwa, dan pasien ppok dengan penyakit penyerta lain yang kronik. kelompok intervensi diberikan acbt dan terapi standar farmakologi, sedangkan kelompok kontrol diberikan terapi standar yaitu terapi farmakologi. intervensi dilakukan 30 menit sebelum responden minum obat. durasi treatment untuk kelompok intervensi adalah satu kali sehari selama 15 – 20 menit perhari selama 3 hari. selama latihan peneliti membimbing responden untuk melakukan tahapan dalam acbt, yaitu : 1) breathing control : responden diposisikan duduk rileks diatas tempat tidur atau di kursi, kemudian dibimbing untuk melakukan inspirasi dan ekspirasi secara teratur dan tenang, yang diulang sebanyak 3 – 5 kali oleh responden. tangan peneliti diletakkan pada bagian belakang toraks responden untuk merasakan pergerakan yang naik turun selama responden bernapas. 2) thoracic expansion exercises : masih dalam posisi duduk yang sama, responden kemudian dibimbing untuk menarik napas dalam secara perlahan lalu menghembuskannya secara perlahan hingga udara dalam paru-paru terasa kosong. langkah ini diulangi sebanyak 3 – 5 kali oleh responden, jika responden merasa napasnya lebih ringan, responden dibimbing untuk mengulangi kembali dari kontrol pernapasan awal. 3) forced expiration technique : setelah melakukan dua langkah diatas, selanjutnya responden diminta untuk mengambil napas dalam secukupnya lalu mengkontraksikan otot perutnya untuk menekan napas saat ekspirasi dan menjaga agar mulut serta tenggorokan tetap terbuka. huffing dilakukan sebayak 2 – 3 kali dengan cara yang sama, lalu diakhiri dengan batuk efektif untuk mengeluarkan sputum. bila ketiga langkah diatas telah dilakukan oleh responden, selanjutnya peneliti membimbing responden untuk merilekskan otot-otot pernapasannya dengan tetap melakukan kontrol pernapasan dan kemudian mengulangi siklus tersebut 3 hingga 5 siklus atau sampai responden merasa dadanya telah bersih dari sputum. alat yang digunakan untuk mengukur vep 1 adalah spirometri, jumlah volume sputum diukur dengan menggunakan gelas ukur, dan mobilisasi sangkar toraks diukur dengan menggunakan midline. pengukuran dilakukan pre-post dilakukan setiap hari selama tiga hari yaitu di hari pertama, hari kedua dan hari ketiga. analisis data penelitian menggunakan software spss. nilai pre post vep 1 , jumlah volume sputum dan mobilisasi sangkar toraks pada kelompok intervensi maupun kontrol dianalisis menggunakan paired t-test sedangkan untuk menilai perbedaan nilai vep 1 , jumlah volume sputum dan mobilisasi sangkar toraks antara kelompok intervensi dan kelompok kontrol menggunakan analisis independent t-test. hasil penelitian karakteristik responden tabel 1 memperlihatkan bahwa karakteristik responden berdasarkan jenis kelamin yang paling banyak adalah laki-laki yang berjumlah 17 orang responden (56,7%), yang terbagi menjadi 9 orang responden (60%) pada kelompok perlakuan dan 8 orang responden (53,3%) pada kelompok kontrol. usia responden yang paling banyak adalah berusia dibawah 65 tahun yang berjumlah 16 orang responden (53,3%). sebagian besar responden (83,3%) baik pada kelompok intervensi maupun kontrol tidak memiliki riwayat infeksi paru dengan riwayat terpapar polusi udara yang berjumlah 24 orang responden (80%), serta riwayat merokok sebanyak 17 orang responden (56,7%). 47 vol. 1 no. 2 juni 2017 tabel 1. distribusi frekuensi karakteristik responden ppok yang rawat inap di rs paru respira yogyakarta (n=30) karakteristik intervensi (n=15) kontrol (n=15) total f % f % f % jenis kelamin laki-laki perempuan 9 6 60 40 8 7 53,3 46,7 17 13 56,7 43,3 umur <65 ≥65 10 5 66,7 33,3 6 9 40 60 16 14 53,3 46,7 riwayat infeksi paru ya tidak 3 12 20 80 2 13 13,3 86,7 5 2 5 16,7 83,3 riwayat terpapar polusi udara ya tidak 12 3 80 20 12 3 80 20 24 6 80 20 riwayat merokok ya tidak 9 6 60 40 8 7 53,3 46,7 17 13 56,7 43,3 sumber: data primer nilai volume ekspirasi paksa detik pertama (vep1) perubahan nilai rerata vep1 pada kedua kelompok dapat dilihat pada grafik berikut ini: grafik 1. rerata vep1 pada kelompok intervensi dan kelompok kontrol grafik 1 memperlihatkan bahwa rerata nilai vep1 kelompok intervensi mengalami peningkatan sebesar 214 poin setelah diberikan latihan acbt, yaitu dari 272,7 ml/dtk saat pre-tes hari pertama menjadi 486,7 ml/dtk pada saat post-tes hari ke-3. sedangkan pada kelompok kontrol yang tidak diberikan latihan acbt, ketika pre-tes hari pertama sebesar 231,3 ml/dtk, lalu meningkat menjadi 290,7 ml/dtk pada saat post-tes hari ke-3. tabel 2. distribusi hasil uji beda nilai vep1 pada kelompok intervensi dan kelompok kontrol kelompok nilai vep1 pre dan post hari ket p value* intervensi (n=15) i pre-post -1,13 0,257 ii pre-post -2,95 0,003 iii pre-post -2,81 0,005 kontrol (n=15) i pre-post 0,54 0,595 ii pre-post -3,95 0,001 iii pre-post -1,79 0,095 *nilai p<0,05 berdasarkan uji paired sample t-test berdasarkan tabel 2, latihan acbt yang diberikan pada awal pertemuan (hari ke-i) pada kelompok intervensi, tidak memberikan pengaruh yang bermakna terhadap nilai vep1 dengan nilai p=0,257, namun pada hari ke-2 dan ke-3, latihan acbt memberikan pengaruh yang bermakna dengan nilai p=0,003 pada hari ke 2 dan nilai p=0,005 pada hari ke-3. hasil uji paired sample t-test perbedaan nilai vep1 pre-tes dan post-tes hari pertama pada kelompok kelompok kontrol, diperoleh nilai p > 0,05 yang artinya tidak ada perbedaan yang signifikan. akan tetapi pada hari ke-2, nilai p=0,001 (< 0,05) yang mengindikasikan adanya perbedaan yang signifikan pada nilai vep1 dan pada hari ketiga kembali tidak terlihat adanya perubahan. nilai volume jumlah sputum perubahan nilai rerata jumlah sputum pada kedua kelompok dapat dilihat pada grafik 2 berikut ini : 48 grafik 2. rerata jumlah sputum pada kelompok intervensi dan kelompok kontrol berdasarkan grafik diatas, nampak bahwa rerata jumlah sputum kelompok intervensi mengalami peningkatan sebesar 0,7 poin setelah diberikan latihan acbt, yaitu dari 0,7 ml saat pre-tes hari pertama menjadi 1,4 ml pada saat post-tes hari ke-3. sedangkan pada kelompok kontrol yang tidak diberikan latihan acbt, ketika pre-tes hari pertama sebesar 1,37 ml menjadi 1,6 ml pada saat post-tes hari ke-3. tabel 3. distribusi hasil uji beda jumlah sputum pada kelompok intervensi dan kelompok kontrol kelompok nilai jumlah sputum pre dan post hari ket p value* intervensi (n=15) i pre-post -1,63 0,102 ii pre-post -1,38 0,168 iii pre-post -1,62 0,106 kontrol (n=15) i pre-post -1,00 0,317 ii pre-post -0,35 0,728 iii pre-post -1,46 0,144 *nilai p<0,05 berdasarkan uji paired sample t-test sumber: data primer tabel 3 menyajikan data analisis jumlah sputum pre-tes dan post-tes pada kelompok intervensi dan kelompok kontrol. hasil uji menunjukkan bahwa, pada kelompok intervensi dan kelompok control terlihat tidak ada perbedaan yang signifikan pada pengeluaran jumlah sputum responden baik pada hari pertama, ke-dua maupun ke-tiga. begitu pula pada kelompok kontrol hari ke-1 dan ke-3. nilai ekspansi thoraks perubahan nilai rerata jumlah sputum pada kedua kelompok dapat dilihat pada grafik 3 berikut ini : grafik 3. rerata ekspansi toraks pada kelompok intervensi dan kelompok kontrol grafik 3 memperlihatkan bahwa rerata nilai ekspansi thoraks kelompok intervensi mengalami peningkatan sebesar 1,7 poin setelah diberikan latihan acbt, yaitu dari 1,3 cm saat pre-tes hari pertama menjadi 3,0 cm pada saat post-tes hari ke-tiga. sedangkan pada kelompok kontrol yang tidak diberikan latihan acbt hanya meningkat 0,13 cm, yaitu ketika pre-tes hari pertama sebesar 1,27 cm, lalu menjadi 1,4 cm pada saat pos-tes hari ke-3. tabel 4. distribusi hasil uji beda nilai ekspansi thoraks pada kelompok intervensi dan kelompok kontrol kelompok nilai ekspansi thoraks pre dan post hari ket p value intervensi (n=15) i pre-post -1,13 0,257 ii pre-post -2,35 0,019 iii pre-post -2,16 0,031 kontrol (n=15) i pre-post -2,24 0,025 ii pre-post -2,12 0,034 iii pre-post -1,34 0,180 sumber: data primer hasil uji menunjukkan bahwa, pada kelompok intervensi yang awalnya pada hari pertama pemberian acbt tidak menunjukkan adanya perbedaan yang signifikan antara nilai pre-tes dan pos-tesnya, akan tetapi pada hari ke-2 dan ke-3 49 vol. 1 no. 2 juni 2017 terlihat ada pengaruh yang bermakna pemberian latihan acbt terhadap perubahan nilai ekspansi thoraks pasien ppok. sedangkan pada kelompok kontrol yang terlihat ada perubahan namun pada hari ke-3 tidak terlihat perbedaan yang signifikan pada nilai ekspansi thoraks pasien ppok.. acbt terhadap nilai vep1, jumlah sputum, dan ekspansi toraks pada pasien ppok tabel 5 memperlihatkan bahwa latihan acbt memberikan pengaruh yang signifikan terhadap jumlah sputum dan ekspansi toraks kelompok intervensi daripada kelompok kontrol yang tidak diberikan acbt dengan nilai p = 0,026 untuk jumlah sputum dan p=0,004 untuk ekspansi toraks. sedangkan pada nilai vep1, acbt tidak memberikan pengaruh yang signifikan dengan nilai p = 0,058. hasil ini mengartikan bahwa acbt efektif dalam membantu pengeluaran sputum dan meningkatkan ekspansi toraks pasien ppok, tetapi kurang efektif dalam meningkatkan nilai vep1. tabel 5. analisis pengaruh acbt terhadap nilai vep1, jumlah sputum, dan ekspansi toraks pasien ppok di rs respira yogyakarta variabel kelompok t p value* vep1 intervensi kontrol -1,89 0,058 jumlah sputum intervensi kontrol -2,22 0,026 ekspansi toraks intervensi kontrol -2,88 0,004 *nilai p berdasarkan uji independent t-test sumber: data primer pembahasan karakteristik responden hasil penelitian berdasarkan karakteristik responden menunjukkan jumlah pasien berjenis kelamin laki-laki yang menderita ppok adalah yang paling banyak yaitu berjumlah 17 orang responden (56,7%). peran jenis kelamin sebagai faktor resiko untuk ppok masih belum jelas. di masa lalu, beberapa studi menunjukkan bahwa prevalensi ppok dan kematian lebih besar di antara laki-laki daripada perempuan, sedangkan studi terbaru menunjukkan bahwa dari negara-negara maju, prevalensi penyakit ini hampir sama pada pria dan wanita yang mungkin mencerminkan perubahan pola merokok tembakau dan akan meningkat pada kelompok usia > 45 tahun (potter, perry, 2006; oemiyati, 2013). hasil penelitian menunjukkan antara kategori usia < 65 tahun dan ≥ 65 tahun memiliki prosentase yang hampir sama pada kejadian ppok. hasil ini sejalan dengan penelitian yang dilakukan oleh lestari yang mendiskripsikan mayoritas penderita ppok adalah usia 67 – 74 tahun dengan perhitungan statistik diperoleh rerata usia yaitu 60,8 tahun (oemiyati, 2013). haraguchi et al (2016) menyatakan semakin bertambah usia terutama pada lanjut usia, kejadian ppok semakin tinggi dan dampak ppok akan semakin berat dibandingkan dengan usia yang lebih muda. selain jenis kelamin dan usia, variabel lain dalam penelitian ini adalah riwayat kesehatan responden yang terdiri dari riwayat infeksi paru, terpapar polusi udara, dan riwayat merokok yang merupakan faktor resiko ppok berdasarkan pdpi tahun 2011 (perhimpunan dokter paru indonesia, 2011). dari hasil penelitian didapatkan sebagian besar responden pada kelompok intervensi maupun kontrol tidak memiliki riwayat infeksi paru dengan jumlah 25 orang responden (83,3%). beberapa responden yang memiliki riwayat terpapar polusi udara yaitu berjumlah 24 orang responden (80%), serta riwayat merokok sebanyak 17 orang responden (56,7%). pdpi tahun 2011 menyatakan bahwa polusi udara mempunyai pengaruh buruk terhadap nilai vep 1 . zat polutan yang paling kuat menyebabkan ppok adalah cadmium, zink, dan debu, serta bahan asap pembakaran / pabrik / tambang. polusi dari tempat kerja misalnya debu-debu oraganik (debu sayuran dan bakteri atau racun-racun dari jamur), industri tekstil (debu dari kapas), dan lingkungan industri (pdpi, 2011). merokok adalah faktor resiko utama ppok walaupun partikel dari berbagai gas juga memberi kontribusi, secara umum telah diterima bahwa merokok merupakan faktor resiko terpenting ppok namun hanya 10% – 20% perokok mengalami gangguan fungsi paru berat yang terkait ppok. dalam gold tahun 2015, menyatakan bahwa perokok memiliki prevalensi lebih tinggi dari kelainan fungsi paru-paru dan gangguan pernafasan, riwayat merokok yang menahun menunjukkan penurunan vep1 yang lebih besar, dan tingkat kematian yang lebih tinggi untuk ppok dibanding bukan perokok. paparan pasif asap rokok juga dapat menyebabkan 50 gejala pernapasan dan meningkatkan beban total paru-paru (oemiyati, 2011; maranata, daniel, 2010). kesenjangan teori dan hasil penelitian menunjukkan bahwa tidak hanya merokok yang dapat mengakibatkan ppok tapi terpajannya dengan zat polutan juga menjadi hal yang perlu diperhatikan. responden banyak yang mengakui bahwa terpapar asap rokok dari teman atau keluarga merokok atau bahkan klien mengaku sudah berhenti merokok tapi penyakitnya dirasakan ketika menginjak umur 40 tahunan. proses patogenesis yang panjang beriringan dengan proses penuaan memberikan dampak yang buruk terhadap kondisi saluran napas. nilai volume ekspirasi paksa detik pertama (vep1) pre-post test pada kelompok intervensi dan kelompok kontrol hasil penelitian menunjukkan rerata nilai vep 1 pada kedua kelompok sama-sama mengalami peningkatan pada post-tes i, post-tes ii, dan post-tes iii, karena baik kelompok intervensi maupun kelompok kontrol mendapatkan terapi medikasi sebagai standar penatalaksanaan ppok di rumah sakit guna mengurangi sesak yang dirasakan pasien. peningkatan nilai vep 1 pada kelompok intervensi yang diberikan latihan acbt, jauh lebih besar dibandingkan dengan kelompok kontrol yang hanya mendapatkan terapi medikasi. smeltzer (2002) menyatakan bahwa sebagian besar pasien dapat menghembuskan sedikitnya 75% atau 80% dari nilai normal kapasitas vital yang berkisar 4500 ml dari kapasitas vital mereka dalam satu detik (vep 1 ) dan hampir semuanya dalam 3 detik (vep3). ketika vep1 dan fvc pasien menurun secara proporsional, aliran udara pulmonal menjadi abnormal dan ekspansi paru maksimal dapat terbatas. jika penurunan vep1 sangat melebihi penurunan fvc, pasien mungkin mengalami obstruksi jalan napas sampai tingkat tertentu (sherwood, 2015). dalam penelitian ini, didapatkan nilai vep 1 yang paling tinggi dari responden mencapai 1600 ml, dengan nilai mean 272,7 – 486,7 pada kelompok intervensi dan 231,3 – 290,7 pada kelompok kontrol, jika dibandingkan antara nilai normal vep 1 berdasarkan teori tersebut, maka hasil ini sangatlah kecil. namun sejak hari pertama pemberian latihan acbt, telah menunjukkan peningkatan nilai mean dan terus meningkat hingga hari ke-3 intervensi. nilai normal pada teori tersebut merupakan nilai normal yang telah ditetapkan oleh gold tahun 2015 berdasarkan hasil penelitian yang telah dilakukan di negara-negara amerika maupun eropa yang memiliki suku bangsa, kebiasaan, keadaan lingkungan, postur tubuh, dan nutrisi yang berbeda dengan indonesia. menurut subagyo (2013), dari beberapa publikasi yang paling mewakili nilai faal paru orang indonesia adalah penelitian tim pneumobile yang dilakukan di jakarta dan surabaya yang telah disesuaikan dengan rekomendasi ats. acbt merupakan metode terapi yang fleksibel yang dapat digunakan pada semua pasien yang mempunyai masalah peningkatan sekresi sputum dan acbt dapat dilakukan dengan dengan atau tanpa asisten. dari penatalaksanaan acbt juga dilaporkan bahwa keluhan sesak nafas yang dirasakan responden menjadi berkurang serta nilai spo2 yang adekuat berkisar 95% 98%. latihan pernafasan yang dilakukan saat acbt menghasilkan peningkatan tekanan transpulmonar, memperluas jaringan paru dan memobilisasi secret dari bronkus. suman sheraz et al (2015 dalam lamuvel et al, 2016) meneliti respon saturasi oksigen pada pasien yang telah diberikan acbt. hasil penelitian menunjukkan terjadi perbedaan yang signifikan pada pco2 dan saturasi oksigen pada kelompok eksperimen. beberapa penelitian lain yang juga mendukung yaitu penelitian yang telah dilakukan oleh mohamed faisal, c.k et al (2012), penelitian senthil et al (2015) dan penelitan lamuvel et al (2016) yang bertujuan untuk mengetahui efektivitas acbt sebagai sarana perawatan pasien ppok. hasil penelitian menunjukkan acbt dapat meningkatkan nilai fvc, vep 1 , pefr, dan spo2. acbt memiliki makna yang sangat tinggi dalam keberhasilan pengelolaan pasien dengan nilai ß<0.05. berdasarkan hasil penelitian tersebut menunjukkan bahwa pemberian latihan acbt yang diberikan, mampu meningkatkan nilai vep 1 pada pasien ppok (faisal, c.k et al , 2012; senthil et al, 2015; lamuvel et al, 2016; melam et al, 2012). nilai volume jumlah sputum pre-pos test pada kelompok intervensi dan kelompok kontrol hasil penelitian menunjukkan rerata jumlah volume sputum pada kedua kelompok sama-sama mengalami peningkatan, karena baik kelompok intervensi maupun 51 vol. 1 no. 2 juni 2017 kelompok kontrol mendapatkan terapi medikasi sebagai standar penatalaksanaan ppok di rumah sakit. meskipun demikian, jumlah volume sputum yang mampu dikeluarkan pasien pada kelompok intervensi yang diberikan latihan acbt jauh lebih besar dibandingkan dengan kelompok kontrol yang hanya mendapatkan terapi medikasi. hasil uji beda jumlah sputum pada penelitian ini menunjukkan nilai p > 0,05 pada kedua kelompok, yang berarti tidak ada perbedaan yang signifikan pada pengeluaran jumlah sputum responden. meskipun hasil uji beda menyatakan bahwa tidak ada perbedaan yang bermakna antara kedua kelompok, namun berdasarkan jumlah rerata volume sputum yang dapat dikeluarkan oleh responden menunjukkan bahwa pada kelompok intervensi mengalami peningkatan sebesar 0,7 poin setelah diberikan latihan acbt, yaitu dari 0,7 ml saat pretes hari pertama menjadi 1,4 ml pada saat post-tes hari ke-3. sedangkan pada kelompok kontrol yang tidak diberikan latihan acbt, ketika pre-tes hari pertama sebesar 1,37 ml menjadi 1,6 ml pada saat post-tes hari ke-3. sputum adalah bahan yang dikeluarkan dengan batuk, kira-kira 75-100 cc sputum disekresikan setiap hari oleh bronkus. peningkatan jumlah produksi sputum merupakan manifestasi klinis dari ppok (bronkhitis) yang paling dini. sputum dapat mengandung debris sel, mukus, darah, pus, atau mikroorganisme (swartz, 1995). beberapa penelitian menyatakan bahwa acbt merupakan teknik yang efektif dalam pembersihan sputum, dengan rata-rata perbedaan menunjukkan peningkatan jumlah sputum yang dapat dikeluarkan selama dan sampai satu jam setelah diberikan acbt (melam et al, 2012: lewis et al, 2012). active cycle of breathing technique (acbt) sebagai salah satu terapi nonfarmakologi mempunyai tujuan utama membersihkan jalan nafas dari sputum yang merupakan produk dari infeksi atau proses patologi penyakit tersebut yang harus dikeluarkan dari jalan nafas agar diperoleh hasil pengurangan sesak nafas, pengurangan batuk, perbaikan pola nafas, serta meningkatkan mobilisasi sangkar thoraks (lestari, 2015; pawadshetty et al, 2016). latihan acbt yang diberikan kepada responden, sangat membantu responden dalam usahanya untuk mengeluarkan sputum yang menumpuk dan lengket tanpa menimbulkan rasa tidak nyaman pada tenggorokan dan dada mereka. hal ini dibuktikan dengan peningkatan jumlah sputum yang mampu dikeluarkan oleh responden, serta laporan responden yang mengatakan bahwa dengan menerapkan langkah-langkah yang diajarkan dalam latihan acbt membuatnya dapat mengeluarkan sputum dengan lebih mudah dan tidak merasa perih pada tenggorokannya dan sakit pada dada. hasil penelitian ini sejalan dengan penelitian lestari pada tahun 2015 yang mendapatkan hasil bahwa jumlah sputum yang dapat dikeluarkan responden setelah penatalaksanaan acbt meningkat, yaitu sebanyak 1,00 ml pada saat pre tes menjadi 6,56 ml pada saat post tes. eaton et al menyatakan studi pertama yang secara sistematis mengevaluasi penerimaan akut dan keadaan yang dapat ditoleransi sebagai efek akut dari teknik bersihan jalan napas (flutter dan acbt dengan dan tanpa postural drainage) pada bronkiektasis. acbt dengan postural drainage (pd) lebih unggul dibanding pemberian acbt saja yang diukur dengan produksi sputum. acbt secara signifikan lebih nyaman daripada acbt dengan pd yang menyebabkan gangguan yang lebih besar dengan kehidupan sehari-hari (eaton et al, 2007). hasil ini menunjukkan bahwa dengan latihan acbt, penderita ppok dapat lebih mudah mengeluarkan sputum sehingga jalan nafas menjadi bersih, selain itu, responden juga melaporkan bahwa keluhan batuk yang dirasakan jauh lebih berkurang. nilai ekspansi thoraks pre-pos test pada kelompok intervensi dan kelompok kontrol hasil penelitian menunjukkan rerata nilai ekspansi toraks pada kedua kelompok sama-sama mengalami peningkatan, namun nilai ekspansi toraks pada kelompok intervensi yang diberikan latihan acbt, jauh lebih besar dibandingkan dengan kelompok kontrol yang hanya mendapatkan terapi medikasi. berdasarkan hasil uji beda pada kelompok intervensi menunjukkan peningkatan signifikansi dari hari ke-1 hingga hari ke-3 pemberian latihan acbt, tapi tidak demikian dengan kelompok kontrol. ini membuktikan bahwa ada pengaruh yang bermakna pemberian latihan acbt terhadap perubahan nilai ekspansi toraks pasien ppok. berbagai macam keadaan dapat mengganggu ventilasi yang memadai, dan konfigurasi dada mungkin menunjukan penyakit paru. peningkatan diameter anteroposterior dijumpai pada ppok tingkat lanjut. diameter anteroposterior 52 cenderung mendekati diameter lateral, sehingga terbentuk dada berbentuk tong. iga-iga kehilangan sudut 45º dan menjadi lebih horizontal. smeltzer (2002), menyatakan barrel chest terjadi sebagai akibat inflasi berlebihan paru-paru, terdapat peningkatan diameter anteroposterior toraks pada pasien dengan emfisema, iganya lebih melebar dan spasium interkostanya cenderung untuk mengembang saat ekspirasi (swartz, 1995). ketidakmampuan beraktivitas pada pasien ppok terjadi bukan hanya akibat dari adanya kelainan obstruksi saluran nafas pada parunya saja, tetapi juga akibat pengaruh beberapa faktor, salah satunya adalah penurunan fungsi otot skeletal. adanya disfungsi otot skeletal akan membatasi kapasitas latihan dari pasien ppok (khotimah, 2013). dasar mekanika pernafasan dari rongga dada adalah inspirasi dan ekspirasi yang digerakkan oleh otot-otot pernafasan. ketika dada membesar karena aksi otot-otot inspirasi, maka kedua paru mengembang mengikuti gerakan dinding dada. dinding dada bagian atas dan sternum mempunyai gerakan ke atas dan ke depan (anterocranial) atau mekanisme pump handle pada inspirasi dan kembali ke posisi semula pada ekspirasi, dinding dada bagian tengah mempunyai gerakan ke samping dan ke depan (lateroanterior) pada inspirasi dan kembali ke posisi semula pada ekspirasi dan dinding dada bagian bawah mempunyai gerakan ke samping dan terangkat (latero cranial) atau mekanisme bucket handle selama inspirasi dan kembali ke posisi semula pada ekspirasi (pryor, 2008). breathing exercise yang menjadi salah satu bagian dari acbt ini didesain untuk melatih otot-otot pernafasan dan mengembalikan destribusi ventilasi, membantu mengurangi kerja otot pernafasan dan membetulkan pertukaran gas serta oksigen yang menurun. breathing exercise dengan metode thoracic expansion exercise, bertujuan untuk meningkatkan fungsi paru dan menambah jumlah udara yang dapat dipompakan oleh paru sehingga dapat menjaga kinerja otototot bantu pernafasan dan dapat menjaga serta meningkatkan ekspansi sangkar thorak (rab, 2010). hasil pengukuran yang telah dilakukan pada penelitian ini memperlihatkan bahwa rerata nilai ekspansi thoraks kelompok intervensi mengalami peningkatan sebesar 1,7 poin setelah diberikan latihan acbt, yaitu dari 1,3 cm saat pre-tes hari pertama menjadi 3,0 cm pada saat post-tes. sedangkan pada kelompok kontrol yang tidak diberikan latihan acbt hanya meningkat 0,13 cm, yaitu ketika pre-tes hari pertama sebesar 1,27 cm, lalu menjadi 1,4 cm pada saat pos-tes hari ke-3. hasil ini sejalan dengan penelitian yang dilakukan oleh hidayat (2015) yang memperlihatkan peningkatan ekspansi sangkar thorak pada saat inspirasi setelah dilakukan metode breathing exercise sebanyak 6 kali terapi yaitu pada daerah axilla dari t0 = 1 cm selisihnya menjadi t6 = 2 cm, pada daerah intercostalis ke-4 dari t0 = 2 cm selisihnya menjadi t6 = 3 cm, pada daerah processus xyphoideus dari t0 = 2 cm selisihnya menjadi t6 = 3 cm. kesimpulan berdasarkan hasil analisa data yang diperoleh dari penelitian ini dapat disimpulkan bahwa active cycle of breathing technique (acbt) mampu membantu meningkatkan nilai ekspansi toraks dan mengatasi masalah kesulitan untuk mengeluarkan sputum pada pasien ppok di rumah sakit paru respira yogyakarta. active cycle of breathing technique (acbt) belum mampu meningkatkan nilai vep1 pada pasien ppok di rumah sakit paru respira yogyakarta. acbt dapat diterapkan sebagai evidance based practice dalam profesionalisme pemberian asuhan keperawatan bagi masyarakat, untuk mengembangkan bentuk pelayanan nonfarmakologis sebagai salah satu intervensi keperawatan dalam mengatasi masalah pada pasien ppok. bagi pasien, acbt ini bisa dijadikan pola hidup pasien, untuk mengurangi akumulasi sputum dalam saluran pernapasan, mengurangi sesak nafas, dan meningkatkan mobilisasi sangkar toraks sehingga kebutuhan oksigennya terpenuhi. daftar pustaka dipiro, cecily v, wels, barbara g, dipiro, joseph t, schwinghammer, terry l. (2015). pharmacotherapy handbook, 9th edition. united states: mcgraw-hill education. kementrian kesehatan ri. (2015). rencana strategis kementrian kesehatan tahun 2015 – 2019. jakarta: keputusan menteri kesehatan republik indonesia nomor hk.02.02/menkes/52/2015. eaton, t., young, p., zeng, i., et al. (2007). a randomized evaluation of the acute efficacy, acceptability and tolerability of flutter and active cycle of breathing with 53 vol. 1 no. 2 juni 2017 and without postural drainage in non-cystic fibrosis bronchiectasis, chron. respir. dis.; 4 (1) :23-30. faisal, mohamed, c.k., puneeth, b., devi, renuka.m., & ajith s. (2012). efficacy of active cycle breathing technique and postural drainage in patients with bronchiectesis – a comparative study. innovative journal of medical and health science 2: 6 nov – dec (2012) 129 – 132. retrievied from http://www. innovativejournal.in/index.php/ijmhs. global initiative for chronic obstructive lung disease (gold). (2015). global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, update 2015. gold. usa. haraguchi mizuha, nakamura hidetoshi, sasaki mamoru, miyazaki masaki, chbachi shotaro, takahashi saeko, asano koichiro, jones paul, betsuyaku tomoko, k-ccr group. (2016). determinants of chronic obstructive pulmonary disease severity in the lateelderly differ from those in younger patients, bmc res notes (2016), 9:7 hidayat faqih. (2015). penatalaksanaan fisioterapi pada ppok di bbkpm surakarta. naskah publikasi, fakultas ilmu kesehatan, ums. ikalius, yunus f, suradi, dan rachma n. 2007. perubahan kualitas hidup dan kapasitas fungsional penderita penyakit paru obstruktif kronis setelah rehabilitasi paru.majalah kedoteran indonesia.vol 57. no12: desember. hal 447 kementrian kesehatan ri. (2013). riset kesehatan dasar (riskesdas). jakarta: bppk kemenkes ri. khotimah, s. 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(2008). physiotherapy for respiratory and cardiac problems adults and paediatrics, 4th edition. london: churchill livingstone. rab, t. (2010). ilmu penyakit paru. jakarta: trans info media. rabe, klausf., hurd, suzanne., anzueto, antonio., barnes, peter j., buist, sonia a., calverley, peter., fukuchi, yoshinosike., jenkins, christine., rodriguez-roisin, roberto., weel, chris van., and zielinski, jan. (2007). global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, gold executive summary. leiden university medical center, pulmonology, leiden, the netherlands respira. (2015). data 10 besar penyakit pasien rawat inap dan rawat jalan. yogyakarta: rumah sakit paru respira yogyakarta. lestari, ririt ika. (2015). manfaat active cycle of breathing technique (acbt) bagi penderita ppok. naskah publikasi, program studi fisioterapi, universitas muhammadiyah surakarta 54 senthil p, suchithra e, koushik kumar n. (2015). effectiveness of active cycle of breathing techniques [acbt] versus acbt with acapella on airway clearance in bronchiectasis, international journal of physical education, sports and health 2015; 1(4): 10-13. sherwood, l. (2015). fisiologi manusia: dari sel ke sistem, edisi 8. jakarta: egc smeltzer, s.c., bare, b.g. (2002). buku ajar keperawatan medikal bedah, volume 1. jakarta: egc. subagyo, ahmad. (2013). nilai normal faal paru orang indonesia pada usia sekolah dan pekerja dewasa berdasarkan rekomendasi american thoracic society (ats) 1987 oleh alsagaff h, mangunegoro h. airlangga university press. surabaya 1993. diakses dari: http:// kolegiumpulmonologi.com/pdf/nilai_normal_faal_ paru_orang_indonesia.pdf dan http://www.klikparu. com/2013/09/nilai-normal-faal-paru-indonesia.html swartz, mark h. (1995). buku ajar diagnostik fisik. jakarta: egc 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 jurnal mjn vol. 2 no. 2 desember 2015.indd 123 muhammadiyah journal of nursing the role of lecturers in nursing educationsiti kholifah muhammadiyah university of jember s.kholifah2509@gmail.com abstract lecturer has a big role in learning accomplishment of nursing students. the duty of nursing lecturers in the learning are required to have several competencies such as ability of knowledge mastery, ability of skills mastery and ability in the terms of attitude. those three competencies must be possessed by lecturers in order to make students accomplish competencies in the form of competency of knowledge mastery, competency of skills mastery and competency of attitude. this article aims to describe the nursing lecturers’ roles in relation with learning process. this explanation hopefully can enhance lecturer’s knowledge in improving quality of learning which aff ect the accomplishment of nursing students as well. the accomplishment of nursing students’ competency can’t be separated from lecturers role in learning process, both in academic fi eld and practical fi eld (clinic). those roles are as an educator, a guide, a leader, a communicator, a role model, an assessor, a counselor, a problem solver, an expertise, a facilitator, a motivator and an inspirator. twelve roles of nursing lecturers in learning process are the elaboration of lecturers’ main role based on the role of nurse in nursing namely assessor, planner, implementer, and evaluators. key words : lecturers’ role, nursing education background learning activity should be directed for helping nursing students in accomplishing competency and it must be appropiate to the purposes which have been determined. principles of eff ective learning which are suitable with learning styles of each students are used because students should be facilitated in accomplishing purposes. eff ective learning techniques have to be adapted with student’s characters, subject’s characters, lecturer’s characters, and the condition of avaliable resource. the freedom to choose the learning technique will give lecturers the chance to do inovation to decide learning system which is suitable with student’s characters and skills. lecturers are free to run their roles as a lecturer but they must refer to student’s competency accomplishment process. opportunity for lecturers to bring inovation in running their role practically is not materialize maximally yet. lecturers tend to implement their role monotonically using old method in learning process and to ignore the diff erent of students’ characters and learning styles. it is caused by several conditions which become obstacles for lecturers in implementing their role and they may come from internal and internal factors. external factors which become obstacles for lecturers in implementing their role are income level, work climate, interpersonal relationship and the avaliable resource. meanwhile, the internal factors are motivation, 124 muhammadiyah journal of nursing work satisfaction, commitment, and work ethic, unpreparednessand the absence of strong willing from lecturer to implementt heir role optimally. sidi (2001) mentioned that lecturer is one strategic and dominant factor which determines level of students’ success to do transformation of knowledge and technology along with internalization of ethics and moral. a big challenge faced by lecturers especially nursing lecturers in performing their role in globalization era is huge amount of fl ow in information and freedom to exchange among countries. it aff ects rapid development and advancement of information and communication technology, so people should reponse to it accurately and wisely. it hopefully can maintain the existence of nursing lecturers in performing their role in nursing to accomplish their competencies. the discussion in this article is limited only in exploring how nursing lecturers implement their role to learning process in academic and practical fi eld (clinic). furthermore, this article aims to describe nursing lecturers role in relation with learning process. the explanation hopefully can increase nursing lecturers’ insight in their eff ortsto enhance the quality of learning process which also aff ect the competency accomplishment of nursing students. definition of nursing lecturer the nursing professional development educator helps to facilitate adult learning and actively involves the learner (american nurses association [ana], 2010). the educator provides feedback to the learners and the organization on the eff ectiveness of learning and the learning activity (ana, 2010). based on dikti (2013), lecturer is a professional educator and researcher with main duty to transform, develop, and spread science and technology through education, research, and community service. according to djamarah (2006), lecturer is an educator who give knowledge to students. in the other words, lecturer is an experienced person in his/her profession fi eld who can make students educated with his/her knowledge. to conclude, lecturer is one of components in learning process which forming potential human resources in accomplishing students competency. characteristics of nursing lecturer based on law (uu) no. 14 year 2005 about teacher and lecturer, lecturers of higher education are required to minimally having master (s2) title as educational background. it is mentioned in acts that elementary and middle school teachers’ requirement is minimally having bachelor (s1) title. whereas, to teach in undergraduate level, lecturers at least must have master (s2) title, besides for postgraduate level should be a doctorate and a professor. in addition, there are competencies should be possessed and developed by lecturers such as pedagogic competency, social competency, personality competency and professionalcompetency which can be implemented in research activity, learning and community service along with preservation of moral value. the law (uu) of republic of indonesia number 12 year 2012 about higher education section 1 number 14 and government law of republic of indonesia number 37 year 2009 about lecturers section 1 number 1 declares that lecturers are professional educators and researchers with main duty to transform, develop and spread knowledge and technology through education, research, and community service. section 2 declares that lecturers obligate to have academic qualifi cation, competency, educator’s certifi cate,having healthy body and mind, and to fulfi ll the other qualifi cation which are required by higher education institution where they work, along with having skill to actualize the purpose of national education. next, section 1 number 4 mentions that certifi cate is a process of giving 125 muhammadiyah journal of nursing certifi cate of educators to lecturers. section 1 number 5 states that educators certifi cate is a formal evidence as acknowledgement given to lecturers as a professional. based on section 12 subsection 1, the next duty of lecturers as the member of academic communityis must transforming knowledge and technology which mastered by them to their students. it is followed by actualizing an atmosphere to study and the learning itself that makes students are able actively develop their potential. subsection 2, lecturers as researchers have the duty to develop a branch of knowledge or technology or both through reasoning and scientifi c research then they should spread it widely. subsection 3, lecturers personally or in a group have to write lesson book or textbook which is published by university or scientifi c publication or bothas one of learning resources and to develop the academic culture and cultivation of readingwriting habit to academic community. the law (uu) of republic of indonesia number 12 year 2012 about higher education section 44 subsection 1, competency certifi cate is a competency acknowledgement of graduate’s achievements which are in line with his/her expert fi eld or out of his fi eld or both. subsection 2, certifi cate of competency as stated by subsection 1 is published by university joining with profession organization, training institute or certifi cation institute accredited to alumni who passed the competency test. section 46 subsection 1, qualifi cation as said in section 45, is achieved through taking accredited master program in higher education which is in line with lecturers’ fi eld of expertise. subsection 2, lecturers should have academic qualifi cation minimally graduated from master program for diploma or bachelor degree. in a study of over 700 teachers at the national center for research on teacher education, some startling discoveries were made by investigators (kennedy, 1991). the premise of the study was built on the beliefs that in order for teachers to learn the craft of teaching, they must have an extensive knowledge of the content, know why and how to teach that content, understand how it is learned and possess the skills needed to incorporate new means of teaching that will maximize the benefi t to the student. meanwhile, according to reynolds, came to the conclusion that entry-level practitioners should possess fi ve minimal qualifi cations: (a) subject content knowledge, (b) ability to use resources and skills to learn as much as possible about the school and the students, (c) strategies to develop and sustain learning communities, (d) cognition of pedagogy in their content area, and (e) the ability to refl ect on their practice and make changes as needed. conclusions relates to nursing lecturers’ qualifi cation based on several rules in indonesia are lecturer obligate to have academic qualifi cation, competency, educators’ certifi cate, maintaining a healthy body and mind along with fulfi lling the other qualifi cation which is stated by the university as prerequisite, and having ability to actualize main purpose of national education. academic qualifi cation is a level of academic education which should be fulfi lled by lecturers. it is proven by a graduation certifi cate which is in line with lecturer’s fi eld, level, and unit of formal education. lecturers should minimally had completed their postgraduate program to guide undergraduate and diploma students, while they should had completed their doctoral program to guide postgraduate students. academic qualifi cation of lecturers is accomplished through university with accredited postgraduate programs. certifi cate of educators for lecturers is given after fulfi lling the prerequisite for having work experience as a teacher at higher education at least 2 years, having academic position minimally as an expert assistant and passed the certifi cation test. standard of lecturers aims to be national reference for organizer of education providers 126 muhammadiyah journal of nursing institution in the development of lecturer’s academic qualifi cation and competency. specifi cally, this standard has a purpose to be guidance for education organizer to arrange numerous policies relates to selection, recruitment, placement, founding, appreciation and lecturer career’s system, a guidance for lecturer to always harmonize their performance with standard of quality which is applied nationally. harmonization of lecturer’s development with other components in the higher education system becomes the reference for lecturer performance so a valid and reliable instrument and procedur of assesment can be accomplished. it can be a reference to asses lecturers’ performances in the unit of health education organizer. the benefi ts for lecturers and nursing institute are the preservation of education quality, while for society it can keep the quality of education service which will aff ect to the improvement of health service as well. the qualifi cations become both a motivation and a challenge for nursing lecturer because education institution should do extra work relates to the improvement of human resources of lecturers. furthermore, the prerequisite for accreditation is lecturers should having education qualifi cation minilally master title. based on data stated by hadi as the leader of aipni in 2014, the amount of bachelor alumni and nursing profession in 2014 are 11323 and 8099 which come from 124 universities. however, the amount of lecturers having bachelor titleof nursing and nonnursing are 980 and 178. for master title, there are 998 lecturers in nursing and 665 in non-nursing. unfortunately, there are only 55 doctorate of nursing and 10 doctorate of non nursing. the fact that there are still lecturers with bachelor title becoma a problem. condition in indonesia currently, the postgraduate program for nursing can only be found in some state universities, such as university of indonesia, padjajaran university, airlangga university, brawijaya university, university of north sumatra and hasanudin university. whereas, doctoral program is only available at university of indonesia. in the other hand, there are some private institutions which are selected by aipni. one of them is faculty of medicine and nursing, university muhammadiyah of yogyakarta that opens postgraduate program for nursing. th cze phenomenon proves that there are still a lot of nursing lecturers who don’t meet the qualifi cations because they don’t continue their study to postgraduate program yet. role of nurse educator several literature had explained the role of nursing lecturers in learning process. benner (2009) stated that nurse educators are tasked with promoting and fostering intellectual training in education, research, and clinical practice. they must seek new ways to educate the next generation of nurses. the professionals of tomorrow need to be bett er prepared through a skill-based apprenticeship of practice, including clinical judgment (benner et al., 2009). while, barth said that (2003) “the teacher should be able to plan lessons, develop a professional relationship with the students, treat all students equally, address the environment of learning, present information that builds on the student’s prior learning, use eff ective evaluation strategies and refl ect on their own practice to improve their teaching”. the role of nurse educator evolved throughout the years from a skills-based on the job educator to that of the professorate in a university sett ing (charron, 1985; creighton, 1983; fitz patrick & heller, 1980; ruby, 1999, 2003: barth). happel (2009) points out that a lecturer is someone who teaches, counsels, inspires, serves as a role model, and supports the growth and development of a nursing student for a fi xed and limited amount of time with the specifi c purpose of socializing the student into a new role. the nurse lecturer’s role in relation to teaching and assessing the undergraduate student in clinical practice 127 muhammadiyah journal of nursing involved the following concepts; the pastoral role, taking a caseload and support for the preceptor. a concern regarding failure to fail the student in the clinical assessment was voiced (mcsharry, 2010). the importance of eff ective communication cannot be underestimated. raising awareness about the existence and subsequent dangers of incivility and lateral violence, along with teaching nurses to ask questions and address the problem behavior, can reduce its incidence and eff ects (griffi n, 2004; cynthia, 2012). sudrajat (2005) revealed that lecturers act as a creator in choosing and arranging method, style and process of learning, a motivator in motivating students to improve the quality of learning, a moderator or facilitator which facilitate students during learning process, a informant/ resource as a place for students to asks, a leader to make students focus during learning process. if we look at theory of nursing called peplau, the role of nurse for patient are as a teacher, a resource, a counselor, a leader, a technical expert, and a surrogate. this concept can be used to describe the role of lecturers to nursing students. sujarwo revealedin an article of sustainable lecturer development that lecturers in a professional position to empower students having roles as : a professional educator and teacher, a motivator which give guidelines and motivation to students, a counselor with helping students in their self development, a facilitator with providing a great training program for students’ activities, an assesor with assesing students’performance based on a set of certain criteria. the nurse lecturer’s role in relation to teaching and assessing the undergraduate student in clinical practice involved the following concepts; the pastoral role, taking a caseload and support for the preceptor. a concern regarding failure to fail the student in the clinical assessment was voiced (mcsharry, 2009). moreover, mcsharry mentioned other role of nursing lecturers while students is having practicum in the clinic “clinical credibility in classroom teaching was identifi ed by nurse lecturers as an area that could be enhanced via a clinical practice role, a fl exible, eclectic model that optimizes the expertise of individual nurse lecturers is advocated. key areas where lecturers can make a positive contribution include faculty practice, clinical research and practice development”. other research planning and guiding student experiences, using formative and summative evaluations, understanding ethical and legal considerations, handling diffi cult students, and incorporating simulation (cangelosi et al., 2009; reid et al., 2013; schoening, 2013; grassley et al., 2015). based on explanation from various resources, it can be concluded that the role of lecturers to the competency accomplishment of nursing students are : 1. planner curriculum is a set of planning and arrangement about learning content and material along with method used as a guidance to conduct learning activities (provision of ministry of health, number: 725/menkes/ sk/v/2003). lecturers as the curriculum planner should be able to plan the curriculum so the purposes and eff orts of learning will be clear. they should know whether the purposes are accomplished or notaccomplished yet, be able to identify obstacles which appear during the learning process, and avoid the out of planning/ purposes growth and development so the students can accomplish the competencies as wish. the best curriculum will not be eff ective if the learning content and material don’t have any relationship with necessity in nursing faculty. after arranging the curriculum principles of nursing faculty or major, detail information about the planning should be made in individual course level. this is necessary to design learning program that can accomplish the goals determine by nursing faculty.the program will be actualized in learning modul 128 muhammadiyah journal of nursing about nursing. the role of lecturer as a course planner is needed as a responsible person of specifi c modul. it is included lecturer as one of curriculum compiler commitee members and taking responsibility of one specifi c modul in curriculum of nursing major in macro, meso, and micro curriculum. meanwhile, a course planner is relates to instructional design. it is a set of activities that facilitate students in learning process and instruction of the activities are also directed to students as an individu such as mentoring system in every course meetings. the conclusion of planner role is designing strategy and learning environment with providing learning experiences needed by students aiming to accomplish certain competency. 2. teacher a person who give knowledge about information that is needed and wanted. the theory of interpersonal relationship of nursing explained by peplau separate the role of educator into two categories: instructional, lecturers give information and explanation in the scope of education and experiential, lecturers use experience as a basic of improvement of instructions’ result. lecturer as an educator has function as planner and organizer of learning process, assesing the learning outcome, giving guidance and training along with doing research and community service especially for educators and higher education (section 39 subsection 2 uu number 20 year 2003). 3. resource a person who gives specifi c answers, necessary information about unidentifi ed problems or a new situation with explaining generally about material conveyed and addinguncompleted information along with doing correction if there is a mistake during students discussion. 4. counselor depdiknas (2007) explained that the aim of guiding and counseling in the school are in order to make the students are able to understanding, accepting themself and planning their future by their own power. the role of counselor must be performed by the lecturer with using skills and credibility give respond for students who needed. the aim of lecturer’s guiding are helping, remembering and understanding students all about what happened with the student’s study so that lecturers are able to guide students who has problems, capable to build students confi dentiality and strengthened student’s nursing competence. the role will work if the lecturers are able to feel empathy, sympathy and care with their students. the conclusion is eff ort to developing the students and give solutions for academic problems and also social-individual problems that infl uence toward students nursing academic development. 5. leader/ manager lecturers as manager, lecturers manage all teaching and learning activities with make dynamic all learning resources. whereas lecturers as a leader means that lecturers play role to enhance their students. a nursing lecturer drive role as a manager and a leader that should have initiative to help facing the problems by cooperating, by participating, managing physical environment, social and individual to achieve the learning goals, until it can enhance and point it with strong power enough for all things including knowledge, performance and good daily att itude. 6. technical expert clinical skill is one of students nursing competence that refer to the goverment regulation (pp) no. 37 year 2009 about lectuters, it explained that lecturers is a profecional educators and pedagogist who 129 muhammadiyah journal of nursing has primary order to transfrom, envolve, and spread their knowledge, technology, and art through education. furthermore, as a nursing lecturer who has roles as a technical expert should be able to serve fi sical treatment by showing clinical skills and using the equipment in the that steps. 7. innovator the role of lecturers is as a innovator through reconditional eff ort and developmental knowledge system with the result of teaching is students’ high enthusiasm and development teaching and learning procces. lecturers make a serious eff ort to fi nd innovation and and new method to inspire the students in delivering the materials while it materials is diffi cult to understand. lecturers should keep their eff ort to fi nd strategies, methods and techniques by using an appropiate model or best practice to used by students nursing until they are able to achieve their competences. 8. motivator/ inspirator hopefully lecturers are able to give direction and motivation for the students by helping nursing students in self developmental and in achiving competences. lecturers do not neet to give lecture but direct the students to ask questions and fi nd the answer by themself or in a group from their own questions. students directed to be able analyze and choose decision in the nursing management context. 9. facilitator the role of nursing lecturers is as a facilitator. those roles are to serve training activities or facilitate students as long as learning process until the students are able to achieve the competences as a nurse. paradigm about learning (scl), lecturers only as facilitator by preparing some learning strategies that probably students choose it, fi nd, arrange the knowledge and the ways to develop students’ skill by employing the students by monitoring and keep they discuss in group eff ectively as long as learning process. 10. role model the role of lecturers as role model means that lecturers as a model for the nursing students in doing learning process eff ectively or in demonstrating step-step to solve their problems. students need to have a lecturers fi gure with teaching mastery and good att itude. be a moral model to show the students how to be a person who has a good moral because it has high eff ect then talk about morality. nursing lecturers have a role as a role model ought to have a good att itude and keep their professional att itude because a lecturers is role model or a person to follow by students. it infl uence nursing students’ competence achievement in att itude and score. 11. communicator lecturers should be able to mastery the subjects in their own fi eld and should be able to share their knowledge eff ectively to their students. furthermore to achieve it, lecturers need to make an eff ective communication between students and lecturers. the role of lecturers as communicator is trying to make a same understanding or knowing what students’ means. nursing lecturers ought to have good communication competences until the message accepted by the students. lecturers with high qualifi cation and expert in their fi eld especially nursing lecturers that should have a communication competence in delivering materials to make the students have high integrity, innovation and skillful. although teaching system that used is student centered learning that students must be active in the learning process. in the reality student keep need lecturers’ direction in the learning process to achive the competition. 12. assessor the role of nursing lecturers is as an assessor has roles to gather, analize, assess 130 muhammadiyah journal of nursing and then give judgement for the students’ success level in the learning process based on criteria that has been prescript. the criteria is including eff ective process aspect or students qualifi cation, identifaying and choosing an appropriate way to scoring students’ learning result that relevance with the competencetion. therefore an expert lecturer should be able to be an expert examiner. brawner is a dean from college of education and art of ifugao state university of philippines who explained in a lecture (2015) that the role of lecturers in nursing education as a nurse role in nursing process. brawner revealed that the roles of nursing lecturers in the learning process is as an assessor, planner, implementer and evaluator. for more detail information would be explain in the table below with the comparison of the role of nurse from nursing education. table 1 role of lecture nursing process role education process appraise physical and psychological needs assessor ascertain learning needs, readiness to learn and learning styles develop care plan based on mutual goal sett ing to meet individual needs planner develop teaching plan based on mutually predetermined behavioral out comes to meet individual needs carry out nursing care interventions using standard procedures implementer perform the act of teaching using specifi c instructional methods and tools determines social outcome physical and psychosocial out comes evaluator determines behavior changes/ out comes in knowledge, skill, aff ective and value. based on some resources that explained about the roles of lecturers in nursing education, so the writer summarize it in the picture about the roles of lecturers in nursing education with the aim is students of nursing education competences achievement that appropriate with the level from kkni given. curriculum planner course planner course planner innovator teacher motivator inspirator fasilitator resource counselour communicator role model 131 muhammadiyah journal of nursing discussion those are some problems that related to the roles of lecturers such as lack of qualifi cation, low of lecturers competences, lack of lecturers’ interest in reading, less hard work and commitment, less of lecturers join in applied research, less of students’ research publication and less of professionals lecturers in the process learning. much improvement has been tried by the government either or aipni about the nursing lecturers’profession but these problems keep being the main problems in nursing education. the main problem in nursing education is there are some lecturers have not qualifi cation in master/master’s degree (s2) that used as one of educator regulation in the university. the lecturers have priority duty, that ideally lecturer’s qualifi cation is doctor education (s3), not only as technologist. the other problems is that lecturers who have been got master’s degree titt le and doctor title that does not a guaranty for more productive and innovative lecturers in doing their work in learning process. those are some internal factors given occasion to those problems happen such as authoritarian of the lecturers, including: commitment, responsibility, care, discipline, honesty, creativity, interest, intrinsic motivation. whereas the external factor is stimulus from out lecturers role such as: position, retain, appreciation, prestige and directionary. next problem is most of nursing lecturers doing their duty in the learning only for accomplish the target curriculum that has been writt en on the syllabus with the result in the implementation, so the students implementation only on learn those materials. the defi nite of science lecture only on the knowledge, not to the understanding the concept, principal and prepositional. lecturers have less interest in motivating and accustom the students to read books, journals, research or others sources about the subject that they learn. lecturers give less feedback or reinforcement in students’ activities. the dominant role of lecturers in the learning process looks that there is transfer of knowledge. there is an argument that the duty of nursing lecturers is to convey their knowledge or give science research assignment for the students. it means that they spent their time to teach students’ cognitive. lecturers rare to apply their role as a guide in the learning process planed for students to have a good morality, have high responsibility, honesty, discipline care and solidarity. the other problems that hamper lecturers’ roles of in the teaching and learning process are the lack of lecturers interested with reading, lack of them join in science forum about philosophy and science principle, a litt le lecturers who has been writt en books, writt en summary of lecturers, teaching materials. lecturers too busy and have a high structural position are lean to lack participate in science activity because lean to bureaucracy activities and administrative so it make the lecturers have defi nite opportunities to read, write, do researchand join in science study that has impact to the prior role realization in the learning process, such as dismissing class activities for their other activity. this condition showed that there are many nursing lecturers who do not implemented their roles optimaly. it infl unce to the students’ nursing competence achievement that the one of indicator achiving the competences is the result of competency achivement. the result of students’ nursing competency achievement showed in june 2014 only 57, 81 % students passed the competences with minimum achievement is 46,7. whereas in november 2014 there are 46,2% with the same minimum achievement. that condition infl uenced by many factors such as, nursing education management, academic culture, commitment, social reality, etc. be sides of the lecturers’ lack and the lecturers’ excess the important thing that should do is creating students who have high competences and also profecional with the society needed and govement regulation. 132 muhammadiyah journal of nursing therefore lecturers need to apply the roles in nursing education ought to the fi rst step to achieving students nursing competences in the att itude, score, knowledge, skills, authority and responsibility that appropiate with nursing education background. coopetation with many sides is needed, such as universities, goverment, society, organisation (aipni, ppni) and stakeholder for optimising the roles of nursing lecturers in learning process and in academic fi eld and practical fi eld (clinic). conclusion the students nursing competence achievement is involving the roles of lecturers in the process learning, in the academic learning, in academic fi eld and in the practical fi eld (clinic). those roles are educator, informant, guide, leader, communicator, role model, assessor, counselor, past master, facilitator, motivator and inspiratory. these twelve nursing lecturers’ roles in the learning process. the means of all those twelve roles of priority nursing lecturer roles is based on the nurse’s roles in nursing process; those roles are assessor, planner, implementer and evaluator. there are many lecturers’ roles that have not undertaken optimally. it infl uences the students’ achievement. therefore the roles realization in the nursing education ought to begin the steps to achieve students’ nursing competences in their att itude, score, knowledge, skills, authority and responsibility based on nursing education background. cooperation with others sides is needed such as with universities, government, community, organization (aipni, ppni) and stakeholder to optimize roles of nursing lecturers in the learning process, academic fi eld and in practical fi eld (clinic). references baker, s. l. (2010). nurse educator orientation: professional development that promotes retention. the journal of continuing education in nursing, 41(9), 413-417. benner, p., sutphen, m., leonard, v., & day, l. (2009, december). educating nurses: a call for radical transformation. san francisco,ca: jossey-bass. brawner, alice y. (2015). assessment and evaluation of learning. lecture in student exchange program, ifsu college of education and arts; philipines cynthia m. clark rn, phd, anef and sara ahten, rn, msn. (2012). beginning the conversation: the nurse educator’s role in preventing incivility in the workplace. georgia nursing. jane s. grassley, phd, rn, ibclc; and andrea lambe, ms, rn. (2015). easing the transition from clinician to nurse educator: an integrative literature review. journal of nursing education • vol. 54, no. 7, 2015 hadi, muhammad. (2014). materi kuliah current nursing curriculum issues and aipni roles. no publish nickitas, d. m. (2012). asking questions and appreciating inquiry: a winning strategy for the nurse educator and professional nurse learner. the journal of continuing education in nursing, 43(3), 106-110. pusat pendidikan dan pelatihan tenaga kesehatan badan ppsdm kesehatan. (2013). standar dosen pendidikan tinggi vokasi tenaga kesehatan. mcsharry, e et al. (2010). the role of the nurse lecturer in clinical practice in the republic of ireland; nurse education in practice 10 (2010) 189–195 saleh, abdul rahman. (2010). hubungan kerja antara dosen dan pustakawan dalam pendidikan tinggi . jurnal pustakawan indonesia volume 11 no. 1. 2010 saputra, oktadoni & lisiswanti, rika. (2015). faktor-faktor yang mempengaruhi keberhasilan pembelajaran keterampilan 133 muhammadiyah journal of nursing klinik di institusi pendidikan dokter. juke unila vol 5 winarni, sri. (2013). integrasi pendidikan karakter dalam perkuliahan. jurnal pendidikan karakter, tahun iii, nomor 1, februari 2013 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). 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 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 health education, counseling, and psychotherapy community-based intervention related to disease, stigma prevention, and family support to reduce the incidence of depression in tuberculosis patients so that they can help complete treatment. suggestions for further research are to conduct intervention research to overcome depression in tuberculosis patients by considering the risk factors for depression in patients. references bøen, h., dalgard, o. s., johansen, r., & nord, e. (2010). socio-demographic, psychosocial and health characteristics of norwegian senior centre users: a cross-sectional study. scandinavian journal of public health, 38(5), 508–517. https://doi.org/10.1177/1403494810370230 chandra, m., rana, p., chandra, k., & arora, v. k. (2019). tuberculosis depression syndemic: a public health challenge. indian journal of tuberculosis, 66(1), 197–202. https://doi.org/10.1016/j.ijtb.2019.02.007 datiko, d. g., jerene, d., & suarez, p. (2020a). stigma matters in ending tuberculosis : nationwide survey of stigma in ethiopia. 1– 10. datiko, d. g., jerene, d., & suarez, p. (2020b). stigma matters in ending tuberculosis: nationwide survey of stigma in ethiopia. in bmc public health (vol. 20, issue 1). biomed central ltd. https://doi.org/10.1186/s12889019-7915-6 duko, b., bedaso, a., & ayano, g. (2020). the prevalence of depression among patients with tuberculosis: a systematic review and meta-analysis. annals of general psychiatry, 19(1), 1–11. https://doi.org/10.1186/s12991020-00281-8 duko, b., gebeyehu, a., & ayano, g. (2015). prevalence and correlates of depression and anxiety among patients with tuberculosis at wolaitasodo university hospital and sodo health center, wolaitasodo, south ethiopia, cross sectional study. bmc psychiatry, 15(1), 1–7. https://doi.org/10.1186/s12888-0150598-3 febi, a. r., manu, m. k., mohapatra, a. k., praharaj, s. k., & guddattu, v. (2021). psychological stress and health-related quality of life among tuberculosis patients: a prospective cohort study. erj open research, 7(3). https://doi.org/10.1183/23120541.002512021 gyimah, f. t., & dako-gyeke, p. (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. (2020). perceived stigma among patient with pulmonary tuberculosis at public health facilities in southwest ethiopia: a cross-sectional study. plos one, 15(12 december). https://doi.org/10.1371/journal.pone.02434 33 perlick, d. a., rosenheck, r. a., clarkin, j. f., sirey, j. a., salahi, j., struening, e. l., & link, b. g. (2001). stigma as a barrier to recovery: adverse effects of perceived stigma on social adaptation of persons diagnosed with bipolar affective disorder. psychiatric services, 52(12), 1627–1632. https://doi.org/10.1176/appi.ps.52.12.1627 roba, a. a., dasa, t. t., weldegebreal, f., asfaw, a., mitiku, h., teklemariam, z., naganuri, m., geddugol, b. j., mesfin, f., befikadu, h., & tesfaye, e. (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 26 ©2023 ijnp (indonesian journal of nursing practices). this is an open-access article distributed under the terms of the creative commonsattribution 4.0 international license https://creativecommons.org/licenses/by/4.0/ open access volume 7, issue 1, june 2023, p. 26-36 corelation 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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(2022). need for cognitive closure predicts stress and anxiety of college students during covid-19 pandemic. personality and individual differences, 187, 111393. https://doi.org/10.1016/j.paid.2021.111393 yusoff, m. s. b., abdul rahim, a. f., baba, a. a., ismail, s. b., mat pa, m. n., & esa, a. r. (2013). the impact of medical education on psychological health of students: a cohort study. psychology, health & medicine, 18(4), 420–430. https://doi.org/10.1080/13548506.2012.740162 https://doi.org/10.18196/ijnp.1256 https://doi.org/10.1016/j.paid.2021.111393 https://doi.org/10.1080/13548506.2012.740162 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 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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(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%) 22 vol. 1 no. 1 desember 2016 abstrak sebanyak 63,4 juta jiwa (27,7%) penduduk indonesia adalah remaja yang terdiri dari laki-laki sebanyak 50,70% jiwa dan perempuan sebanyak 49,30% jiwa . perkiraan persentase remaja yang meningkat dengan pesat dapat menyebabkan remaja rentan menuai berbagai persoalan. salah satu persoalan tersebut adalah perilaku seksual bebas di kalangan remaja. sikap jelas sangat mempengaruhi perilaku. memegang teguh suatu sikap yang mengarah pada suatu objek memberikan satu alasan untuk berperilaku mengarah pada objek itu dengan suatu cara tertentu. sesuai dengan penjelasan-penjelasan tersebut, remaja sangat penting untuk menentukan sikap terhadap suatu stimulus khususnya stimulus seksual, sehingga perilaku seksual yang menyimpang dapat dicegah dengan segera serta menghapuskan asumsi bahwa hubungan seks hanya sebatas hal yang bersifat rekreatif saja. tujuan dari penelitian ini adalah untuk mengetahui gambaran sikap seksual remaja. desain yang digunakan adalah desain deskriptif kuantitatif dengan menggunakan metode cross sectional. teknik pengambilan sampel dalam penelitian ini adalah simple random sampling. penelitian dilakukan di sma “x” yogyakarta pada bulan februari 2016. 64 responden (61,5%) dikategorikan rendah pada dimensi permissiveness. 68 responden (65,4%) dikategorikan tinggi pada dimensi birth control. 58 responden (55,8%) dikategorikan tinggi pada dimensi communion. 39 responden (37,5%) dikategorikan rendah pada dimensi instrumentality. kata kunci : remaja, sikap seksual, sikap seksual remaja abstract as much as 63.4 million people (27.7%) of indonesian population is composed of adolescents, boys as many as 50.70% people () and girls as alma ananda alieva noor wahyudina1, rahmah2 1 mahasiswa ilmu keperawatan umy, 2 dosen ilmu keperawatan umy e-mail : alievaalmaalieva@gmail.com karakter seksual remaja akhir di yogyakarta info artikel: masuk : 26 agustus 2016 revisi : 18 november 2016 diterima : 30 november 2016 doi number : 10.18196/ijnp.1147 23 vol. 1 no. 1 desember 2016 many as 49.30% people. estimation of the percentage of adolescents are increasing rapidly. it can cause various problems. one of the issue is the sexual behavior among adolescents. the attitude obviously affects behavior. keep up an attitude that leads to an object gives one reason to the object in a certain way. appropriate with the explanations, adolescents are very important to determine the attitude to a stimulus, especially a sexual stimulus, so the deviant sexual behavior can be prevented immediately and to eliminate the assumption that sex is limited to things that are recreational only. the objective of this study is to know the representation/illustration of sexual behavior of adolescents. this study was used quantitative descriptive design using cross sectional method. the sampling technique in this study was stratified random sampling. the study was conducted in sma “x” yogyakarta in february 2016. as much as 64 respondents (61.5%) was categorized as low on permissiveness dimension . as much as 68 respondents (65.4%) was categorized as high on birth control dimensions. as much as 58 respondents (55.8%) was categorized as high on communion dimensions (the close relationship between two people). as much as 39 respondents (37.5%) was categorized as low on instrumentality dimensions. key word: adolescent, adolescents sexual attitude, sexual attitude pendahuluan hasil sensus penduduk tahun 2010 menunjukan bahwa jumlah penduduk indonesia sebesar 237,6 juta jiwa. sebanyak 63,4 juta (27,7%) diantaranya adalah remaja yang terdiri dari laki-laki sebanyak 32.164.436 jiwa (50,70%) dan perempuan sebanyak 31.279.012 jiwa (49,30%). besarnya jumlah penduduk kelompok remaja ini akan sangat mempengaruhi pertumbuhan penduduk di masa yang akan datang (badan kependudukan dan keluarga berencana nasional/ bkkbn, 2011). menurut perkiraan, persentase remaja di daerah istimewa yogyakarta (diy) mencapai 24,13% dengan pertumbuhan tiga kali lipat lebih (3,24%) dibandingkan dengan pertumbuhan penduduk. perkiraan presentase remaja yang meningkat dengan pesat dapat menyebabkan remaja rentan menuai berbagai persoalan (badan perencanaan pembangunan daerah/ bappeda diy, 2013).salah satu persoalan tersebut adalah perilaku seksual bebas di kalangan remaja, yang didasari oleh keterbukaan seksual. menurut suryoputro dkk (2007), perilaku seksual salah satunya dipengaruhi oleh sikap seksual. sikap merupakan cara seseorang berfikir/ berespon terhadap stimulus. ketika respon tersebut ditunjukan melalui suatu aksi, maka hal tersebut disebut dengan perilaku. azwar (2007), menerangkan kerangka pemikiran yang diwakili oleh ahli seperti chave, bogardus, lapierre, mead dan gordon allport. menurut kelompok pemikiran ini sikap merupakan semacam kesiapan untuk bereaksi terhadap suatu objek dengan cara-cara tertentu yang kemudian disebut perilaku. kesiapan yang dimaksud merupakan kecende rungan yang potensial untuk bereaksi dengan cara tertentu apabila individu dihadapkan pada suatu stimulus yang menghendaki adanya respon. sikap jelas sangat mempe ngaruhi perilaku. memegang teguh suatu sikap yang mengarah pada suatu objek memberikan satu alasan untuk berperilaku mengarah pada objek itu dengan suatu cara tertentu. sesuai dengan penjelasan-penjelasan tersebut, remaja sangat penting untuk menentukan sikap terhadap suatu stimulus khususnya stimulus seksual, sehingga perilaku seksual yang menyimpang dapat dicegah dengan segera serta menghapuskan asumsi bahwa hubungan seks hanya sebatas hal yang bersifat rekreatif saja. berbagai kerugian dapat timbul karena perilaku seksual tersebut terlebih jika remaja tidak mampu menyikapinya serta mengendalikan dirinya sendiri. kerugian yang muncul pada remaja putri salah satunya adalah kehamilan. kehamilan bisa saja terjadi karena mereka sudah memasuki masa pubertas yang ditandai dengan menarche (awal menstruasi). data konseling kehamilan tidak diinginkan perkumpulan keluarga berencana indonesia (pkbi) diy pada remaja usia 11-24 tahun 2011 yaitu 246 kasus paling tinggi dialami oleh remaja, salah satunya remaja di sekolah menegah atas (sma). beberapa remaja yang mengalami kehamilan tidak diinginkan pada usia sekolah mempunyai beban ganda selain dalam kondisi kehamilan tidak diinginkan juga akan ada persoalan dengan pendidikannya yaitu dikeluarkan dari sekolah, 24 dijauhi sebayanya, gurunya serta keluarganya. selain itu juga di beberapa kasus mereka harus menyerah pada pilihan perkawinan dengan pelaku. begitu pula pada remaja putra, jika perilaku seksual pranikah dibudidayakan, maka moral calon pemimpin bangsa akan rusak. selain bangsa yang dirugikan, hak-hak yang seharusnya dimiliki remajapun tercabut, misalnya hak pendidikan, hak atas tubuh, hak menentukan kapan akan menikah atau tidak. selain kehamilan, data konseling rifka annisa di dapatkan kasus kekerasan dalam pacaran tahun 2009-2012 yaitu 139 kasus. hal yang lebih mencengangkan lagi, data surveilans dinas kesehatan diy untuk human immunodeficiency virus (hiv) & acquired immunodeficiency syndrome (aids) mencatat bahwa pada tahun 2013 terdapat anak yang berusia berkisar 19 tahun yang mengidap hiv sebanyak 82 orang, serta aids sebanyak 48 orang (bappeda diy, 2013). dari fakta tersebut, remaja yang masih termasuk dalam usia sekolah, dan akan memasuki masa dewasa perlu mendapat perhatian serius berupa pencegahan berbagai penyimpangan. keberhasilan penduduk pada kelompok umur dewasa sangat tergantung pada masa remajanya. apabila umur remaja berhasil dilewati dengan baik maka kualitas penduduk yang bersangkutan pada fase umur dewasa akan cenderung lebih baik dan selanjutnya akan menghasilkan generasi yang berkualitas. apabila tidak dipersiapkan dengan baik remaja sangat berisiko terhadap perilaku seksual pranikah (bkkbn, 2011). allah swt. telah dengan jelas menyebutkan dalam al-qur’an, bukan hanya mencegah namun mengharamkan hambanya untuk melakukan perilaku seks bebas/ berzinah. sesuai dengan q. s. al-isra’ ayat 32: “dan janganlah kamu mendekati zina; sesungguhnya zina itu adalah suatu perbuatan yang keji. dan suatu jalan yang buruk” (q.s. al-isra’: 32). metode penelitian desain yang digunakan adalah desain deskriptif kuantitatif. penelitian dilakukan di sma “x” yogyakarta pada bulan februari 2016. populasi dari penelitian ini adalah remaja usia 15-17 tahun yang terdaftar sebagai murid di sma “x” yogyakarta kelas x, xi dan xii. jumlah populasi dari penelitian ini adalah 127 orang, terdiri dari kelas x berjumlah 38 orang, kelas xi berjumlah 39 orang dan kelas xii berjumlah 50 orang. sampel penelitian berdasarkan penghitungan rumus slovin adalah 106 siawa yang dipilih secara acak sederhana. lolos uji etik penelitian dengan no 017/epfkik umy/i/2016. sikap seksual pada penelitian ini diukur dengan kuesioner “brief sexual attitude scale (bsas)” yang dikembangkan oleh hendrick, dkk. (2006). bsas terdiri dari 23 soal yang digolongkan berdasarkan 4 dimensi sikap seksual, yaitu permissiveness (keterbukaan), birth control (pengendalian terjadinya kehamilan), communion (hubungan yang erat antara 2 orang), dan instrumentality (kesenangan/ orientasi terhadap hubungan seksual). brief sexual attitude scale (bsas) merupakan kuesioner baku yang yang secara empiris reliable dan valid dengan x2 (21,525) = 29.88, p < .001. kuesioner ini dinyatakan baku dan reliable pada semua item soal serta memiliki sikap psikometrik yang kuat. namun, karena peneliti melakukan pengalihan bahasa dari bahasa inggris ke bahasa indonesia, maka peneliti akan melakukan uji validitas dan reliabilitas ulang pada kuesioner tersebut. jenis uji validitas yang digunakan pada penelitian ini adalah uji validitas isi (content validity). pengujian dilakukan pada setiap item soal melalui tahap konsultasi dengan 2 orang ahli di program studi ilmu keperawatan fakultas kedokteran dan ilmu kesehatan universitas muhammadiyah yogyakarta.pada uji cvi ini, tidak ada item soal yang tidak relevan, sehingga tidak ada 1 soalpun yang dibuang, hanya ada beberapa item soal yang mengalami perubahan susunan kata tanpa merubah makna dari soal tersebut. skor dari uji cvi ini adalah 0,896. hal ini menunjukan bahwa instrumen dikatakan valid. adapun metode perhitungan koefisien reliabilitas yang digunakan adalah metode alpha cronbach. sampel dalam uji reliabilitas ini sebanyak 30 orang siswa/ siswi di sma “y” yogyakarta, dengan signifikasi á = 5% maka di dapatkan angka r tabel 0,396. setiap pertanyaan dalam suatu konsep pengukuran dinyatakan reliabel 25 vol. 1 no. 1 desember 2016 jika koefisien reliabilitasnya e” 0,396 yang berarti bahwa secara keseluruhan alat ukur thelah memiliki konsistensi internal yang dapat diandalkan. berdasarkan hasil uji reliabilitas alpha cronbach, diketahui bahwa nilai alpha sebesar 0,861. berdasarkan nilai tersebut item-item pada kuesioner brief sexual attitude scale dinyatakan reliabel, karena nilai alpha > angka r tabel. analisis data yang digunakan adalah analisis univariat berupa tampilan frekuensi dan prosentase dengan bantuan komputer. hasil penelitian tabel 1. karakteristik responden (n = 106 ) 24 cronbach, diketahui bahwa nilai alpha sebesar 0,861. berdasarkan nilai tersebut item-item pada kuesioner brief sexual attitude scale dinyatakan reliabel, karena nilai alpha > angka r tabel. analisis data yang digunakan adalah analisis univariat berupa tampilan frekuensi dan prosentase dengan bantuan komputer. hasil penelitian tabel 1. karakteristik responden (n = 106 ) no karakteristik % total 1 jenis kelamin laki – laki perempuan 64.6% 42.4% 100% 2 usia 15 tahun 16 tahun 17 tahun 16.15% 39.37% 51.48% 100% 3 informasi mengenai seksualitas teman orangtua film pacar televisi radio koran internet 28.3% 11% 19.2% 4.4% 10.1% 1.1% 6.6% 28.3% 100% 4 berbicara dengan orangtua mengenai seks ya tidak 34.3% 72.7% 100% total 100% gambaran sikap seksual remaja di sma “x” yogyakarta gambar 1 menunjukan bahwa 64 responden (61,5%) di sma “x” yogyakarta dikategorikan rendah pada dimensi permissiveness. sebanyak 68 responden (65,4%) digolongkan tinggi pada dimensi birth control. pada dimensi communion, sebayak 58 responden (55,8%) dikategorikan tinggi, 39 responden (37,5%) dikategorikan rendah pada dimensi instrumentality. pembahasan pada penelitian ini, 64 orang (60%) responden adalah laki-laki. hal tersebut dikarenakan 60% murid sma “x” yogyakarta adalah laki-laki. sehingga perbandingan jenis kelamin responden sesuai dengan jenis kelamin seluruh murid sma “x” yogyakarta.dalam hal frekuensi komunikasi sebaya, laki-laki lebih bebas dalam membicarakan berbagai hal mengenai seksualitas dan pornografi bersama teman lakilaki lainnya. pertumbuhan dan perkembangan organ seksual pada laki-laki biasanya lebih lambat dari perempuan, sehingga keinginan mereka untuk berfikir, berbincang dan melakukan suatu hal yang berhubugan dengan seks menjadi lebih nampak pada masa remaja dibandingkan dengan remaja perempuan (holman, 2014; potter & perry, 2005). sma “x” yogyakarta memiliki proporsi jumlah siswa perkelas yang hampir sama. kelas x sebesar 30%, kelas xi 30% dan kelas xii 40%. hal tersebut disebabkan oleh konstannya jumlah siswa yang masuk dan keluar. ditinjau gambar 1 gambaran sikap seksual ditinjau dari 4 dimensi sikap seksual di sma “x” yogyakarta tahun 2016 (n=106) gambaran sikap seksual remaja di sma “x” yogyakarta gambar 1 menunjukan bahwa 64 responden (61,5%) di sma “x” yogyakarta dikategorikan rendah pada dimensi permissiveness. sebanyak 68 responden (65,4%) digolongkan tinggi pada dimensi birth control. pada dimensi communion, sebayak 58 responden (55,8%) dikategorikan tinggi, 39 responden (37,5%) dikategorikan rendah pada dimensi instrumentality.24 cronbach, diketahui bahwa nilai alpha sebesar 0,861. berdasarkan nilai tersebut item-item pada kuesioner brief sexual attitude scale dinyatakan reliabel, karena nilai alpha > angka r tabel. analisis data yang digunakan adalah analisis univariat berupa tampilan frekuensi dan prosentase dengan bantuan komputer. hasil penelitian tabel 1. karakteristik responden (n = 106 ) no karakteristik % total 1 jenis kelamin laki – laki perempuan 64.6% 42.4% 100% 2 usia 15 tahun 16 tahun 17 tahun 16.15% 39.37% 51.48% 100% 3 informasi mengenai seksualitas teman orangtua film pacar televisi radio koran internet 28.3% 11% 19.2% 4.4% 10.1% 1.1% 6.6% 28.3% 100% 4 berbicara dengan orangtua mengenai seks ya tidak 34.3% 72.7% 100% total 100% gambaran sikap seksual remaja di sma “x” yogyakarta gambar 1 menunjukan bahwa 64 responden (61,5%) di sma “x” yogyakarta dikategorikan rendah pada dimensi permissiveness. sebanyak 68 responden (65,4%) digolongkan tinggi pada dimensi birth control. pada dimensi communion, sebayak 58 responden (55,8%) dikategorikan tinggi, 39 responden (37,5%) dikategorikan rendah pada dimensi instrumentality. pembahasan pada penelitian ini, 64 orang (60%) responden adalah laki-laki. hal tersebut dikarenakan 60% murid sma “x” yogyakarta adalah laki-laki. sehingga perbandingan jenis kelamin responden sesuai dengan jenis kelamin seluruh murid sma “x” yogyakarta.dalam hal frekuensi komunikasi sebaya, laki-laki lebih bebas dalam membicarakan berbagai hal mengenai seksualitas dan pornografi bersama teman lakilaki lainnya. pertumbuhan dan perkembangan organ seksual pada laki-laki biasanya lebih lambat dari perempuan, sehingga keinginan mereka untuk berfikir, berbincang dan melakukan suatu hal yang berhubugan dengan seks menjadi lebih nampak pada masa remaja dibandingkan dengan remaja perempuan (holman, 2014; potter & perry, 2005). sma “x” yogyakarta memiliki proporsi jumlah siswa perkelas yang hampir sama. kelas x sebesar 30%, kelas xi 30% dan kelas xii 40%. hal tersebut disebabkan oleh konstannya jumlah siswa yang masuk dan keluar. ditinjau gambar 1 gambaran sikap seksual ditinjau dari 4 dimensi sikap seksual di sma “x” yogyakarta tahun 2016 (n=106) gambar 1 gambaran sikap seksual ditinjau dari 4 dimensi sikap seksual di sma “x” yogyakarta tahun 2016 (n=106) pembahasan pada penelitian ini, 64 orang (60%) responden adalah laki-laki. hal tersebut dikarenakan 60% murid sma “x” yogyakarta adalah laki-laki. sehingga perbandingan jenis kelamin responden sesuai dengan jenis kelamin seluruh murid sma “x” yogyakarta. dalam hal frekuensi komunikasi sebaya, laki-laki lebih bebas dalam membicarakan berbagai hal mengenai seksualitas dan pornografi bersama teman laki-laki lainnya. pertumbuhan dan perkembangan organ seksual pada laki-laki biasanya lebih lambat dari perempuan, sehingga keinginan mereka untuk berfikir, berbincang dan melakukan suatu hal yang berhubugan dengan seks menjadi lebih nampak pada masa remaja dibandingkan dengan remaja perempuan (holman, 2014; potter & perry, 2005). sma “x” yogyakarta memiliki proporsi jumlah siswa perkelas yang hampir sama. kelas x sebesar 30%, kelas xi 30% dan kelas xii 40%. hal tersebut disebabkan oleh konstannya jumlah siswa yang masuk dan keluar. 26 ditinjau dari segi usia, responden didominasi oleh remaja berusia 17 tahun yaitu sebesar 51 orang (48%). usia 17 tahun meru pakan masa remaja pertengahan yang biasanya menduduki bangku sma. usia 17 tahun merupakan masa dimana seseorang ada pada transisi masa remaja pertengahan dan masa remaja akhir. pada usia ini seseorang menda patkan informasi yang lebih banyak dan bervariasi dari usia sebelumnya termasuk informasi mengenai hal yang berkaitan dengan seks (potter & perry, 2005). sumber-sumber informasi mengenai seks yang didapatkan oleh responden pada penelitian ini didominasi oleh internet dan teman. teori skiner (1938) dalam notoat modjo (2012) mengatakan bahwa pembentukan atau terja dinya perubahan sikap dan perilaku pada hakekatnya adalah sama dengan proses belajar yang terkenal dengan teori stimulus organisme respon (sor). teori ini mendasarkan pada asumsi bahwa penyebab terjadinya peru bahan sikap dan perilaku tergantung pada kualitas rangsang (stimulus) yang berkomunikasi dengan organisme. adapun stimulus yang dianggap berarti oleh remaja adalah teman dan media informasi terutama internet. penelitian lembaga peduli remaja kriya mandiri (lprkm) surakarta (2009) menunjukkan bahwa tempat terbanyak yang dijadikan sarana untuk mengetahui informasi tentang seks adalah dari sumber informasi media dan teman sebaya. dari jumlah responden 352 remaja yang masih berstatus pelajar sma di surakarta, sebesar 56% menyatakan media online/ internet menjadi sarana untuk mengetahui informasi tentang seks, kemudian terbanyak kedua adalah teman sebaya sebesar 15%, diikuti orang tua 12%, dan sisanya dida patkan dari koran, tv, radio, pasangan, dan film (sosiawan, 2010). berdasarkan teori skiner maka sikap seksual remaja disebabkan oleh adanya stimulus atau rangsangan dari teman sebaya dan sumber informasi dalam hal ini media massa yang terdiri dari media cetak dan media elektronik akan diterima dalam bentuk organisme (perhatian, pengertian, dan penerimaan) dan pada akhirnya akan membentuk atau merubah sikap remaja dalam hal ini sikap seksualnya. jadi, teman dan sumber informasi baik media cetak maupun media elektronik dapat mempengaruhi remaja dalam mengekspresikan sikap seksual mereka (sarwono, 2011). teman dianggap berarti oleh remaja karena perubahan secara seksual yang terjadi pada remaja diantaranya timbul proses perkembangan dan kematangan organ reproduksi. kematangan organ reproduksi tersebut mendorong remaja melakukan hubungan sosial baik dengan teman sejenis maupun dengan lawan jenis. remaja berupaya mengembangkan diri melalui pergaulan yang erat dengan teman mereka (sarwono, 2011). remaja yang memiliki pengalaman berbicara dengan orang tua mengenai seks hanya sebanyak 34 orang (32%), dengan kata lain, banyak remaja yang menjadi responden penelitian ini tidak dibekali pengetahuan yang memadai tentang seks dari orang tua dalam upaya memasuki masa peralihannya. hal ini disebabkan orang tua merasa tabu membicarakan masalah seksual kepada anaknya dan hubungan orang tua dengan anak menjadi jauh sehingga anak berpaling ke sumber-sumber lain yang tidak akurat khususnya teman sebaya (sarwono, 2011). selain itu, faktor yang mem pe ngaruhi komunikasi remaja dengan orang tua mengenai seks yaitu kurangnya keterbukaan, respon yang kurang baik, rasa empati, penyampaian informasi yang menarik, ketidaknyamanan saat berkomunikasi, ketidakyakinan bahwa masalah bisa teratasi dengan berkomunikasi, sikap kasar orang tua, dan kesibukan orang tua yang membuat orang tua menganggap seks bukanlah hal yang penting untuk dibicaraan. gambaran komunikasi yang dilakukan subjek dengan orang tuanya tentang masalah seksual yaitu kurangnya inisiatif berkomunikasi danberdiskusi, orang tua suka mengalihkan pembicaraan, orang tua memberikan pengertian bahwa seks itu sehat selama dilakukan setelah menikah, orang tua tidak melarang membahas masalah seks sepanjang langsung bertanya pada orang tua, subjek merasa malu membicarakan masalah seks, orangtua tidak menjelaskan seks secara terbuka di depan umum (karya, 2012). jawaban pada seluruh poin pernyataan dimensi permissiveness, responden didominasi oleh jawaban 27 vol. 1 no. 1 desember 2016 “sangat tidak setuju/ sts”. hal tersebut berbeda dengan jawaban pada dimensi birth control yang sebagian besar jawabannya didominasi oleh jawaban “setuju/ s”. permissiveness merupakan keterbukaan seksual yang berarti seberapa jauh seorang remaja dapat menerima hal-hal yang berbau seksual. penelitian ini menunjukan bahwa sebagian besar responden kurang dapat menerima hal yang berkaitan dengan seks. karya (2012) menemukan bahwa remaja kadang merasa malu jika harus membicarakan masalah seks dalam waktu yang mereka anggap tidak tepat. remaja juga enggan membicarakan masalah seks karena merasa malu jika orang lain dan orang tua mengetahui masalah seksualnya. hal itu menyebabkan remaja cenderung bersikap tertutup terhadap subjek pembicaraan yang berkaitan dengan seks, terlebih lagi mereka tidak nyaman apabila membicarakannya dengan orang tua atau orang lain selain teman mereka, karena pada masa remaja friends oriented merupakan ciri khasnya. pada dimensi birth control, dominasi jawaban responden adalah “setuju/ s”. hal ini berarti kontrol remaja terhadap terjadinya kehamilan adalah tinggi. berdasarkan studi di 3 kota jawa barat pada tahun 2009, remaja lebih takut pada resiko sosial (antara lain: takut kehilangan keperawanan/ virginitas, takut hamil di luar nikah, dan takut menghamili karena hal-hal tersebut akan jadi bahan gunjingan masyarakat), dibanding resiko seksual, khususnya menyangkut kesehatan reproduksi dan kesehatan seksualnya. meskipun demikian, beberapa remaja mengalami ketakutan akan kesehatan reproduksi mereka seperti aborsi yang tidak aman, terutama mereka yang sudah memiliki informasi yang cukup mengenai seks. di banyak bagian dunia, kehamilan remaja sangat erat kaitannya dengan aborsi tidak aman. di negaranegara berkembang, komplikasi dari kehamilan dan aborsi yang tidak aman adalah penyebab utama kematian untuk anak perempuan usia 15-19 (gennari, 2013; gray, azzopardi, kennedy, willersdorf, dan creati 2013). diperkirakan 3 juta aborsi tidak aman terjadi setiap tahun di kalangan perempuan di kelompok usia ini di negara-negara berkembang (who, 2011 dalam gennari, 2013). dunia kesehatan tealah mengkaji fakta bahwa remaja yang hamil menghadapi dua kali lipat risiko kematian akibat komplikasi yang berhubungan dengan kehamilan relatif terhadap wanita berusia 20-an (gennari 2013). info tersebut sangat mudah diakses oleh semua kalangan, termasuk remaja. berita di berbagai media baik media cetak maupun media lainnya membuat remaja merasa perlu untuk menjaga dirinya dari kehamilan. meskipun perilaku seksual seperti berhubungan seks tidak dapat mereka tahan, namun mereka merasa perlu untuk tidak mencelakakan diri mereka. penelitian ini juga menunjukan bahwa sebagian besar responden sangat tidak menyetujui jika melakukan hubungan seks dengan lebih dari satu partner/ pasangan dalam satu waktu. remaja menganggap memiliki pacar lebih dari satu merupakan hal yang tidak seharusnya dilakukan, apalagi melakukan hubungan seks lebih dari satu orang dalam satu waktu (sarwono, 2011). pernyataan dan data tersebut didukung oleh data lain pada penelitian ini, yaitu 58 orang (54,7%) responden pada penelitian ini menganggap hubungan seks merupakan komunikasi terdekat anttara dua orang, tanda cinta serta intensitas dalam hubungan antara 2 orang, yang berarti mereka menganggap seks merupakan hal yang eksklusif untuk 2 orang saja. banyaknya responden yang tidak menyetujui jika melakukan hubungan seks dengan lebih dari satu partner/ pasangan dalam satu waktu juga erat kaitannya dengan norma dan moral yang berlaku. penanaman norma dan moral pada masa kanak-kanak merupakan tanggung jawab orang tua, mereka akan menjaga agar anak mereka tidak melakukan hal-hal yang melanggar moral dan norma yang berlaku, terlebih lagi informasi mengenai bahaya hubungan seksual pada masa remaja membuat orang tua lebih protektif kepada anaknya (suwarjo, 2008). data pada dimensi birth control menunjukan bahwa sebagian besar responden setuju bahwa “lakilaki harus berbagi tanggung jawab untuk mencegah/ mengkontrol kehamilan” hal tersebut berarti responden 28 menganggap kehamilan sebagai tanggung jawab berhubungan seks merupakan tanggung jawab lakilaki. hal tersebut tidak sesuai dengan pendapat azniar (2013), yang mengemukakan bahwa tanggung jawab dalam berhubungan seks harus ditanggung oleh kedua belah pihak, baik laki-laki maupun perempuan. tanggung jawab seks berarti membuat keputusan yang menghormati nilai dan tujuan masing-masing serta mendorong kepercayaan diri remaja, bukan membuat remaja merasa bersalah atau malu. hal lain yang perlu menjadi perhatian adalah budaya tabu di sebagian besar masyarakat indonesia untuk membicarakan urusan seksualitas dalam wacana publik merupakan salah satu hambatan kultural dalam upaya mengembangkan pendidikan seks yang rasional dan bertanggung jawab. padahal pendidikan seks merupakan hal yang sangat penting pada masa remaja. minimnya pengetahuan remaja mengenai seks menyebabkkan hubungan seksual pranikah yang dilakukan remaja tidak didasarkan pada pengetahuan bagaimana cara mencegah agar tidak terjadi kehamilan misalnya melalui penggunaan kontrasepsi, namun lebih didorong untuk memuaskan kebutuhan seksual di antara mereka. data pada dimensi communion menunjukan dominasi jawaban netral pada peryataan “seks adalah bagian yang sangat penting dari kehidupan”. kecenderungan bersikap netral pada pernyataan tersebut dapat disebabkan oleh minimnya pengetahuan remaja tentang kebutuhan dasar manusia yang salah satunya adalah seks. selain itu, masa remaja berada pada dua sisi, yaitu sisi positif dan negatif. mereka cenderung mencari hal yang lebih dominan untuk menentukan sikap dan berprilaku karena pilihan sikap remaja biasanya bersifat fluktuatif dan tidak teratur, yang kemudian akan memilih sisi positif atau negatif mereka. terlebih lagi, pada masa remaja seseorang akan lebih dekat dengan lingkungan diluar rumah yang didoinasi oleh temanteman (erickson dan wong, 2010; potter & perry, 2005). jumlah jawaban paling sedikit pada dimensi communion ada pada pernyataan nomer 18 yang berbunyi “seks biasanya intensif/ terus menerus dilakukan, pengalaman yang tak tertahankan” yaitu sebanyak 5 orang (4,7%) responden. remaja kadang menganggap obrolan mengenai seks atau berhubungan seks merupakan hal yang menggelitik, cenderung malu untuk dibicaraan bahkan menganggap hubungan fisik terkadang menjijikan, sehingga remaja mungkin menganggap “intensif/ terus menerus dilakukan, pengalaman yang tak tertahankan” bukan merupakan bagian dari hubungan seks (holman & sillars, 2011). data yang didapatkan pada dimensi instrumentality menunjukan bahwa 42 orang (39,6%) responden tidak setuju pada pernyataan “tujuan utama dari seks untuk menikmati diri sendiri”. hal tersebut sesuai dengan penelitian yang dilakukan oleh wardhani (2012) yang menemukan bahwa bukan keinginan untuk menikmati diri sendiri yang menjadi tujuan remaja berhubungan seksual/ melakukan perilaku seksual, melainkan rasa ingin tahu dan fantasi seksual lah yang menyebabkan remaja ingin mempraktekan apa yang orang dewasa lakukan, salah satunya berpacaran bahkan berhubunan seks. teori yang dikemukakan rice (2012) menyatakan bahwa remaja bersikap terhadap stimulus seksual dengan cara yang beragam, namun pada awalnya mereka menanggapinya sebagai wujud ‘mengobati’ rasa penasaran saja yang kemudian apabila remaja tidak memiliki informasi serta koping yang tepat, sikap tersebut akan berubah menjadi perilaku seks. secara umum perilaku seks remaja bermula dari perilaku otoerotik (autoerotic behavior), dimana perilaku ini dimulai dari rasa ingin tahu dan menikmati pengalaman seks sendirian. perilaku ini juga selalu berkaitan dengan fantasi erotis. banyak hasil penelitian menunjukkan remaja baik laki-laki maupun perempuan melakuan masturbasi. namun demikian setelah remaja beranjak dewasa terutama ketika berada di sekolah menengah mereka mengalami pergeseran dari otoerotik kepada perilaku sosioseksual (sociosexual behavior). perilaku sosioseksual remaja ini telah melibatkan orang lain yang umumnya adalah teman-teman sebaya mereka. remaja lebih intim dengan lawan jenisnya bahkan dengan sesama jenisnya (homosexsuality). perilaku necking dan petting merupakan aktivitas umum disamping kontak genital 29 vol. 1 no. 1 desember 2016 atau intercourse. remaja juga lebih sering melakukan oral seks karena dirasa lebih aman dan menghindari kehamilan di luar nikah (zastrow & kirst-ashman, 2012). kesimpulan dimensi permissiveness (keterbukaan seksual) didominasi oleh kategori rendah. dimensi birth control (pengendalian terjadinya kehamilan) didominasi oleh kategori tinggi. dimensi communion (hubungan yang erat antara 2 orang) didominasi oleh kategori tinggi. dimensi instrumentality 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(2013). adolescents pregnancy in indonesia: a literature review. australia: australian demographic and social research institute. 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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(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/ vol. 1 no. 3 desember 2017 83 indonesian journal of nursing practices mukhripah damaiyanti1, dwi rahmah fitriani1 1 faculty of health science, universitas muhammadiyah kalimantan timur email: muda101180@gmail.com the relation of educational level, academic achievement (gpa) and depression among pub lic school adolescent info artikel masuk revisi diterima doi number : : 30 september 2017 : 15 november 2017 : 30 november 2017 : 10.18196/ijnp.1365 abstract depres s i on i s a worl wi de mental heal th probl em ps ychol ogy di s order i n adol es cent. depres s i on i s one of the emoti onal probl ems , hopel es s nes s and hel pl es s nes s are i ts mai n caus es . the other word, depres s i on i s apreval ent probl em among col l ege’s s tudent abi l i ty to perform acti vi ti es of dai l y l i fe. thi s des cri pti ve correl ati on s tudy ai med to des cri be the rel ati on of educati onal l evel , academi c achi evement (gpa) and depres s i on among publ i c s chool adol es cents of samari nda muni ci pal , eas t kal i mantan provi nce, indones i a. a total of 552 adol es cents i n s eni or hi gh s chool aged between 14-19 years were recrui ted through s trati fi ed cl us ter s ampl i ng. the i ns truments was the center for epi demi ol ogi c studi es depres s i on (ces-d). the data were anal yzed by s tati s ti cal method i ncl udi ng t-tes t, chi -s quare, and pears on correl ati on. the res ul t s howed the preval ence of depres s i on i n thi s s ampl e of indones i an adol es cents was 52.7%. adol es cent femal es s howed al mos t equal preval ence of depres s i on than adol es cents ’ mal es (26.6%, 26.1%), res pecti vel y. there was s i gni fi cant rel ati ons hi p between adol es cents ’ depres s i on and educati onal l evel (x²= 8.039, p val ue= 0.018). speci fi cal l y, bas ed on the fi ndi ngs s ugges t i nterventi ons program to reduce depres s i on i n adol es cents by gi vi ng heal th educati on wi th s peci fi c mental heal th i n s chool . some programs a r e abl e to do i n s chool s uch as couns el i ng center, s tres s management program, ti me management, and s creeni ng about negati ve l i fe events . thi s s trategy need to i ncl ude the parti ci pati on of other pers onnel s uch as cl as s coordi nator and heal th workers to be s ucces s ful of progra m. keywords: adol es cents , depres s i on, publ i c hi gh s chool mukhripah i¹, dwi r introduction in the rapid world changes nowadays, a significant contributor to the global burden of disease and affects people in all communities across the world is depression (who, 2012). depression is one of the emotional problems, hopelessness and helplessness are its main causes. the other word, depression is aprevalen t problem among college’s student ability to perform activities of daily life. (khursid et al, 2015). according to national institute of mental health (2012) found that many students experience the first symptoms of depression during their college. more than 1.75 billion proportion around the world is young people with aged from 10 and 24 years (who, 2008). in young people, the prevalance of depression is 0. 3 percent in preschool children and 2 percent in school children as well as 4-8 percent in adolescents (sabate, 2004). meanwhile, based on between the ages of 13 and 18 year-old sufferin g mailto:muda101180@gmail.com indonesian journal of nursing practices 84 depression have 8.4% and 15.9%, respectively (wagstaff, 2012). ministry of health of indonesia (2009) mentioned that adolescents suffering depression increased gradually from 43 million or 19.61% adolescents aged from 10 to 19 years to 62 million of all population between 2006 and 2008, respectively. depression has some significant impact for adolescents. they prepare for their transition to adult life (mccan, lubman, & clark, 2012) and also depression in youth presents a certain burden for adolescent (perry et al. 2007). based on the world health organization in world health report explain that depression called the silent epidemic is an outbreak of a disease that may no t be perceived directly as a result, but a result of the disease, which then burst and become maj o r contributors to the cause of human death. friends, peers, teachers as well as parents are group of population that receive the effects of depression from adolescent. (zgambo et al, 2012) and negative impact on school performance (unicef, 2004). depression in young people are associated with poor acade mi c performance, social dysfunction, substance abuse, and attempted and completed suicide (brent, 2002), felt sad or hopeless for a prolonged period of time, to the point that these feelings impaired from doing usual activities (cdc, 2011) , the occurrence of substance use, nonsuicidal selfinjury, and suicide ideation or behavior as well as with depression, suicidality, and impaired functioning later in life (taliaferro et al. 2013), experience emotional suffering and pro b l e ms i n daily living and functioning, such as decreased participant in social activities or impairment in social and interpersonal relationship (corona et al. 2013; liu et al. 2000; woodgate, 2006), difficulties with peer relationship, low self esteem including body image disturbance (mcphee & andrews, 2006), as we ll as potential disharmony at home (farmer, 2002). research shows that the increasing rates of depression in adolescents because adolescents experiencing school problems (shaffer & waslick , 2002, sriphet, 2001, wagstaff & polo, 2012). common co-occurring problems for depressed children and adolescent are academic underachievement, school attendance problems , and school failure (hammen et al. 1999) including rising amount of schoolwork, assignment deadlines, and exams (vatanasin et al. 2012). when adolescents got depression, they are ofte n face problems in their school not only academic progress but also themselves like loss of energy and motivation that needed in academic achievement so that they cannot concentrate and focus in the classroom during study i n the school . (shaffer & waslick, 2002; sriphet, 2001). at times, depression is one of the common psychiatric diagnoses that make adolescents to school refusers. adolescents leave hopes to study and success in the school as well as think how to reach academic achievement. sometimes, b as e d on condition and situation they decided to withdrawn from attending school (king & bernstein, 2001). and also, depressed adolescents commonly have difficulties interacting with their same-age peers. depresse d adolescents may have more difficulty developi ng effective social problem solving, leading to a greater chance of being rejected or perceived as less competent in a variety of areas by their peers (shaffer & waslick, 2002). hence, adolescents who experience depression are heavy problems to them (wagstaff, 2012). in indonesia, based on national education system (2013) educational level in high school consist different grade from grade 11 to grade 12. curriculum used is a competency-based curriculum that includes subjects and student learning loads every class is different. for instance, students who study in the grade 12 they must prepare to follow the last study examination that called in indonesia is national exam. 3rd grade high school students in particular as examinees often view the national exam as a scary thing because the standard graduation rate continues to increase. simamo ra (2014) conducted a research about description of adolescent depression in high school found that adolescent who in the grade 12 experience depression than adolescents who study betwe en grade 10 and 11. additionally, research by poulin, hand, boudreau & santor (2005) showing the vol. 1 no. 3 desember 2017 85 result that predictor of depression risk is academic performance for males and females adolescents. methods the design of this research was a descriptive correlation. sample of the present study was consisted of 552 students (276 male, 276 female) using calculated daniel formula (daniel, 1999, as cited zaied, 2014), which was selected by startified cluster sampling with age 14 to 19 years from three public colleges of city samarinda, eas t kalimantan. in this study focus to public high school because the first and main difference between public schools and private schools is the legal basis. although public and private schools have services which is the same, but they have different legal umbrella. private schools have to obey the laws foundation (law no.28 year 2008), while the public schools refer to the legislation of the national education system (law no.20 year 2003), article 50 clause 6 (fajar, 2011). there is one part of questionnaire to assess demographic data of respondents. it involved age, sex, educational level, educational achievement (gpa), parental education and occupation as well as family income. the center for epidemiologic studies depres si on (ces-d) scale to measured depressive sympto ms of the adolescents and consists of 20 items (radloff, 1977). there are four component of depression, including depressed effect, p o s i tiv e affect, somatic and retarded activity, and interpersonal relationship. these instruments, al l of answer in each items question respondents will be judged during the past week how often they experienced depressive symptoms. there are responses options on a 4-point scale: 0 (rarely or none of the time/less than once a week), 1 (some or a little of the time/1-2 days a week), 2 (occasionally or moderate amount of time/-4 days a week), or 3 (most or all of the time/5-7 days a week). a total ces-d score range betw e e n zero and 60, showed level depression that greater if have the score is higher. if individual indicate a high level of depressive symptoms, they have scores of 16 and above and 23 or mo re reflected significant depression. several researchers translated the ces-d into the indonesia language and found to be valid as a screening tool for depression in adolescent. hence, the indonesia version of ces-d of the siwanto which cut-off point score at 20 was be used in this study. descriptive statistics of frequency, pe rcentage, mean, and standard deviations were calculated to analyzed the socio-demographic and the prevalence of depression. a bivariate analysis used the pearson correlation for interval variables and chi-square for dichotomous variables. results the mean age of respondents was 16.31 which similar between male and female. the majority (68.7%) of subjects were in aged 16-17 years with male higher of percentage than female. meanwhile, the 14-15 years group was largest group with female than male. most (85%) of participants was islam. female had slightly higher educational achievement (gpa) compare d than male. mostly male had gpa between 2.00 – 2.99 while female had gpa from 3.00 – 4.00. the fathers were the heads of household found mostly amongst the respondents. about 85% of respondents reported that they live with married parents and nuclear family characteristic with two parents (47.8%). half (50.4%) of respondents have household head completed senior high school with the largest worked of them as business and (45.8%) average income per mo n th of household head around 80 usd. indonesian journal of nursing practices 86 table 1. number, percentage and depression classification of the respondents classified by depression cut off point depression scores total (n=552) n (%) male (n=276) n (%) female (n=276) n (%) t p cesd < 20 261 (47.3) 132 (23.0) 129 (23.4) cesd ≥ 20 291 (52.7) 144 (26.1) 147 (26.6) 0.216 0.398 x̄ = 20.68 sd= 6.584 x̄ = 20.45 sd= 6.395 x̄ = 20.92 sd= 6.771 *p= statistical significant α ≤ .05 table 1 showed that the prevalence of depression in this sample of indonesian adolescents was 52.7%. interestingly, the percentage of depression both of male and female is almost equal (26.6%, 26.1%, respectively). and the result found there was no significant difference mean score of depression between male and female. table 2 number, percentage and depression of the respondents between male and female based on educational level educational total depression no depression level n (%) n (%) n (%) grade 10 186 (33.6) 84 (15.2) 102 (18.4) grade 11 184 (33.3) 98 (17.7) 86 (15.6) grade 12 total 182 (33.0) 552 (100) 109 (19.7) 291 (52.7) 73 (13.2) 261 (47.3) as shown in table 2, these results indicate that the prevalence of depression differs based on educational level in high school. re spondents whose in grade 10 have percentage of no depression slightly higher than percentage of depression. however, respondents in grade 11 and 12 have percentage of depression more than respondents whose no depression. and as the grade advanced (grade 12), the percentage of depression showed a tendency to increase. table 3 means and standard deviations of the educational achievemnet (gpa) between male and female variables total (n=552) male (n=276) female (n=276) mean (sd) mean (sd) mean (sd) 95% ci t p educational achievement (gpa) 2.39 (0.539) 2.30 (0.533) 2.49 (0.529) 0.2770.100 -4.169 0.000* *p= statistical significant α ≤ .05 vol. 1 no. 3 desember 2017 87 table 4 means and standard deviations of educational achievement (gpa): a comparison between depression and no depression variables total (n=552) depression (n=291) no depression (n=261) mean (sd) mean (sd) mean (sd) 95% ci t p educational achievement (gpa) 2.39 (0.539) 2.40 (0.544) 2.39 (0.533) -0.0750.105 0.328 0.743 *p= statistical significant α ≤ .05 as shown in table 3, along with descriptive statistic for male and female and the result of ttest of selected variables between sexes. differences mean between male and female were statistically significant was educational achievement (gpa). however, in table 4, differences mean between depression had no statistically significant of educational achievement (gpa) table 5 relationship educational level, educational achievement (gpa) and adolescents’ depression using chi-square and pearson correlation variables depression value (x²) df p-value 1. educational level 8.039 2 0.018* r p-value 2. educational achievement (gpa) 0.000 0.999 *p= statistical significant α ≤ .05 as shown in table 5, educational level was significant related to adolescents’ depression. discussion the prevalence of depression in indonesian adolescents was 52.7% which higher than study by asmika et al. (2008) found that prevalence of depression in adolescents of senior high school in malang district, indonesia was 39.3%. apart f ro m that, the prevalence was considerably higher when compared with studies of adolescents in other countries. for instance, the range of prevalence of adolescents depression from 10% 35 % were australia, america, the united kingdom, nigeria and iran whereas the range of prevalence between 36 and 45 percent were korea, china and thailand (busari, 2012, costel l o et al. 2006, hyun et al. 2009, mccan et al. 2012, modabber-nia et al. 2007, walsh, 2009, vatanasin et al. 2012). relationship between educational level and adolescent depression showed that there was relation in this study. there are many results o f a study that found that students in high school to experience more severe depression by level of education (asmika, 2008). the respondents we re enrolled in the school setting that may stressors of both developmental task and their study. the participants in this study were studying in three high schools under jurisdiction of departme n t o f national education indonesia and focus this study to public high school. based on national education system in indonesia (2013) educational level in high school consist different grade from grade 11 to grade 12 and curriculum used is a competency-based curriculum. even though the y were studying in the same school environments but they received different subjects, curriculum indonesian journal of nursing practices 88 and burden in each level (asmika, 2008). exactly students in grade 12, they must prepare the last examination that called in indonesia is national exam that consequently experiences depre s si on than students in grade 10 and 11. currently, education curriculum in indonesia is heavy than other country (kapiyani, 2016). targeted curriculum that is too high, the climate is not conducive to learning, giving the task a very dense, and rigorous assessment system less fair and could be a factor causing depression factor derived from the curriculum (alestelo et al. 2002). likewise, strict application of school discipline and more prioritizing punishment, school climate that is less convenient, and facility and pre-learning tool is very limited also trigger the formation factors of depression in student who come from schools factors. considering their education achievement (gpa) it was found that there was no relationship with adolescent depression. this finding was supported by previous studies in in china (chen & li 2000), in indonesia (septianto, 2014), and also in iran (shahmohammadi, 2014). according to chen & li (2000) suggest that depression in adolescents schools in china not because of educational achievement, but because the process of school activities such as the number o f assignments and homework. school adoles ce nts are required to maintain attention and concentration during the process. in indonesia, study by septianto (2014) reported that one of reason adolescents get depression in the school is increasing the performance of study in the learning process in schools. therefore, they thin k is not important about the last results in their learning. the most important how to adolescents in the school can get education through process. also supported study by shahmohammadi (2014) stated that depression among adolescents in iran is not related with educational achievement in school but they have experience depression because school schedule is too crowded, students learning with too much content studied as well as how to prepare test. related in this study find i ng that study load, time pressure during study and problems in accomplishing tasks or essay were problems of study faced adolescent in school that related to depression. conclution and recommendation there most important to developing prevention and intervention program to reduce depression in adolescents is give health education with specific mental health in academic 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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. (2017). pengaruh hipnoterapi terhadap intensitas nyeri pada pasien post section cesarea di rumah sakit pku muhammadiyah kabupaten temanggung. prosiding seminar nasional dan internasional, 1(1), 163–171. akgul, a., guner, b., çırak, m., çelik, d., hergünsel, o. & bedirhan, s. (2016). the beneficial effect of hypnosis in elective cardiac surgery: a preliminary study. thoracic and cardiovascular surgeon, 64(7), 581–588. https://doi.org/10.1055/s-0036-1580623 aman, s. (2010). empat jam pinter hipnosis, misi media, jakarta. amraoui, j., pouliquen, c., fraisse, j., dubourdieu, j., rey dit guzer, s., leclerc, g., de forges, h., jarlier, m., gutowski, m., bleuse, j.p., janiszewski, c., diaz, j. & cuvillon, p. 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(2019). the effect of hypnosis on intraoperative hemorrhage and postoperative pain in rhinoplasty. international journal of clinical and experimental hypnosis, 67(3), 262–277. https://doi.org/10.1080/00207144.2019.161 2670 joudi, m., fathi, m., izanloo, a., montazeri, o. & jangjoo, a. (2016). une évaluation de l’effet de l’hypnose sur l’analgésie postopératoire https://doi.org/10.1055/s-0036-1580623 https://doi.org/10.1001/jamanetworkopen.2018.1164 https://doi.org/10.1001/jamanetworkopen.2018.1164 https://doi.org/10.1016/j.pmn.2018.05.005 https://doi.org/10.1007/s00586-019-05886-6 https://doi.org/10.1007/s00586-019-05886-6 https://doi.org/10.1080/00207144.2019.1612670 https://doi.org/10.1080/00207144.2019.1612670 indonesian journal of nursing practices 117 après une cholécystectomie laparoscopique. international journal of clinical and experimental hypnosis, 64(3), 365–372. https://doi.org/10.1080/00207144.2016.117 1113 kendrick, c., sliwinski, j., yu, y., johnson, a., fisher, w. & kekecs, z. (2017). hypnosis for acute prosedural pain : a critical review. hss public access, 64(1), 75–115. https://doi.org/10.1080/00207144.2015.109 9405 lew, m.w., kravits, k., garberoglio, c. & williams, a.c. 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(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. 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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(2020). clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. lancet (london, england), 395(10229), 1054–1062. https://doi.org/10.1016/s01406736(20)30566-3 https://doi.org/10.1136/postgradmedj-2020-138577 https://doi.org/10.1136/postgradmedj-2020-138577 https://doi.org/10.31539/jks.v4i1.1587 https://www.who.int/health-topics/coronavirus%23tab=tab_1 https://www.who.int/health-topics/coronavirus%23tab=tab_1 https://covid19.who.int/region/searo/country/id/ https://covid19.who.int/region/searo/country/id/ https://doi.org/10.1016/j.ijid.2020.03.017 https://doi.org/10.1016/s0140-6736(20)30566-3 https://doi.org/10.1016/s0140-6736(20)30566-3 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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(2019). a study on instant ginger drink effect in enhancing postpartum breastfeeding in immediate post cesarean delivery. journal of the medical association of thailand, 102(3), 259–263. shahri, m. m., nourian, m., varzeshnejad, m., & nasiri, m. (2020). the effect of oketani breast massage on successful breastfeeding, mothers’ breastfeeding support need, and breastfeeding self-efficacy: a clinical trial study. in review. https://doi.org/10.21203/rs.3.rs-64870/v1 sulistiana, m. p., marfuah, d., mutiar, a., & nurhayati, n. (2021). the effect of oxytocin and endorphin massage to uterine involution in post-partum mothers: a literature review. kne life sciences, 680–688. https://doi.org/10.18502/kls.v6i1.8742 sweet, l., & vasilevski, v. (2022). evaluation of a new lactation device ‘lactamo’ designed to apply massage, heat or cold, and compression to the breast. international breastfeeding journal. 17,23. https://doi.org/10.1186/s13006-022-004669 ulep, v. g., zambrano, p., datu-sanguyo, j., vilarcompte, m., belismelis, g. m. t., pérezescamilla, r., carroll, g. j., & mathisen, r. (2021). the financing need for expanding paid maternity leave to support breastfeeding in the informal sector in the philippines. maternal & child nutrition, 17(2), e13098. https://doi.org/10.1111/mcn.13098 usnawati, n., hanifah, a. n., & septianti p, t. (2021). monograf kombinasi acupressure points for lactation dan breast massage untuk memantau waktu pengeluaran asi dan kecukupan asi bagi bayi. media sains indonesia, 2021. uvnasmoberg, k., ekstrom bergstrom, a., buckley, s., & massaroti, c. (2020). maternal plasma levels of oxytocin during breastfeeding—a systematic review. plos one. 15(8): e0235806. https://doi.org/10.1371/journal.pone.0235806 zhang, x., chen, l., xuemiao, w., & wang, x. (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 75 vol. 1 no. 2 juni 2017 perceived barriers of cervical cancer screening among married women in minggir, godean, gamping sub-districts, sleman district yogyakarta yusi riwayatul afsah1 1 maternity department, faculty of medicine and health sciences, universitas muhammadiyah yogyakarta, jl.lingkar selatan, tamantirto, kasihan, bantul, yogyakarta, indonesia e-mail: yusira35@gmail.com abstract coverage of cervical cancer screening in indonesia has only reached 5% and cervical cancer in indonesia is still relatively high. the aimed of this cross-sectional study were to explore perceived barriers of cervical cancer screening and regular screening history among 384 married women in sleman, yogyakarta. data were collected using modified questionnaire items from champion health beliefs model scale. results showed that only 13.8% of respondent have regular screening. most of respondent in both group regular and non-regular/never had screening perceived that they preferred a female doctor to conduct a screening. significant association was found between perceived barriers for screening and women’s regular screening history (p-value =0.000). important barriers reported from this study were male physicians, time-consuming for screening procedure, and embarrassment. effort to increase screening need to focus on women who have high perceived barriers so that cervical cancer screening’s promotion can be achieved. keywords: cervical cancer screening, perceived barriers, women. introduction cervical cancer ranks the second most frequent cancer in women in indonesia after breast cancer (who/ico, 2010). according to who/ico (institute catala d’oncologia) (2010), indonesia has a population of 227,345,000 with an at risk population of developing cervical cancer (15 years and older) at around 79.14 million. current estimates indicate that every year around 13,762 indonesian women will be diagnosed with cervical cancer and 7493 will subsequently die from the disease. incidence rate of cervical cancer in indonesia 2011 reached 100 per 100,000 populations with accumulated distribution in java and bali expected to increase 25% within the next 10 years if no preventive measures are put into place info artikel: masuk : 6 maret 2017 revisi : 26 mei 2017 diterima : 1 juni 2017 doi number : 10.18196/ijnp.1264 cl ick to b uy n ow !pd f-x change editor track er-s o ft w are .co m c lic k t o b uy n ow !pd f-x change editor track er-s o ft w are .co m http://tracker-software.com/product/pdf-xchange-editor http://tracker-software.com/product/pdf-xchange-editor 76 (rasjidi, 2012). each day there are 41 new cases of cervical cancer culminating in 20 women dying daily in indonesia; or it could be roughly estimated that every hour a woman dies from cervical cancer in the country and the highest prevalence of women die from this disease is in yogyakarta with approximately 100/100,000 (agustina, 2014; yuliatin, 2010). indonesian government has set a minimum target of reaching 80% cervical cancer screening (ccs) coverage among indonesian women in line with the who recommendation of targeting population at risk of cervical cancer (kemenkes, 2013). in fact, coverage of cervical cancer screening in indonesia has only reached 5% and cervical cancer in indonesia is still relatively high (aziz, 2012). previous literature have reported that women’s beliefs regarding which refer to perceived susceptibility, perceived severity, perceived benefits, and perceived barriers are important factors that influence their decisions to get regular ccs (brotto et al, 2008; lee-lin et al, 2007; mcfarland, 2009; paskett et al, 2004; reis et al, 2012). nonetheless, most of these studies have been conducted in other countries including the us (lee-lin et al, 2007; mcfarland, 2009); the uk (fallowfield, et al, 2010; sawaya et al, 2009); turkey (reis et al, 2012; esin et al, 2011); taiwan (hsu et al, 2011); cambodia dan lao pdr (dang et al, 2010); jordan (amarin et al, 2008); india (roy et al, 2008); and malaysia (wong et al, 2008). there are 11 published ccs studies in indonesian women; notwithstanding, none of these have focused on women perceived barriers of ccs, but only examined on demographic factors, behavior, and barriers to ccs which are already well-established knowledge. the purpose of this study was; therefore, to examine and describe women perceived barriers of ccs among married women in sleman, yogyakarta, and relationship between perceived barriers of ccs and women ccs history. methode a descriptive cross-sectional study was conducted from july to september, 2014 with convenience sampling to recruit 384 participants aged 21 to 55 years who joined in the monthly family welfare activities including 3 sub-districts (minggir sub-district, godean sub-district, and gamping subdistrict), sleman district, yogyakarta, organized by the local governments. women who had been diagnosed with cervical cancer and unmarried were excluded. a package of questionnaire used in this study had 3 parts. part 1 was demographic data developed by the researcher to assess age, age of marriage, religion, level of education, income per month, health insurance information, types of health care facilities available, and source of health information. part 2 was perceived barriers of ccs measured by 15 questions modified champion health beliefs model scale (chbm). all of the items across the subscales have five-point likert-type response choices: strongly disagree (scores 1 point) through to strongly agree (scores 5 points). part 3 was cervical cancer screening history form in terms of whether they had a test within the past 1-3 years with yes/ no response. the content validity index (cvi) was 0.95 and exhibited cronbach’s alpha coefficients was 0.81. univariate and bivariate analysis was used in this study. bivariate association between women’s belief with chbmscale items and regular ccs history was examined using chisquare. the study was approved by the ethical committee institute review board (irb) of khon kaen university, thailand no. 4.3.03: 17/2014. result the average age in both group who have regular ccs and non-regular/never had ccs was 30 to 55 years. the majority of the participants in both groups were muslim. more than half of the participants in each group graduated senior high school and had low income or below the regional minimum wage in indonesia. the majority of women who had ccs regularly reported that they had health insurance. in contrast, most of the women without history of ccs had no health insurance. most of participants in both groups went for a health examination at government health care facilities and obtain health information from mass media. the demographic characteristics of participants presented in detail in table 1. cl ick to b uy n ow !pd f-x change editor track er-s o ft w are .co m c lic k t o b uy n ow !pd f-x change editor track er-s o ft w are .co m http://tracker-software.com/product/pdf-xchange-editor http://tracker-software.com/product/pdf-xchange-editor 77 vol. 1 no. 2 juni 2017 table 1. demographic characteristics of participants (n=384) demographic characteristics regular ccs (n=53) n (%) non-regular/ never had ccs (n=331) n (%) age (years) 21 – 29 2 (3.8) 65 (19.6) 30 – 55 51 (96.2) 266(80.4) age when get married 16 – 19 3 (5.7) 33 (10) 20 – 24 32 (60.2) 145 (43.9) 25 – 29 17 (32.2) 125 (37.7) ≥ 30 1 (1.9) 28 (8.4) religion muslim 45 (84.9) 299 (90.3) christian 6 (11.3) 21 (6.4) catholic 2 (3.8) 11(3.3) level of education elementary school 4 (7.5) 40 (12.1) junior high school 4 (7.5) 43 (13.0) senior high school 23 (43.5) 137 (41.4) diploma 4 (7.5) 20 (6.0) university graduate 18 (34.0) 90 (27.2) no education 1 (0.3) income per month < minimum wage 34 (64.1) 254 (76.7) > minimum wage 19 (35.9) 77 (23.3) health insurance yes 34 (64.2) 122 (36.9) no 19 (35.8) 209 (63.1) medical care access government hospital 5 (9.4) 19 (5.7) primary health care 24 (45.4) 191 (57.7) private hospital 5 (9.4) 29 (8.8) private medical practitioner 19 (35.8) 89 (26.9) herbal medicine 3 (0.9) demographic characteristics regular ccs (n=53) n (%) non-regular/ never had ccs (n=331) n (%) health information sources print media 10 (18.8) 62 (18.8) electronic media 25 (47.2) 164 (49.5) health care provider 13 (24.5) 63 (19.0) family 3 (5.7) friends 2 (3.8) 42 (12.7) almost all of the participants never had any ccs experience. interestingly, only (13.8%) from the total number of participants reported that they had ccs regularly. the most frequent used ccs method was pap smear test. the detail of ccs history showed in table 2. table 2. the frequency and percentage of ccs history of participants (n=384) history of ccs frequency percentage ccs regularly history (at least once in the past 1-3 years) yes 53 13.8 no 331 86.2 the last ccs occasion (at least once at any time in life) never had any ccs 310 80.7 after gave birth 28 7.3 annual physical examination 26 6.8 others (e.g. free examination, menopause time, abdominal pain symptom) 20 5.2 the last ccs method never had any ccs 310 80.7 pap smear test 58 15.1 visual inspection with acetic acid (via) 10 2.6 human papilloma virus test (hpv-test) 6 1.6 concerning barriers to use, the majority of the women in both group regular ccs and non-regular/never had ccs cl ick to b uy n ow !pd f-x change editor track er-s o ft w are .co m c lic k t o b uy n ow !pd f-x change editor track er-s o ft w are .co m http://tracker-software.com/product/pdf-xchange-editor http://tracker-software.com/product/pdf-xchange-editor 78 perceived that they preferred a female doctor to conduct a ccs. some item responses in the perceived barriers scale showed that more women in the regular ccs group did not believe the barriers to ccs compared with women in the non-regular/never had ccs group, such as did not know where to go for a ccs, embarrassment, having a ccs takes too much time, ccs is too painful, health professionals doing ccs are usually men as opposed to women (, other problems are more important than having a ccs, and no health center close to their home. the detail of perceived barriers of ccs showed in table 3 table 3. frequency and percentage of participants with perceived barriers on chbm-based items chbm items regular ccs (n=53) n (%) non-regular/never had ccs (n=331) n (%) 1. i am afraid to have a ccs for fear of a bad result strongly disagree 8 (15.1) 8 (15.1) disagree 29 (54.7) 29 (54.7) neutral 4 (7.5) 4 (7.5) agree 10 (18.9) 10 (18.9) strongly agree 2 (3.8) 2 (3.8) 2. i don’t know where to go for a ccs strongly disagree 15 (28.3) 46 (13.9) disagree 27 (50.9) 144 (43.5) neutral 1 (1.9) 41 (12.4) agree 6 (11.3) 90 (27.2) strongly agree 4 (7.5) 10 (3) 3. i would be ashamed to lie on a gynecologic examination table and show my private parts to have a ccs strongly disagree 15 (28.3) 23 (6.9) disagree 21 (39.6) 161 (48.6) neutral 6 (11.3) 31 (9.4) agree 10 (18.9) 106 (32) strongly agree 1 (1.9) 10 (3) 4. having a ccs takes too much time strongly disagree 6 (11.3) 22 (6.6) disagree 25 (47.2) 113 (34.1) neutral 5 (9.4) 67 (20.2) chbm items regular ccs (n=53) n (%) non-regular/never had ccs (n=331) n (%) agree 14 (26.4) 119 (36) strongly agree 3 (5.7) 10 (3) 5. having a ccs is too painful strongly disagree 8 (15.1) 17 (5.1) disagree 30 (56.6) 156 (47.1) neutral 9 (17) 96 (29) agree 5 (9.4) 57 (17.2) strongly agree 1 (1.9) 5 (1.5) 6. health professional doing ccs are usually a men more than women strongly disagree 10 (18.9) 24 (7.3) disagree 25 (47.2) 127 (38.4) neutral 8 (15.1) 108 (32.6) agree 5 (9.4) 56 (16.9) strongly agree 5 (9.4) 16 4.8) 7. i have other problems more important than having a ccs strongly disagree 10 (18.9) 42 (12.7) disagree 29 (54.7) 163 (49.2) neutral 9 (17) 80 (24.2) agree 4 (7.5) 37 (11.2) strongly agree 1 (1.9) 9 (2.7) chbm items regular ccs (n=53) n (%) non-regular/never had ccs (n=331) n (%) 8. i am too old to have a ccs regularly strongly disagree 14 (26.4) 55 (16.6) disagree 30 (56.6) 218 (65.9) neutral 3 (5.7) 24 (7.3) agree 6 (11.3) 31 (9.4) strongly agree 3 ( .9) 9. there is no health center close to my house to have a ccs strongly disagree 10 (18.9) 42 (12.7) disagree 29 (54.7) 155 (46.8) neutral 7 (13.2) 40 (12.1) cl ick to b uy n ow !pd f-x change editor track er-s o ft w are .co m c lic k t o b uy n ow !pd f-x change editor track er-s o ft w are .co m http://tracker-software.com/product/pdf-xchange-editor http://tracker-software.com/product/pdf-xchange-editor 79 vol. 1 no. 2 juni 2017 chbm items regular ccs (n=53) n (%) non-regular/never had ccs (n=331) n (%) agree 6 (11.3) 79 (23.9) strongly agree 1 (1.9) 15 (4.5) 10. if there is cervical cancer development in my destiny, having a ccs cannot prevent it strongly disagree 14 (26.4) 59 (17.8) disagree 26 (49.1) 173 (52.3) neutral 8 (15.1) 57 (17.2) agree 4 (7.5) 33 (10) strongly agree 1 (1.9) 9 (2.7) 11. i prefer a female doctor to conduct a ccs strongly disagree 4 (7.5) 3 ( .9) disagree 7 (13.2) 15 (4.5) neutral 1 (1.9) 12 (3.6) agree 28 (52.8) 206 (62.2) strongly agree 13 (24.5) 95 28.7) 12. i will never have ccs if i have to pay for it strongly disagree 13 (24.5) 35 (10.6) disagree 26 (49.1) 183 (55.3) neutral 1 (1.9) 38 (11.5) agree 9 (17) 59 (17.8) strongly agree 4 (7.5) 16 (4.8) 13. my husband would not permit me to have a ccs strongly disagree 13 (24.5) 57 (17.2) disagree 38 (71.7) 213 (64.4) neutral 2 (3.8) 43 (13) agree 13 (3.9) strongly agree 5 (1.5) 14. i am afraid that i will not be able to explain to my husband why i need ccs strongly disagree 11 (20.8) 45 (13.6) disagree 33 (62.3) 204 (61.6) neutral 6 (11.3) 53 (16) agree 1 (1.9) 26 (7.9) strongly agree 2 (3.8) 3 ( .9) chbm items regular ccs (n=53) n (%) non-regular/never had ccs (n=331) n (%) 15. other people may have negative attitudes toward me if i come to get ccs strongly disagree 12 (22.6) 51 (15.4) disagree 27 (50.9) 186 (56.2) neutral 6 (11.3) 52 (15.7) agree 7 (13.2) 36 (10.9) strongly agree 1 (1.9) 6 (1.8) based on bivariate analysis, there was significant association between women’s perceived barriers and women’s regular ccs history. on the other hand, 3 demoghrapic variables that had significant association with women’s regular ccs history were age, income per month, and health insurance. the detail of the assotiation presented in table 4. tabel 4 association between demographic variables, hbm variables and women’s regular cervical cancer screening (ccs) history variable regular ccs history (yes/no) x2 p-value age 5.244 .022* age of marriage 1.330 .249 religion 1.442 .230 level of education 1.283 .257 income per month 4.325 .038* health insurance status 14.108 .000* medical care access 1.481 .224 health information .105 .746 perceived barriers 38.685 .000* *statistical significant at α = .005 discussion of the 384 married women who participated in this study, around 19.3% of participants showed that they have ccs experience at least once at any time in life. however, only 13.8% had ccs regularly every 1-3 years as suggested cl ick to b uy n ow !pd f-x change editor track er-s o ft w are .co m c lic k t o b uy n ow !pd f-x change editor track er-s o ft w are .co m http://tracker-software.com/product/pdf-xchange-editor http://tracker-software.com/product/pdf-xchange-editor 80 by physician or health care provider. this number has been higher than the national coverage 4 years ago that said ccs coverage only reached 5%. around 7.3% participants stated that their last ccs experience was post giving birth. this is because ccs is not integrated in postpartum check-up. postpartum maternal health services in indonesia incorporated physical examinations (checking vital signs, examination of the peak height of the uterus, lochia and other vaginal fluids, and breast examination), provision of advice pertaining to exclusive breastfeeding, provision of communication, information, education and communication (iec) concerning postpartum maternal and newborn infant health, as well as family planning services postpartum (indonesian ministry of health, 2013). pap smear was a test that most married women had obtained for their last ccs method, while around 3% received visual inspection with acetic acid (via). beside that, only 1.6% had had a hpv-test as their last ccs method; this is because the hpv test is the most expensive screening method. via is available from public hospital, private medical practitioners from doctors and midwives. cost estimation for via test is around rp. 15,000 – rp. 50,000 (1 – 4 usd). via costs are cheaper if compared with pap smear; yet, people are more familiar with pap smear than via. this is due to lack of socialization about the difference between via and pap smear in the community, especially in rural communities. in bivariate analysis, age was significantly associated with ccs history (p=0.022). this finding was supported by studies in canada, and in accordance with nigerian study which reported a significant association between age and ccs participation in the bivariate model; but the association did not hold in the multivariate model (cerigo et al., 2013; olumide et al., 2014). the results from this study revealed that the majority of the women in both groups married when they were young adults (20-24 years); however, this did not make them eager to come and get a ccs until they reached a certain age or symptoms presented themselves income per month was found to be significantly correlated with ccs history (p=0.038). this finding supported other study by chang, et al., (2017) who found that total income per month was significantly associated with women’s participation to get a ccs in korea. this could be due to the expensive cost of ccs in indonesia. therefore, women in both the low income and high income groups were reluctant to think again of going to get a ccs when they did not have any complaints in terms of their health condition. on the other hand, health insurance status was found to be statistically significant when associated with ccs (p=0.000) amid bivariate analysis. these finding confirmed a report by roy, tricia, & tang (2008) who found that health insurance coverage was significantly associated with ccs among indian women with different religions. this study showed that more than half of the participants 64% who had regular ccs had health insurance. women will get a free screening if they had health insurance and vice versa. perceived barriers were found to be significantly associated with women’s ccs history (p=0.000). concerning individual items in the perceived barriers scale, almost all of married women with regular ccs and women without regular ccs felt that they would prefer a female doctor to conduct a ccs. this is because the majority of the participants in this study are muslim, and muslim women are likely to choose a female doctor when getting a ccs. this statement was supported by guimond & salman (2013) who stated that muslim women wish to reject showing a sensitive part of their body to anyone other than a biological family member or husband. moreover, 24.5% of married women with regular ccs and 22.6% among married women who had no ccs regularly perceived that they will never have ccs if they have to pay for it. this finding confirmed the significance of medical expenses on women’s decision to get ccs. cost barriers pertaining to ccs were also mentioned by a quarter of participants in ghana and most women in mexico (abotchie, & shokar, 2009; leyva et al., 2006). the problem of health care service access is still felt by some married women. around 28.4% of the participants without regular ccs reported that there was no health center close to their home to have a ccs. the number is higher compared with only 13.2% in the women with regular ccs. approximately 18.9% of married women with regular ccs and 30.2% of women who had never had ccs regularly stated that they did not know where to go for a ccs. similarly, leyva et al., (2006) reported that most mexican women perceived that difficulty of health care access is one of the important barriers to getting a ccs. cl ick to b uy n ow !pd f-x change editor track er-s o ft w are .co m c lic k t o b uy n ow !pd f-x change editor track er-s o ft w are .co m http://tracker-software.com/product/pdf-xchange-editor http://tracker-software.com/product/pdf-xchange-editor 81 vol. 1 no. 2 juni 2017 in some items, married women in the non-regular/ never had ccs group had more perceived barriers to ccs than women who had regular ccs such as fear of a bad result, they had other problems more important than having a ccs, they were afraid that they would not be able to explain to their husband why they needed a ccs, ccs would take too much time, and ccs is too painful. similar result in study reported by awodele et al. (2011) showed that around 14.4% of participants in nigeria believed that a ccs is painful. being worried about pain, result, and time-consumed appear to be barriers to ccs and should be addressed amid future intervention. interestingly, none of the married women with regular ccs agreed that their husband would not permit them to have a ccs, while 5.4% of women without regular ccs agreed with this statement. the small number of participants also shown among hispanic and indian women agreed that partner permission was one of the barriers to having a ccs (byrd et al., 2004; roy et al., 2008). moreover, a small number of married women perceived that if cervical cancer is their destiny, having ccs cannot prevent it, and they believed that negative perceptions from others would appear if they went to get a ccs, while 11% felt that they were too old to have a ccs. in general, women partaking in this study seemed to have high perceived barriers of ccs. when comparing to the two groups, this study presented that the women in the non-regular ccs group perceived higher barriers than the women with regular ccs in terms of fear of bad result, do not know where to go for a ccs, embarrassment, time taken, ccs is too painful, the presence of male health care workers, other problem more important than having a ccs, no health center close to their home, cost of ccs, husband’s permission, and afraid in terms of explaining to their husband why they need a ccs. conclusion to sum up, these outcomes suggest reasons for the low ccs coverage among married women. in the final model, health insurance coverage and perceived barriers scale were found to be significant predictors of ever having had regular ccs. the specific barriers mentioned in this study may be taken into account amid health education interventions to encourage ccs which likely to be developed in the future by the indonesian government in collaboration with health care providers. the success of a screening program is highly dependent on the willingness and presence of women who are at risk to participate in such a program. effort to increase screening need to focus on women who have high perceived barriers so that cervical cancer screening’s promotion can be achieved. acknowledgement the author wish to thank the participants in this study and to the sleman regent for giving permission to conduct the study. referensi abotchie, p.n., & shokar, n.k. (2009). cervical cancer screening among college students in ghana: knowledge and health beliefs. int j gynecol cancer, 19(3), 412–416. agustina, d. (2014). daerah istimewa yogyakarta (diy) paling banyak kasus kanker serviks, yogyakarta, indonesia. retrieved january 10, 2015, from http:// www.tribunnews.com amarin, z.o., badria, l.f., & obeidat, b.r. (2008). attitudes and beliefs about cervical smear testing in ever-married jordanian women. eastern mediterranean health journal, 14, no. 2. department of obsgyn, jordan university of science and technology, irbid, jordan. awodele, o., et al. (2011). a study on cervical cancer screening amongst nurses in lagos university teaching hospital, lagos, nigeria. j.cancer education, 26, 497– 504. retrieved november 03, 2014, from http: //www. ncbi.nlm.nih.gov/pmc/articles/pmc3161190 aziz, f. (2012). sexual intercourse is a risk factor of cervical cancer. media indonesia (p.5). brotto, l.a., et al. (2008). reproductive health practices among indian, indo-canadian, canadian east asian, and euro-canadianwomen: the role of acculturation. j obstet gynaecol can, 30, 229-38 byrd, t.l., peterson, s.k., chavez, r., & heckert, a. (2004). cervical cancer screening beliefs among young hispanic women. prev. med, 38, 192–197. cerigo, h., coutlée, f., franco, e.l., & brassard, p. (2013). factors associated with cervical cancer screening uptake cl ick to b uy n ow !pd f-x change editor track er-s o ft w are .co m c lic k t o b uy n ow !pd f-x change editor track er-s o ft w are .co m http://tracker-software.com/product/pdf-xchange-editor http://tracker-software.com/product/pdf-xchange-editor 82 among inuit women in nunavik, quebec, canada. bmc public health, 13, 438. retrieved november 02, 2014, from http://www.biomedcentral.com/content/pdf chang, h. k., et al (2017). factors associated with participation in cervical cancer screening among young koreans: a nationwide cross-sectional study. bmj open. 2017; 7(4), 1-9. dang, j., lee, j., & tran, j.h. (2010). knowledge, attitudes, and beliefs regarding breast and cervical cancer screening among cambodian, laotian, thai, and tongan women. j canc educ 25:595–601. usa. esin m.n., bulduk s., & ardic a. (2011). beliefs about cervical cancer screening among turkish married women. j canc educ (2011) 26:510–515. springer. turkey. fallowfield, l., et al. (2010). awareness of ovarian cancer risk factors, beliefs and attitudes towards screening: baseline survey of 21 715 women participating in the uk collaborative trial of ovarian cancer screening. british journal of cancer 103, 454 – 461. uk. hawkins, n.a., benard, v.b., greek, a., roland, k.b., manninen, d., & saraiya, m. (2013). patient knowledge and beliefs as barriers to extending cervical cancer 2 screening intervals in federally qualified health centers. preventive medicine. ypmed-03718; page no: 5; 4c: usa. hsu, y., cheng, y., hsu k., fetzer, s.j., & chou, c. (2011). knowledge and beliefs about cervical cancer and human papillomavirus among taiwanese undergraduate women. oncology nursing forum. vol. 38. us. lee-lin, e.e., et al. (2007). korean american women’s beliefs about breast and cervical cancer. oncol nursing forum, 34, 713-20. leyva, m., byrd, t., & tarwater, p. (2006). attitudes towards cervical cancer screening: a study of beliefs among women in mexico. californian journal of health promotion, 4(2), 13-24. mcfarland, d.m. (2009). beliefs about the causes of cervical cancer in botswana: implications for nursing. int nursing review, 56, 426-32. ministry of health republic of indonesia. (2013). jkn menjamin deteksi dini kanker leher rahim dan payudara. jakarta. retrieved march 1, 2014, from http://www. depkes.go.id/index.php olumide, a., olatunbosun, f., & oluwatosin, o. (2014). knowledge, perception and predictors of uptake of cervical screening among rural nigerian women. journal of public health and epidemiology, 6(3), 119-124. retrieved october 25, 2014, from http://www.academicjournals. org paskett, e.d., tatum, c., rushing, j., et al. (2004). racial differences in knowledge, attitudes, and cancer screening practices among a tri racial rural population. cancer, 101, 2650-9. rasjidi. (2012). kanker serviks dan penanganannya. yogyakarta. nuha medika. reis, n. et al. (2012). knowledge, behavior and beliefs related to cervical cancer and screening among turkish women. asian pacific j cancer prev, 13, 1463-1470. roy, b., tricia, & tang, t.s. (2008). cervical cancer screening in kolkata, india: beliefs and predictors of cervical cancer screening among women attending a women’s health clinic in kolkata, india. journal of cancer education. retrieved november 20, 2013, from http://www.ncbi. nlm.nih.gov sawaya, et al. (2009). ending cervical cancer screening: attitudes and beliefs from ethnically diverse older women. am j obstet gynecol 2009; 200:40.e1-40.e7. uk. wong, l., wong, y.l., low, w.y., khoo, e.k., & shuib, r. (2008). cervical cancer screening attitudes and beliefs of malaysian women who have never had a pap smear: a qualitative study. international journal of behavioral medicine, 15: 289–292. france. world health organization. (2013). screening for cervical cancer. diakses 24 januari 2014,http://www.who.int/ cancer/detection/cervical_cancer_screening/e/ yuliatin, s. (2010). cegah dan tangkal ca. serviks. surabaya: java pustaka group. cl ick to b uy n ow !pd f-x change editor track er-s o ft w are .co m c lic k t o b uy n ow !pd f-x change editor track er-s o ft w are .co m http://tracker-software.com/product/pdf-xchange-editor http://tracker-software.com/product/pdf-xchange-editor 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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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 77 vol. 1 no. 1 desember 2016 pengaruh situasional terhadap kecemasan mahasiswa program studi d iii keperawatan menghadapi ujian skill laboratorium: studi mixed methods yulifah salistia budi1, shanti wardaningsih2, moh afandi2 1 magister keperawatan universitas muhammadiyah yogyakarta, jln. lingkar selatan tamantirto, kasihan, bantul, yogyakarta, 55183 2 program studi magister keperawatan, universitas muhammadiyah yogyakarta, jln. lingkar selatan tamantirto, kasihan, bantul, yogyakarta, 55183 e-mail: yulifahsalistia@gmail.com abstrak tujuan penelitian: untuk mengetahui pengaruh situasional terhadap kecemasan dan tingkat kecemasan mahasiswa prodi d iii keperawatan stikes banyuwangi dalam menghadapi ujian skill lab. metode: penelitian ini menggunakan metode penelitian gabungan model sekuensial eksplanatori, yang melibatkan mahasiswa, dosen dan laboran yang dilakukan pada 1620 januari 2017. data yang didapat dianalisis dengan uji statistik kruskal wallis, dilanjutkan analisis kualitatif secara manual kemudian disimpulkan dari kedua analisis tersebut. hasil: hasil penelitian secara kuantitatif bahwa sebagian besar responden mengalami kecemasan ringan, dengan uji statistik kruskal wallis didapatkan pengaruh yang tidak signifikan pada situasional terhadap kecemasan mahasiswa. hasil uji kualitatif di dapatkan empat tema yaitu kebisingan, temperatur ruangan, timing ujian dan persiapan lingkungan. kesimpulan: didapatkan bahwa kecemasan mahasiswa berada pada tingkat ringan, terdapat pengaruh faktor situasional terhadap kecemasan mahasiswa program studi d iii keperawatan stikes banyuwangi dalam menghadapi ujian skill lab. hasil ini diharapkan ada tindak lanjut untuk mahasiswa, dosen, dan laboran dari pihak terkait untuk mengatasi kecemasan mahasiswa menghadapi ujian skill lab terkait situasional atau suasana saat ujian skill lab. kata kunci : cemas, mahasiswa keperawatan, skill lab abstract purpose: the purpose of this study wasto determine the influence of situational to anxiety and anxiety levels of diploma nursing students at institute of health sciences banyuwangi in the skill exam laboratory. method: this study used a mixed methods with explanatory sequential models, by involved were students, lectures and the lab staff in january, 16th-20 th 2017. the info artikel: masuk : 27 agustus 2016 revisi : 20 november 2016 diterima : 3 desember 2016 doi number : 10.18196/ijnp.1151 78 quantitative analysis used kruskall wallis test, followed by a qualitative analysis of manually categorizing data then inferred from both the analysis. result: the result of quantitative method that the majority of respondents were in mild anxiety levels, by kruskall wallis obtained a not significant influence on situational to anxiety of diploma nursing student in the exam skills lab. qualitative results indicated to four themes: noisy, temperature skill room, timing in the exam skill lab and preparation of the situational. conclusion: that the majority of respondents were in mild anxiety levels and there’s the influence of situational to anxiety in diploma nursing students. by that results, to have follow-up for students, examiner, and the lab staffs from relevant parties concerned to overcome the student’s anxiety toward the lab skills exam related in atmosphere skill lab exam. keywords: anxiety, lab skills, nursing students pendahuluan jenjang diploma iii keperawatan berperan sebagai perawat terampil dalam menyelesaikan masalah keperawatan secara mandiri dan berke lompok yang direncanakan sesuai dengan standar asuhan keperawatan, dengan kemampuan menerima tanggung jawab terhadap keputusan dan tindakan asuhan keperawatan professional, sesuai dengan lingkup praktik dan hukum atau peraturan perundangan (aipdiki, 2014). untuk memenuhi kemampuan tersebut maka dilakukan suatu uji kompetensi dimana pada ujian tersebut nantinya bertujuan untuk mengukur kemampuan mahasiswa. dimana dari data tingkat kelulusan uji kompetensi cenderung masih fluktuatif. prosentase lulusan terjadi pada periode i tahun 2015 yaitu 29,49% untuk diploma iii keperawatan, pada periode ii tahun 2015 terjadi kenaikan prosentase kelulusan menjadi 64,38 % (dikti, 2016). faktor yang mempengaruhi kelulusan uji kompetensi yaitu adanya perbedaan persepsi pencapaian kompetensi pada instrumen yang digunakan antar penguji dan peserta, selain itu stress dan kecemasan juga berpengaruh pada hasil uji kompetensi (pratiwi & mufdillah, 2009). standart minimal kompetensi dapat diketahui dengan penyelenggaraan uji kompetensi dengan ujian skill lab (osce/osca) yang merupakan suatu metode penilaian mahasiswa atau lulusan pendidikan kesehatan yang lebih kompleks (turner & dankoski, 2008). ujian merupakan salah satu cara mengevaluasi mahasiswa terhadap suatu materi belajar dan juga menjadi sumber kecemasan bagi mahasiswa (basuki, 2015). ujian skill lab harus dapat dilaksanakan secara cepat dan tepat serta harus dilakukan secara lengkap tanpa terlewati satu unsur pun dalam waktu uji yang singkat (± 10 menit tiap satu keterampilan), untuk mendapatkan nilai yang bagus (arief, s. & sumarni, 2013). hal tersebut memungkinkan timbulnya kecemasan pada mahasiswa keperawatan sebelum melaksanakan ujian lab klinik keperawatan. menurut kemenkes ri (2010) bahwa suatu laboratorium dapat berfungsi efektif dan efisien harus memperhatikan hal-hal terkait persyaratan minimal, yaitu jenis dan jumlah peralatan, serta bahan habis pakai berdasarkan pada kompetensi yang akan dicapai, bentuk dan desain laboratorium harus memperhatikan keselamatan atau keamanan dan kenyamanan, adanya standart operasional prosedur atau instruksi kerja, adanya pelaporan dan dokumentasi dari setiap kegiatan praktikum di masing-masing laboratorium. jumlah peserta yang diajar, kebutuhan untuk ketenangan, temperatur ruangan, pencahayaan, kebisingan, ventilasi udara, dan perabot ruangan sangat penting ketika memilih tempat (potter & perry, 2010). kecemasan dalam menghadapi ujian merupakan suatu manifestasi emosi yang bercampur baur dan dialami oleh seorang individu sebagai reaksi dalam menghadapi ujian yang dapat mempengaruhi fisik dan psikis. menurut peplau (1952) dalam suliswati (2014) ada empat tingkatan yaitu (1)kecemasan ringan, dihubungkan dengan ketegangan yang dialami seharihari. individu masih waspada serta lapang persepsinya meluas, menajamkan indra. dapat memotivasi individu untuk belajar dan mampu memecahkan masalah secara efektif dan menghasilkan pertumbuhan dan kreatifitas, (2) kecemasan sedang, individu terfokus hanya pada pikiran yang menjadi perhatiannya, terjadi 79 vol. 1 no. 1 desember 2016 penyempitan lapangan persepsi, masih dapat melakukan sesuatu dengan arahan orang lain, (3) kecemasan berat, lapangan persepsi individu sangat sempit. pusat perhatiannya pada detil yang kecil dan spesifik dan tidak dapat berfikir hal-hal lain. seluruh perilaku dimaksudkan untuk mengurangi kecemasan dan perlu banyak perintah/arahan untuk terfokus pada area lain, dan (4) panik, dimana individu kehilangan kendali diri dan detil perhatian hilang. karena hilangnya kontrol, maka tidak mampu melakukan apapun meskipun dengan perintah. terjadi peningkatan aktivitas motorik, berkurangnya kemampuan berhubungan dengan orang lain, penyimpangan persepsi dan hilangnya pikiran rasional, tidak mampu berfungsi secara efektif. biasanya disertai dengan disorganisasi kepribadian. adapun faktor-faktor yang mempengarui kecemasan mahasiswa menghadapi skill test menurut yang, et all (2014) yaitu sikap pengawas ujian, suasana ujian, ketrampilan mahasiswa, ujian itu sendiri dan perasaan intern yang dialami oleh mahasiswa itu sendiri (tidak yakin lulus). untuk mengurangi kecemasan, individu mempunyai mekanisme pertahanan diri yaitu mekanisme dan strategi koping. mekanisme koping adalah cara yang dilakukan individu dalam menyelesaikan masalah, menyesuaikan diri dengan perubahan serta respon terhadap situasi yang mengancam. berdasarkan tingkatan ansietas membutuhkan lebih banyak energi untuk mengatasi ancaman tersebut. sedangkan strategi koping adalah cara yang dilakukan untuk mengubah lingkungan atau situasi atau menyelesaikan masalah yang sedang dirasakan/dihadapi. (rasmun, 2009). menurut ahyar (2010) menyebutkan bahwa faktor-faktor yang mempengaruhi strategi koping yaitu kesehatan fisik, keyakinan atau pandangan positif, ketrampilan memecahkan masalah, ketrampilan sosial, dukungan sosial dan materi. maka, rumusan masalah pada penelitian ini adalah seberapa level kecemasan mahasiswa dan apakah ada pengaruh situasional terhadap kecemasan mahasiswa d iii keperawatan menghadapi ujian skill lab? penelitian ini bertujuan untuk mengidentifikasi tingkat kecemasan mahasiswa menghadapi ujian skill lab, pengaruh situasional atau suasana ruang ujian terhadap kecemasan dalam menghadapi ujian skill lab pada mahasiswa prodi d iii keperawatan. metode penelitian ini dilakukan di stikes banyuwangi pada tanggal 16-20 januari 2017. metode penelitian yang digunakan yaitu metode gabungan (mixed methods) antara metode penelitian kuantitatif dan kualitatif. strategi yang digunakan dalam metode penelitian ini yaitu eksplanatoris sekuensial dimana urutan analisis kuantitatif dan kualitatif, yang bertujuan untuk mengidentifikasi komponen konsep (subkonsep) melalui analisis data kuantitatif dan kemudian mengumpulkan data kualitatif guna memperluas informasi yang tersedia. mixed method menghasilkan fakta yang lebih komprehensif dalam meneliti masalah penelitian, karena penelitian ini memiliki kebebasan untuk menggunakan semua alat pengumpul data yang dibutuhkan. sedangkan kuantitatif atau kualitatif hanya terbatas pada jenis alat pengumpul data tertentu saja. u n t u k d a t a k u a n t i t a t i f d i p e r o l e h d e n g a n membagikan kuesioner nstas yang berisi empat faktor yang mempengaruhi kecemasan mahasiswa mengahadapi ujian skill lab yang mana nanti responden memilih salah satu jawaban pada setiap faktor tersebut dan instrumen zsas yang telah tervalidasi kepada responden yaitu mahasiswa prodi diii keperawatan stikes banyuwangi dengan tehnik total sampling sebanyak 66 mahasiswa. kemudian data diuji dengan uji statistik kruskall wallis menggunakan program paket komputer. data kualitatif diperoleh dengan tehnik fgd pada partisipan (6 mahasiswa) dan wawancara mendalam kepada lima informan (4 dosen dan 1 laboran) yang dilakukan di laboratorium dan ruang dosen dengan pengambilan sampel menggunakan purposive sampling, kemudian hasilnya dianalisis secara sistem manual dengan pengkodean untuk menentukan makna final atau tema. 80 hasil a. analisa kuantitatif tabel 1. karakteristik responden berdasarkan tingkat kecemasan mahasiswa (n=66) variabel frekuensi persentase (%) tingkat kecemasan ringan 42 63,6 sedang 22 33,3 berat 2 3,1 sumber : data primer 2017 berdasarkan tabel 1. tingkat kecemasan responden sebagian besar berada pada level ringan yaitu 63,6%. tabel 2. karakteristik responden berdasarkan usia, jenis kelamin dan integritas fisik (n=66) variabel frekuensi persen (%) ρ value usia 0,514** 18 17 25,8 19 28 42,4 20 16 24,2 21 5 7,6 jenis kelamin 0,011* laki-laki 18 27,3 perempuan 48 72,7 integritas fisik sehat 66 100 sumber : data primer 2017 * ρ < 0,05 signifikan hasil uji kruskal wallis ** ρ > 0,05 tidak ada pengaruh signifikan hasil uji kruskal wallis tabel 3. distribusi responden berdasarkan faktor situasional yang mempengaruhi kecemasan (n=66) frekuensi persen (%) sangat tidak setuju 1 1,5 tidak setuju 3 4,5 netral 26 39,4 frekuensi persen (%) setuju 33 50,0 sangat setuju 3 4,5 sumber : data primer 2017 berdasarkan tabel di atas sebagian besar responden menjawab setuju, hal ini berarti faktor situasional mempengaruhi 50% responden terhadap kecemasan. setelah di uji menggunakan uji statiktik krukall walis di dapatkan hasil ρ hitung > 0,05 yaitu 0,074 berarti ho diterima, artinya situasional tidak berpengaruh secara signifikan terhadap kecemasan mahasiswa menghadapi ujian skill lab. b. analisa kualitatif analisis tema dilakukan setelah data dikumpulkan melalui fgd, wawancara terstruktur yang disusun menjadi transkrip verbatim dan beberapa dokumen yang berkaitan dengan ujian skill lab. hasil analisa data tersebut dilakukan pemaknaan kemudian dikategorisasikan berdasarkan teori dan mengacu pada tujuan khusus penelitian. proses pembentukan masing-masing tema dijabarkan dalam bentuk bagan yang menjelaskan tentang proses pembentukan tema. tahapan pembentukan tema diawali dengan pembentukan koding makna kemudian kategorisasi dan tahap terakhir adalah perumusan tema. berat 2 3,1 sumber : data primer 2017 berdasarkan tabel 1. tingkat kecemasan responden sebagian besar berada pada level ringan yaitu 63,6%. tabel 2. karakteristik responden berdasarkan usia, jenis kelamin dan integritas fisik (n=66) variabel frekuensi persen (%) ρ value usia 0,514** 18 17 25,8 19 28 42,4 20 16 24,2 21 5 7,6 jenis kelamin 0,011* laki-laki 18 27,3 perempuan 48 72,7 integritas fisik sehat 66 100 sumber : data primer 2017 * ρ < 0,05 signifikan hasil uji kruskal wallis ** ρ > 0,05 tidak ada pengaruh signifikan hasil uji kruskal wallis tabel 3. distribusi responden berdasarkan faktor situasional yang mempengaruhi kecemasan (n=66) frekuensi persen (%) sangat tidak setuju 1 1,5 tidak setuju 3 4,5 netral 26 39,4 setuju 33 50,0 sangat setuju 3 4,5 sumber : data primer 2017 berdasarkan tabel di atas sebagian besar responden menjawab setuju, hal ini berarti faktor situasional mempengaruhi 50% responden terhadap kecemasan. setelah di uji menggunakan uji statiktik krukall walis di dapatkan hasil ρ hitung > 0,05 yaitu 0,074 berarti ho diterima, artinya situasional tidak berpengaruh secara signifikan terhadap kecemasan mahasiswa menghadapi ujian skill lab. b. analisa kualitatif analisis tema dilakukan setelah data dikumpulkan melalui fgd, wawancara terstruktur yang disusun menjadi transkrip verbatim dan beberapa dokumen yang berkaitan dengan ujian skill lab. hasil analisa data tersebut dilakukan pemaknaan kemudian dikategorisasikan berdasarkan teori dan mengacu pada tujuan khusus penelitian. proses pembentukan masing-masing tema dijabarkan dalam bentuk bagan yang menjelaskan tentang proses pembentukan tema. tahapan pembentukan tema diawali dengan pembentukan koding makna kemudian kategorisasi dan tahap terakhir adalah perumusan tema. koding kategori tema ramai keadaan ruang ujian ramai kebisingan ruang ujian gaduh berisik bagan 1. pembentukan tema kebisingan ruang ujian berdasarkan pernyataan mahasiswa dan informan tentang kebisingan ruang ujian saat ujian skill lab yaitu: “…diluar rame..keburu pindah ruangan yang lain pula, soalnya masuknya gak barengan sih buk tiap ruangan..” (p3, p, 19 thn) “…suasana ruang ujiannya buk, gaduh banget kalo ujian…” (p4, l, 19 thn) koding kategori tema masuk gak barengan memulai barengan pengaturan waktu ujian timing ujian penguji telat bagan 2. pembentukan tema timing ujian bagan 1. pembentukan tema kebisingan ruang ujian berdasarkan pernyataan mahasiswa dan informan tentang kebisingan ruang ujian saat ujian skill lab yaitu: “…diluar rame..keburu pindah ruangan yang lain pula, soalnya masuknya gak barengan sih buk tiap ruangan..” (p3, p, 19 thn) “…suasana ruang ujiannya buk, gaduh banget kalo ujian…” (p4, l, 19 thn) 81 vol. 1 no. 1 desember 2016 berat 2 3,1 sumber : data primer 2017 berdasarkan tabel 1. tingkat kecemasan responden sebagian besar berada pada level ringan yaitu 63,6%. tabel 2. karakteristik responden berdasarkan usia, jenis kelamin dan integritas fisik (n=66) variabel frekuensi persen (%) ρ value usia 0,514** 18 17 25,8 19 28 42,4 20 16 24,2 21 5 7,6 jenis kelamin 0,011* laki-laki 18 27,3 perempuan 48 72,7 integritas fisik sehat 66 100 sumber : data primer 2017 * ρ < 0,05 signifikan hasil uji kruskal wallis ** ρ > 0,05 tidak ada pengaruh signifikan hasil uji kruskal wallis tabel 3. distribusi responden berdasarkan faktor situasional yang mempengaruhi kecemasan (n=66) frekuensi persen (%) sangat tidak setuju 1 1,5 tidak setuju 3 4,5 netral 26 39,4 setuju 33 50,0 sangat setuju 3 4,5 sumber : data primer 2017 berdasarkan tabel di atas sebagian besar responden menjawab setuju, hal ini berarti faktor situasional mempengaruhi 50% responden terhadap kecemasan. setelah di uji menggunakan uji statiktik krukall walis di dapatkan hasil ρ hitung > 0,05 yaitu 0,074 berarti ho diterima, artinya situasional tidak berpengaruh secara signifikan terhadap kecemasan mahasiswa menghadapi ujian skill lab. b. analisa kualitatif analisis tema dilakukan setelah data dikumpulkan melalui fgd, wawancara terstruktur yang disusun menjadi transkrip verbatim dan beberapa dokumen yang berkaitan dengan ujian skill lab. hasil analisa data tersebut dilakukan pemaknaan kemudian dikategorisasikan berdasarkan teori dan mengacu pada tujuan khusus penelitian. proses pembentukan masing-masing tema dijabarkan dalam bentuk bagan yang menjelaskan tentang proses pembentukan tema. tahapan pembentukan tema diawali dengan pembentukan koding makna kemudian kategorisasi dan tahap terakhir adalah perumusan tema. koding kategori tema ramai keadaan ruang ujian ramai kebisingan ruang ujian gaduh berisik bagan 1. pembentukan tema kebisingan ruang ujian berdasarkan pernyataan mahasiswa dan informan tentang kebisingan ruang ujian saat ujian skill lab yaitu: “…diluar rame..keburu pindah ruangan yang lain pula, soalnya masuknya gak barengan sih buk tiap ruangan..” (p3, p, 19 thn) “…suasana ruang ujiannya buk, gaduh banget kalo ujian…” (p4, l, 19 thn) koding kategori tema masuk gak barengan memulai barengan pengaturan waktu ujian timing ujian penguji telat bagan 2. pembentukan tema timing ujian bagan 2. pembentukan tema timing ujian berdasarkan hasil analisa kualitatif yang melibatkan mahasiswa, dosen dan laboran didapatkan pernyataan yaitu: “…coba aja kalo pengujinya itu masuknya barengan semua, jadi khan memulainya bareng…” (p2, p, 18 thn) “…pengujinya beberapa ada yang suka datang telat dan memberikan kelonggran waktu kepada mahasiswa yang tidak menguasai skill lab sehingga mengganggu timing saat ujian” (i5, p, 34 thn) berdasarkan hasil analisa kualitatif yang melibatkan mahasiswa, dosen dan laboran didapatkan pernyataan yaitu: “…coba aja kalo pengujinya itu masuknya barengan semua, jadi khan memulainya bareng…” (p2, p, 18 thn) “…pengujinya beberapa ada yang suka datang telat dan memberikan kelonggran waktu kepada mahasiswa yang tidak menguasai skill lab sehingga mengganggu timing saat ujian” (i5, p, 34 thn) koding kategori tema ruangan panas suhu ruang ujian temperatur ruangan bagan 3. pembentukan tema temperatur ruangan berdasarkan pernyataan mahasiswa dan informan tentang suhu ruang ujian yaitu: “…ruangannya panas…” (p5, p, 19 thn) “…hanya saja ruangan agak panas…(i2, l, 35th) koding kategori tema persiapan ruangan pengkondisian ruang ujian persiapan lingkungan bagan 4. pembentukan tema persiapan lingkungan berdasarkan pernyataan informan tentang persiapan lingkungan ruang ujian skill lab yaitu: “..persiapan ruangan untuk ujian skill lab oleh petugas laboratorium pada h-2 pelaksanaan ujian..” (i5, p, 27th) berdasarkan hasil analisa kualitatif yang melibatkan mahasiswa, dosen dan laboran di dapatkan empat tema yaitu kebisingan ruang ujian, timing ujian, temperatur ruangan dan persiapan lingkungan. pembahasan a. karakteristik responden (jenis kelamin dan usia) pada penelitian ini lebih dari separuh responden adalah perempuan mengalami kecemasan ringan. dari hasil uji statistik kruskal wallis menunjukkan bahwa jenis kelamin memiliki pengaruh signifikan terhadap kecemasan. hal tersebut didukung oleh penelitian sebelumnya yang dilakukan oleh lallo, et al (2013) bahwa mahasiswa perempuan memiliki kemungkinan hampir tiga kali untuk mengalami kecemasan daripada lakilaki. menurut kaplan & sadock (2010) menyatakan bahwa wanita lebih sering mengalami kecemasan daripada pria. wanita memiliki tingkat kecemasan yang lebih tinggi dibandingkan pria. hal ini dikarenakan bahwa wanita lebih peka dengan emosinya, yang pada akhirnya mempengaruhi perasaan cemasnya. sehingga dalam hal ini jenis kelamin mempengaruhi kecemasan mahasiswa menghadapi ujian skill lab. untuk usia, pada penelitian ini sebagian besar responden berusia 19 tahun, dan dari hasil uji statistik dengan kruskal wallis menunjukkan bahwa usia tidak berpengaruh terhadap kecemasan mahasiswa. menurut ramaiah (2007) menyatakan bahwa kriteria diagnostik untuk gangguan kecemasan pada umumnya adalah berusia 18 tahun atau lebih. tingkat maturasi individu akan mempengaruhi tingkat kecemasan. kecemasan pada remaja mayoritas disebabkan oleh perkembangan seksual. pada dewasa berhubungan dengan ancaman konsep diri, dimana konsep diri merupakan pengetahuan individu tentang diri (wigfield dan karpathian, 1991 dalam potter & perry, 2010). skill tes sangat relevan terjadi pada kalangan mahasiswa dalam hal ini mahasiswa keperawatan (yang et al, 2014). data tersebut memperlihatkan bahwa dalam usianya, mereka berusaha untuk mencari solusi atau memperbaiki situasi dalam menyelesaikan masalah yang sedang mereka alami, sehingga bisa menekan kecemasan dengan strategi koping. bagan 3. pembentukan tema temperatur ruangan berdasarkan pernyataan mahasiswa dan informan tentang suhu ruang ujian yaitu: “…ruangannya panas…” (p5, p, 19 thn) “…hanya saja ruangan agak panas…(i2, l, 35th) berdasarkan hasil analisa kualitatif yang melibatkan mahasiswa, dosen dan laboran didapatkan pernyataan yaitu: “…coba aja kalo pengujinya itu masuknya barengan semua, jadi khan memulainya bareng…” (p2, p, 18 thn) “…pengujinya beberapa ada yang suka datang telat dan memberikan kelonggran waktu kepada mahasiswa yang tidak menguasai skill lab sehingga mengganggu timing saat ujian” (i5, p, 34 thn) koding kategori tema ruangan panas suhu ruang ujian temperatur ruangan bagan 3. pembentukan tema temperatur ruangan berdasarkan pernyataan mahasiswa dan informan tentang suhu ruang ujian yaitu: “…ruangannya panas…” (p5, p, 19 thn) “…hanya saja ruangan agak panas…(i2, l, 35th) koding kategori tema persiapan ruangan pengkondisian ruang ujian persiapan lingkungan bagan 4. pembentukan tema persiapan lingkungan berdasarkan pernyataan informan tentang persiapan lingkungan ruang ujian skill lab yaitu: “..persiapan ruangan untuk ujian skill lab oleh petugas laboratorium pada h-2 pelaksanaan ujian..” (i5, p, 27th) berdasarkan hasil analisa kualitatif yang melibatkan mahasiswa, dosen dan laboran di dapatkan empat tema yaitu kebisingan ruang ujian, timing ujian, temperatur ruangan dan persiapan lingkungan. pembahasan a. karakteristik responden (jenis kelamin dan usia) pada penelitian ini lebih dari separuh responden adalah perempuan mengalami kecemasan ringan. dari hasil uji statistik kruskal wallis menunjukkan bahwa jenis kelamin memiliki pengaruh signifikan terhadap kecemasan. hal tersebut didukung oleh penelitian sebelumnya yang dilakukan oleh lallo, et al (2013) bahwa mahasiswa perempuan memiliki kemungkinan hampir tiga kali untuk mengalami kecemasan daripada lakilaki. menurut kaplan & sadock (2010) menyatakan bahwa wanita lebih sering mengalami kecemasan daripada pria. wanita memiliki tingkat kecemasan yang lebih tinggi dibandingkan pria. hal ini dikarenakan bahwa wanita lebih peka dengan emosinya, yang pada akhirnya mempengaruhi perasaan cemasnya. sehingga dalam hal ini jenis kelamin mempengaruhi kecemasan mahasiswa menghadapi ujian skill lab. untuk usia, pada penelitian ini sebagian besar responden berusia 19 tahun, dan dari hasil uji statistik dengan kruskal wallis menunjukkan bahwa usia tidak berpengaruh terhadap kecemasan mahasiswa. menurut ramaiah (2007) menyatakan bahwa kriteria diagnostik untuk gangguan kecemasan pada umumnya adalah berusia 18 tahun atau lebih. tingkat maturasi individu akan mempengaruhi tingkat kecemasan. kecemasan pada remaja mayoritas disebabkan oleh perkembangan seksual. pada dewasa berhubungan dengan ancaman konsep diri, dimana konsep diri merupakan pengetahuan individu tentang diri (wigfield dan karpathian, 1991 dalam potter & perry, 2010). skill tes sangat relevan terjadi pada kalangan mahasiswa dalam hal ini mahasiswa keperawatan (yang et al, 2014). data tersebut memperlihatkan bahwa dalam usianya, mereka berusaha untuk mencari solusi atau memperbaiki situasi dalam menyelesaikan masalah yang sedang mereka alami, sehingga bisa menekan kecemasan dengan strategi koping. bagan 4. pembentukan tema persiapan lingkungan berdasarkan pernyataan informan tentang persiapan lingkungan ruang ujian skill lab yaitu: “..persiapan ruangan untuk ujian skill lab oleh petugas laboratorium pada h-2 pelaksanaan ujian..” (i5, p, 27th) berdasarkan hasil analisa kualitatif yang melibatkan mahasiswa, dosen dan laboran di dapatkan empat tema yaitu kebisingan ruang ujian, timing ujian, temperatur ruangan dan persiapan lingkungan. pembahasan a. karakteristik responden (jenis kelamin dan usia) pada penelitian ini lebih dari separuh responden adalah perempuan mengalami kecemasan ringan. dari hasil uji statistik kruskal wallis menunjukkan bahwa jenis kelamin memiliki pengaruh signifikan terhadap kecemasan. hal tersebut didukung oleh penelitian sebelumnya yang dilakukan oleh lallo, et al (2013) bahwa mahasiswa perempuan memiliki kemungkinan hampir tiga kali untuk mengalami kecemasan daripada laki-laki. menurut kaplan & sadock (2010) menyatakan bahwa wanita lebih sering mengalami kecemasan daripada pria. wanita memiliki tingkat kecemasan yang lebih tinggi dibandingkan pria. hal ini dikarenakan bahwa wanita lebih peka dengan emosinya, yang pada akhirnya mempengaruhi perasaan cemasnya. sehingga dalam hal ini jenis kelamin mempengaruhi kecemasan mahasiswa menghadapi ujian skill lab. untuk usia, pada penelitian ini sebagian besar responden berusia 19 tahun, dan dari hasil uji statistik dengan kruskal wallis menunjukkan bahwa usia tidak berpengaruh terhadap kecemasan mahasiswa. menurut ramaiah (2007) menyatakan bahwa kriteria diagnostik untuk gangguan kecemasan pada umumnya adalah berusia 18 tahun atau lebih. tingkat maturasi individu akan mempengaruhi tingkat kecemasan. kecemasan pada remaja mayoritas disebabkan oleh perkembangan seksual. pada dewasa berhubungan dengan ancaman konsep diri, dimana konsep diri merupakan pengetahuan individu tentang diri (wigfield dan karpathian, 1991 dalam potter & perry, 2010). skill tes sangat relevan terjadi pada kalangan mahasiswa dalam hal ini mahasiswa keperawatan (yang et al, 2014). data tersebut memperlihatkan bahwa dalam usianya, mereka berusaha untuk mencari solusi atau memperbaiki situasi dalam menyelesaikan masalah 82 yang sedang mereka alami, sehingga bisa menekan kecemasan dengan strategi koping. hal tersebut seiring dengan konsep strategi koping (ahyar,2010) yang menyatakan bahwa faktor yang mempengaruhi strategi koping salah satunya adalah dengan ketrampilan memecahkan masalah dan kesehatan fisik. dan hal tersebut juga didukung bahwa semua responden dalam keadaan sehat saat dilakukan penelitian. b. pengaruh situasional terhadap kecemasan mahasiswa menghadapi ujian skill lab dari hasil penelitian, tingkat kecemasan responden lebih dari separuh berada pada level ringan dialami oleh responden wanita berada pada usia 19 tahun. menurut peplau (1952) dalam suliswati (2014) bahwa cemas ringan dihubungkan dengan ketegangan yang dialami sehari-hari. individu masih waspada serta lapang persepsinya meluas, menajamkan indra. dapat memotivasi individu untuk belajar dan mampu memecahkan masalah secara efektif dan menghasilkan pertumbuhan dan kreatifitas. pada penelitian ini mahasiswa masih berada pada level ringan sehingga mereka mampu memecahkan masalah secara efektif dan menghasilkan pertumbuhan dan kreatifitas. kemudian hal tersebut di dukung oleh dosen dan laboran yang menyatakan persiapan mereka selama pembelajaran praktikum dan saat akan menguji serta pernyataan mereka saat menjumpai mahasiswa yang mengalami kecemasan, yaitu dengan menanyakan kesiapan mahasiswa sebelum memulai ujian dan menenangkan mahasiswa. laboran menyiapkan ruangan dengan mengatur jarak penguji dengan mahasiswa, membuat tata tertib untuk dosen dan mahasiswa yang harusnya dipatuhi. dengan hasil data tersebut, maka mahasiswa sebagian besar mengalami kecemasan yang masih ringan dan dapat diatasi dengan mekanisme koping individu dan strategi koping mereka, sehingga situasional berada pada level yang tidak berpengaruh secara signifikan secara kuantitatif. berdasarkan hasil kualitatif dengan menanyakan kembali jawaban dari kuesioner yang digunakan bahwa separuh dari responden berasumsi bahwa faktor lingkungan mempengaruhi terhadap kecemasan. dari uji statistik kruskal wallis menunjukkan bahwa faktor lingkungan tidak berpengaruh secara signifikan terhadap kecemasan mahasiswa. hasil fgd dengan mahasiswa, bahwa mereka tidak nyaman dengan lingkungan yang ramai dan panas serta pengaturan waktunya. pada hasil rekapitulasi kuesioner nstas bahwa pilihan netral dari responden lebih cenderung setuju terhadap pertanyaan tentang situasi lingkungan ujian. keefektifan suatu pembelajaran pada mahasiswa dipengaruhi pula oleh dukungan fasilitas untuk menjadi bagian dari suatu tim. jika lingkungan tidak terstruktur dengan baik, hal ini dapat membuat mahasiswa mudah terancam dan mengalami kecemasan (papastavrou, e, et al, 2010). dimana untuk hal tersebut juga sudah diatur dalam kemenkes ri (2010), mengenai manajemen iklim pembelajaran laboratorium. faktor lingkungan fisik merupakan faktor dimana pengajaran dilakukan sehingga membuat proses belajar menjadi menyenangkan atau menjadi suatu pengalaman yang menyulitkan. dalam hal ini, harus memilih lingkungan yang membantu untuk memfokuskan diri pada tugas pembelajaran. jumlah peserta yang diajar, kebutuhan untuk ketenangan, temperatur ruangan, pencahayaan, kebisingan, ventilasi udara, dan perabot ruangan sangat penting ketika memilih tempat (potter & perry, 2010). dari hasil fgd dengan mahasiswa menjelang ujian, bahwa mereka menyatakan ada beberapa penguji yang telat sehingga mengganggu timing ujian yang terbatas dan waktu memulainya tidak bersamaan. ping et al,(2008) menyatakan bahwa yang menyebabkan performa mahasiswa mengalami penurunan yaitu kegugupan akibat pembatasan waktu, kurangnya pemahaman materi, pasien tidak kooperatif, perasaan tertekan dan kurang percaya diri. saat osce mahasiswa mengalami kesulitan dalam manajemen waktu dan hal tersebut menyebabkan timbulnya perasaan tertekan (esswi et al, 2013). 83 vol. 1 no. 1 desember 2016 strategi koping mampu menekan kecemasan mahasiswa, seperti yang dilakukan oleh mahasiswa saat menghadapi ujian yaitu dengan mencari lingkungan yang tenang dengan tidak mendengarkan keramaian yang dilakukan oleh mahasiswa yang lain sehingga kecemasan mahasiswa masih berada pada level ringan. maka dalam penelitian ini walaupun secara kuantitatif didapatkan hasil yang tidak signifikan terhadap kecemasan, tetapi sebenarnya bagi mahasiswa situasional cenderung mempengaruhi timbulnya kecemasan. dari kecenderungan tersebut mahasiswa menggunakan strategi koping untuk meminimalkan kecemasan mereka menjelang ujian skill lab. kesimpulan pada penelitian ini disimpulkan bahwa kecemasan mahasiswa berada pada tingkat ringan, dan terdapat pengaruh faktor situasional/lingkungan terhadap kecemasan mahasiswa program studi d iii keperawatan stikes banyuwangi dalam menghadapi ujian skill lab. hasil ini diharapkan ada tindak lanjut untuk mahasiswa, dosen, dan laboran dari pihak terkait untuk mengatasi kecemasan mahasiswa menghadapi ujian skill lab terkait situasional atau suasana saat ujian skill lab bahwa perlunya standarisasi ruang ujian yang nyaman untuk mahasiswa dan penguji serta mahasiswa dapat memilih atau menggunakan strategi koping yang lebih tepat dalam mengatasi kecemasan menjelang ujian skill lab. daftar pustaka ahyar. (2010). konsep diri dan mekanisme koping dalam aplikasi keperawatan. (diakses 9 agustus 2015). tersedia dari: www.e-psikologi.com arief, s., & sumarni. (2013). hubungan kecemasan menghadapi ujian skills lab modul shock dengan prestasi yang dicapai pada mahasiswa fk universitas gajah mada angkatan 2000. diakses 5 mei 2013 dari http://www.ebookspdf.org/download/kecemasan.html basuki, i., & hariyanto. (2015). asesmen pembelajaran. remaja rosdakarya offset. bandung. dikti. (2016). uji kompetensi nasional progam pendidikan d3 keperawatan untuk profesionalitastenaga perawat. diakses 19 april 2016 dari http://belmawa.ristekdikti.go.id esswi,a., badawy, a.s., & shaliabe,h. (2013). osce in maternity and community health nursing: saudi nursing student’s perspective. american journal of research communication, vol.1, no.3, 143-162 kaplan, hi, saddock, bj & grabb, ja. (2010). kaplan-sadock sinopsis psikiatri ilmu pengetahuan prilaku psikiatri klinis. bina rupa aksara. tangerang. kemenkes ri. (2010). standart laboratorium keperawatan pendidikan tenaga kesehatan. jakarta: badan ppsdm kesehatan lallo, d.a., kandou, l. f. j., & munayang, h. (2013). hubungan kecemasan dan hasil ujian uas-1 mahasiswa baru fakultas kedokteran universitas sam ratulangi manado tahun ajaran 2012/2013. e-journal universitas sam ratulangi. vol 1, no 2. papastavrou, e., lambrinou, e., tsangari, h., saarikoski, m. & leino-kilpi, h. (2010). student nurses experience of learning in the clinical environment. nurse education in practice, vol. 10, no. 3, pp. 176-82 ping, l.t., subramaniam, k., & krishnaswamy, s. (2008). original article test anxiety : state , trait and relationship with exam. , 15(2). potter, p.a & perry, a.g. (2010). buku ajar fundamental keperawatan: konsep, proses, dan praktik.edisi 4.volume 1.alih bahasa: yasmin asih, dkk. jakarta, egc pratiwi, c., & mufdlillah. (2009). faktor-faktor yang mempengaruhi hasil uji kompetensi dengan metode osca lulusan diii kebidanan di propinsi diy. ramaiah. (2007). kecemasan: bagaimana mengat asi penyebabnya. pustaka obor. jakarta. rasmun. (2009). stress koping dan adaptasi. cv. sagung seto. jakarta suliswati. (2014). konsep dasar keperawatan kesehatan jiwa. egc. jakarta. tim bahan penyusunan kurikulum aipdiki. (2014). bahan pengembangan kurikulum prodi d iii keperawatan. asosiasi institusi pendidikan diploma iii keperawatan regional 6 jawa timur. surabaya. yang, r., lu, y., chung, m. & chang, s. (2014). developing a short version of the test anxiety scale for baccalaureate nursing skills test a preliminary study. nurse education in practice, vol. 14, no. 6, pp. 586-590. indonesian journal of nursing practices 54 indonesian journal of nursing practices shanti wardaningsih1, dian pepriana widyaningrum1 1 program studi ilmu keperaw atan fkik, universitas muhammadiyah yogyakarta korespondensi: shanti wardaningsih email: shanti.w ardaningsih@umy.ac.id pengaruh intervensi doa dan dz ikir a l ma’tsurat terhadap s kor d epresi p ada pasien diab etes m elitus di p uskesmas mlati 1 info artikel online issn doi : : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.2179 abstrak latar belakang : di abetes mel i tus merupakan penyaki t metabol i k yang dapat menyebabkan depres i . penanganan depres i dapat di l akukan s ecara farmakol ogi dan non -farmakol ogi . sal ah s atu penanganannya dengan doa dan dzi ki r al -ma’ts urat. metode i ni mempunyai manfaat s eperti kenyamanan dan ketenangan pada hati terutama keti ka mengal ami depresi . tujuan : untuk mengetahui pengaruh doa dan dzi ki r al -ma’ts urat terhadap s kor depres i pas i en di abetes mel i tus di pus kes mas ml ati 1. metode : quasy experiment with (non equivalent control group) pretest posttest. juml ah s ampel 34 res ponden terdi ri dari 17 res ponden kel ompok kontrol dan 17 res ponden kel ompok i ntervens i dengan tekni k purpossive samping untuk menentukan kel ompok kontrol dan i ntervens i dengan menggunakan i ntervens i doa dan dzi ki r al -ma’ts urat. data di uj i dengan uj i parametri k pai red t-test dan independent t-test. hasil : terdapat pengaruh doa dan dzi ki r al -ma’ts urat terhadap s kor depres i pas i en di abetes mel i tus . has i l paired t-test kel ompok kontrol ni l ai p value =0,350 ti dak terdapat pengar uh s i gni fi kan. sedangkan kel ompok i ntervens i ni l ai p value=0,000, menunj ukkan adanya pengaruh i ntervens i doa dan dzi ki r al -ma’ts urat. anal i s a dengan menggunakan independent t-test, di dapatkan p value =0,000 pada post-test kedua kel ompok menunj ukkan perbeda an s ecara s i gni fikan. has i l dari penel i ti an i ni dapat di gunaka n s eb a ga i as uhan keperawatan hol i s ti k dal am penanganan depres i pas i en diabetes mel i tus . kesimpulan : terdapat pengaruh doa dan dzi ki r al -ma’ts urat terhadap s kor depres i pas i en di abetes mel i tus . kata kunci : doa dan dzi ki r al -ma’ts urat, depres i , di abetes mel i tus abstract background: diabetes mellitus is a metabolic disease that can cause depression. treatment of depression can be done pharmacologically and non-pharmacologically. one of non-pharmacology treatment is with prayer and dhikr al-ma'tsurat. this method has benefits such as comfort and tranquility in the mind especially when someone is depressed. objective: the study is to know the influence of prayer and dhikr alma'tsurat against depression score of diabetes mellitus patient at the public health centre (phc) mlati 1. mailto:muda101180@gmail.com 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/3481 vol. 2 no. 2 desember 2018 55 method: quasi-experiment with pretest-posttest (non-equivalent control group). the sample size of 34 respondents consisted of 17 control group respondents and 17 respondents of the intervention group with purposive sampling technique to determine the control group and intervention by using the intervention of prayer and dhikr al-ma'tsurat. data were tested with parametric paired t-test and independent t-test. result: there is an influence of prayer and dhikr al-ma'tsurat against depression score of diabetes mellitus patient. result paired t-test control group value p-value = 0.350 there is no significant influence. while the intervention group value p -value = 0,000, indicating the influence of prayer intervention and dhikr alma'tsurat. analysis of independent t-test p-value = 0.000 in the post-test of both groups showed significant differences. the results of this study can be used as holistic nursing care in the treatment of diabetes mellitus patients depression. conclusion: there is the influence of prayer and dhikr al-ma'tsurat against depression scores of patients with diabetes mellitus. keywords: prayer and dhikr al-ma'tsurat, depression, diabetes mellitus. mukhripah i¹, dwi r pendahuluan diabetes melitus merupakan suatu penyakit metabolik yang memiliki ciri-ciri tingginya kadar gula dalam darah disertai munculnya gejala khas seperti sering buang air kecil, rasa haus dan lap ar yang berlebihan serta berat badan menurun drastis tanpa sebab yang jelas, karena adanya kerusakan sekresi insulin, kerja insulin atau secara bersamaan (purnamasari, 2010). world health organization (who) telah memperkirakan diabetes melitus merupakan faktor risiko tinggi kematian ketiga setelah hipertensi dan penggunaan rokok, dan jumlah pasien diabetes melitus sebanyak 320,5 juta jiwa. indonesia menempati posisi ketujuh terbanyak pasien diabetes melitus (international diabetes federation, 2015). hasil riset kesehatan dasar di daerah istimewa yogyakarta pada tahun 2013, angka kejadian diabetes melitus sebesar2,6% dan menempati urutan pertama dari seluruh provin si di indonesia. menurut undang-undang nomor 38 (2014) dalam bab 1 ketentuan umum pasal 1 mengatakan bahwa keperawatan adalah kegiatan pemberian asuhan kepada individu, keluarga, kelompok, atau masyarakat, baik dalam kead aan sakit maupun sehat”. pentingnya asuhan keperawatan bagi individu maupun kelompok masyarakat yang mengalami diabetes melitus dalam keadaan sakit maupun sehat. dalam pelayanan keperawatan, ruang lingkup dan batasannya sudah ditetapkan pada lokakarya nasional tentang pengertian keperawatan tah u n 1983 sebagai berikut “keperawatan adalah suatu bentuk pelayanan profesional yang merupakan bagian integral dari pelayanan kesehatan, didasarkan pada ilmu dan kiat keperawatan, berbentuk pelayanan bio-psiko-sosial-spiritual yang komprehensif, ditujukan kepada individu, keluarga dan masyarakat baik sakit maupun sehat yang mencakupseluruh proses kehidupan manusia” (kusnanto 2004). pada fenomena saat ini perawat terkadang lalai memperhatikan bagaimana gambaran psikologi pasien diabetes melitus dan mereka lebih fokus pada fisiknya saja. dalam kondisi penyembuhan yang lama serta biaya banyak menjadikan pasien dan keluarga berada pada keadaan depresi. depresi merupakan suatu keadaan mental yang menurun, ditandai dengan kesedihan, perasaan putus asa dan tidak bersemangat (dorland, 2002). masalah yang ada adalah stress situasional seperti kurangnya pengetahuan, problem lingkungan dan ekonomi yang tidak diharapkan, dapat menyebabkan masalah dalam penyembuhan indonesian journal of nursing practices 56 pasien diabetes melitus (firdaus, 2013). prevalensi gangguan mental emosional pada penduduk indonesia 6,0 %. provinsi dengan prevalensi ganguan mental emosional tertinggi adalah sulawesi tengah, sulawesi selatan, jawa barat, di yogyakarta, dan nusa tenggara timur (riskesdas, 2013). tingginya kejadian ini perlu adanya penanganan khusus bagi psikologi pas i e n diabetes melitus. untuk menangani masalah depresi yang dialami pasien diabetes melitus dapat menggunaan terapi farmakologi seperti antidepresan tetapi ketika menjalankan terapi ini harus mengetahui efek samping dan tepat dosis (prasetyo, 2015) dan juga terapi non farmakologi seperti psikoterapi yaitu dengan menyelidiki pemicu depresi, mengenali masalah, memperbaiki hubungan, membantu meningkatkan kepercayaan diri dan mengubah kualitas hidup menjadi lebih baik (canfield, 2016) dengan terapi dzikir dapat mengurangi kecemasan atau depresi (wulandari, 2013). disisi lain seperti apa yang disebutkan dalam al-qura’an dalam surat ar-ra’du ayat 28 yang artinya ”(yaitu) orangorang yang beriman dan hati mereka menjadi tentram dengan mengingat allah. ingatlah, hanya dengan mengingat allah hati menjadi tentram”. doa dan dzikir merupakan ruhnya ibadah sebagai bentuk rasa syukur kita kepada al lah dan pengontrol hati yang efektif, serta dapat membentengi diri dari keburukan. doa dan dzi k i r al-ma’tsurat merupakan kumpulan doa, dzikir dan ayat al-qur’an yang ditulis oleh hasan al banna memiliki arti indah akan dapat menenangkan hati pembacanya (al-banna, 2007). doa dan dzikir al-ma’tsurat memiliki banyak manfaat yang sangat membantu dalam pengurangan skor depresi pada seseorang. metode jenis penelitian ini termasuk rancangan quasy experiment untuk menilai pengaruh doa dan dzikir al-ma’tsurat terhadap skor depresi pasien diabetes melitus. penelitian ini menggunakan pre test dan post test pada kelompok eksperimen dan kelompok kontrol (notoatmodjo, 2012). penderita diabetes melitus di puskesmas ml ati 1 berjumlah 210 penderita, dari jumlah tersebut peneliti mengambil 30 orang pasien diabetes melitus untuk dijadikan perwakilan dari pop u l as i penderita diabetes melitus, karena dengan populasi 30 orang dapat mewakili keakuratan populasi (dempsey, 2002). sampel dari penelitian ini adalah sebagian dari pasien diabetes melitus di wilayah puskesmas mlati. dengan menggunakan pengambilan sampel berupa purposive sampling dengan cara menentukan sampel yang sesuai dengan yang dikehendaki peneliti, sehingga sampel tersebut dapat mewakili karakteristik tersebut (nursal am, 2008). jumlah sampel sebanyak 30 sampel dengan ditambah 10% untuk mengatasi masalah penyimpangan populasi atau jika terdapat e k l u si jadi total keseluruhan 34 yang terdiri dari 17 kelompok intervensi dan 17 kelompok kontrol (notoatmodjo, 2012). hasil analisa univariat untuk mendistribusikan frekuensi variabel yang terdiri dari usia, jenis kelamin, pengkonsumsian obat, lama me n d e rita diabetes melitus serta skor depresi pada p re d an post test pada responden. kemudian menganalisa bivariat yaitu dengan menguji normalitas apakah data terdistribusi normal atau tidak dengan menggunakan shapiro wilk karena sampel kurang dari 50. dari hasil uji normalitas didapatkan pada kelompok kontrol nilai sig>0,05 terdistribusi normal dan pada kelompok intervensi pre test nilai sign>0,05 dan post test nilai sign <0,05 kemudian dilakukan uji compute pre test dan post test dan hasil akhinya keduany a nilai nilai sign > 0,05 dan terdistribusi normal. analisa data untuk mengetahui perubahan skor pre-post test dari transformasi data yang terdistribusi normal dan skala variabel numerik maka digunakan uji paired-t test hasil statistik akan didapatkan nilai signifikasi. jika nilai sig.>0,05 maka ho diterima dan ha ditolak, sebaliknya jika nilai sig.<0,05 maka ho ditolak dan ha diterima (nursalam, 2008). hasil analisa univariat gambaran karakteristik responden vol. 2 no. 2 desember 2018 57 tabel 1. distribusi frekuensi responden kelompok kontrol dan kelompok intervensi. berdasarkan data distribusi frekuensi karakteristik responden, didapatkan bahwa golongan usia responden terbanyak adalah usia > 55 tahun sebanyak 14 responden pada kelompok kontrol dan 12 responden kelompok intervensi. jenis kelamin terbanyak pada penelitian ini adalah perempuan sebanyak 12 responden pada kelompok kontrol dan 13 responden kelompok intervensi. lama menderita diabetes melitus terbanyak adalah 16 responden pada kelompok kontrol dan 16 responden kelompok intervensi. pengkonsumsian obat adalah rutin sebanyak 13 responden kelompok kontrol dan 13 responden kelompok intervensi. tabel 2. gambaran skor depresi pada kelompok kontrol dan intervensi. berdasarkan hasil penelitian skor depresi pada kelompok kontrol dan kelompok intervensi prepost test didapatkan nilai mean, std. deviation, minimum dan maximum pada gambaran depresi responden pasien diabetes melitus. uji normalitas setelah mendapatkan hasil pre-post dari kedua kelompok kemudian data dianalisis menggunakan shapiro-wilk karena sampel kurang dari 50. analisa dari masing-masing data diperoleh nila p> 0,05 yang menunjukkan sebaran data adalah normal. sebaran data normal merupakan syarat data tersebut menggunakan analisa stastik parametik (dahlan, 2014) tabel 3. sebaran data kelompok kontrol dan kelompok intervensi karakteristik responden kelompok kontrol kelompok intervensi jumlah (%) jumlah (%) us i a 36-45 (dewas a akhi r) 45-55(l ans i a awal ) >55(l ans i a akhi r) total 1 2 14 17 5,9 11,8 82,3 100 0 5 12 17 0 29,5 70,5 100 jeni s kel ami n perempuan laki -l aki total 12 5 17 70,6 29,4 100 13 4 17 76,5 23,5 100 lama menderi ta di abetes mel i tus <11 tahun >11 tahun total 16 1 17 94,1 5,9 100 16 1 17 94,1 5,9 100 pengkons ums i an obat ruti n jarang total 13 4 17 76,5 23,5 100 13 4 17 76,5 23,5 100 kelompok pre test post test kel ompok (kontrol ) mean std. devi ati on mi ni mum maxi mum 13,35 5,419 4 20 12,35 4,582 3 21 kel ompok (intervens i ) mean std. devi ati on mi ni mum maxi mum 10,24 5,032 3 20 6,24 4,493 1 17 kelompok uji shapiro-wilk (nilai p-value) keterangan kelompok kontrol pre test post test 0,144 0,890 normal normal kelompok intervensi pre test post test 0,900 0,562 normal normal indonesian journal of nursing practices 58 hasil dari analisis uji normalitas pada kedua kelompok data pada tabel 3, didapatkan hasil nilai p>0,05 sehingga dapat disimpulkan bahwa distribusi keseluruhan data adalah normal yang selanjutnya dianalisa dengan statistik parametri k paired t-test. analisa bivariat tabel 4. paired samples test (kelompok kontrol dan intervensi) keterangan mean std. deviation nilai t nilai pvalue kelompok kontrol pre testpost test 1,000 4,287 0,962 0,350 kelompok intervensi pre testpost test 0,27 0,22 4,965 0,000 berdasarkan hasil analisis statik dari paired t-tes t pada kelompok kontrol didapatkan nilai pvalue=0,350 (p>0,05), yang berarti tidak terdapat perbedaan yang bermakna. sedangkan pada kelompok intervensi didpatkan nilai pvalue=0,000 (p<0,05), nilai yang signifikan (p) yang kurang dari 0,05 menunjukkan adanya pengaruh dari intervensi doa dan dzikir al ma’tsurat yang telah diberikan. analisa ini u n tu k mengetahui adanya perbedaan yang signifikan dari hubungan antar variabel dalam satu kelompok. tabel 5. independent samples t-test (post test kelompok kontrol dan intervensi pada tabel di atas, nilai signifikasi pada po s t test kedua kelompok didapatkan nilai p-value= 0,000 hal ini menunjukkan bahwa nilai post-test pada kelompok kontrol dan intervensi berbeda s e cara signifikan. pembahasan penelitian ini dilakukan untuk mengetahui pengaruh intervensi doa dan dzikir al -ma’tsurat terhadap skor depresi pasien diabetes melitu s d i puskesmas mlati 1 sleman yogyakarta. karakteristik responden berdasarkan jenis kelamin, responden terban y ak adalah perempuan. gangguan psikologis de pre s i sering dikaitkan dengan stressor jangka panjang seperti penyakit diabetes melitus yang tidak dapat disembuhkan yang akan membuat timbulnya masalah depresi. perbedaan jenis kelamin pun juga dapat mempengaruhi skor depresi karena laki-laki mereka sering berpikir dengan menggunakan logika dan lebih memilih untuk langsung menghadapi sumber permasalahan tersebut beda dengan perempu an yang mana cenderung menggunakan perasaan dan mudah emosional (harista, 2016). menurut garnita (2012) faktor yang mempengaruhi jenis kelamin perempuan lebih banyak dari laki -laki antara lain dampak dari diabetes gestasional pada ibu dan bayi, tingginya pravelensi diabetes melitus pada wanita usia tua karena harapan hidup wanita lebih tinggi dari perempuan i n d ek s masa tubuh serta tekanan darah yang lebih tinggi pada wanita. dilihat dari segi usia terbanyak pasien diabetes melitus yang mengalami depresi adalah pada usia lebih dari 60 tahun, hal ini dikarenakan penurunan kualitas hidup yang membuat ban y ak lansia mengalami depresi. menurut djali dan sappaile, (2013), salah satu faktor yang mempengaruhi munculnya gejala depresi pada usia lanjut yaitu penyakit degeneratif salah satunya diabetes melitus yang berupa perubahan emosi, kognitif tingkah laku dan biologis akibat dari penurunan hidup pada lansia. seseorang yang berusia lebih dari 45 tahun memiliki peningkatan resiko diabetes melitus karena faktor degeneratif yaitu menurunya fungsi tub u h khususnya pada kemampuan sel β pankreas dalam memproduksi insulin (pangemanan, 2014). pada penelitian yang dilakukan oleh hannan, (2013), faktor yang mempengaruhi dalam kepatuhan pengkonsumsian obat salah satunya adalah dukungan emosional untuk mengurangi kelompok nilai p-value post-test kelompok kontrol dan kelompok intervensi 0,000 vol. 2 no. 2 desember 2018 59 anxietas dan depresi pasien diabetes melitus. ketika pasien patuh dalam mengkonsumsi obat, maka gula darah dalam tubuh pasien terkontrol dan jika gula darah terkontrol depresi yang dialaminya akan semakin berkurang, dari hasil penelitian didapatkan responden rutin dalam mengonsumsi obat sehingga tidak ada yang mengalami depresi berat. faktor yang mempengaruhi kepatuhan dalam pengkonsumsian obat yaitu pengetahuan pasien , sikap pasien dengan kapatuhan berobat, motivasi pasien dalam kepatuhan berobat (tombokan dkk, 2015 ). lama menderita diabetes kebanyakan dialami pasien kurang dari 11 tahun. berdasarkan penelitian ramdhani (2016) lama menderita diabetes minimal 9 bulan dan terlama 4 tahun. semakin lama pasien menderita diabe tes semakin berkurang depresi yang dialaminya, karena kebanyakan pasien mengalami depresi setelah diiagnosa diabetes melitus, yang akan menyebabkan banyak masalah sepeti pengendalian diet, biaya pengobatan dan ketakutan akan komplikasi lainnya (firdaus, 2013) pengaruh doa dan dzikir al-ma’tsurat terhadap skor depresi pada pasien diabetus melitus. depresi merupakan penyakit psikologis yang banyak berkaitan dengan penyakit kronis salah satunya diabetes melitus. banyak faktor yang menyebabkan terjadinya depresi pada pasien diabetes melitus. penelitian yang dilakuk an o l eh harista dan arief (2015) depresi pada pasien diabetes melitus berhubungan dengan buru k n ya kontrol gula darah, kurangnya motivasi dari keluarga, jenis kelamin dan rasa khawatir akan terjadinya komplikasi. berdasarkan hasil penilaian uji paired t-test didapatkan data yang tidak signifikan terjadinya penurunan pada kelompok kontrol nilai pvalue>0,05pada data pre-posttest. sedangkan hasil dari kelompok intervensi menunjukkan data terdapat pengaruh yang signifikan dengan nilai pvalue<0,05 pada data pre-posttest pada kelompok yang telah dilakukan intervensi doa dan dzikir al-ma’tsurat pada pasien diabetes melitus menurut kuswandari (2016) terapi dzikir memiliki efek memacu sinyal molekul dan neurotransmitter untuk mengeluarkan opiat endogen yaitu endorfin enkefalin yang akan menimbulkan rasa senang, bahagia, dan membuat respon tubuh menjadi rileks. seperti yang terdapat pada firman allah “ (yaitu) orangorang yang beriman dan hati mereka menjadi tentram dengan mengingat allah. ingatlah, hanya dengan mengingat allah hati menjadi tentram” (q.s. ar-ra’du ayat 28). efek inilah yang menjadikan depresi pasien diabetes melitus berkurang, karena hati menjadi rileks dan nyaman serta hati tentram. kesimpulan karakteristik responden sebagian besar berusia lebih dari 60 tahun, dan banyak yang berjenis kelamin perempuan, rata-rata lama menderita diabetes kurang dari 11 tahun dan pengonsumsian obat rutin. nilai skor depresi pada kelompok kontrol tanpa diberikan terapi doa dan dzikir al-ma’tsurat tidak terdapat pengaruh pada penurunan depresi. sedangkan nilai skor depresi pada kelompok intervensi setelah diberikan intervensi doa dan dzikir al ma’tsurat terdapat pengaruh pada penurunan skor depresi. perbedaan skor depresi antara kelompok kontrol dan kelompok intervensi juga menunjukkan perbedaan secara signifikan. rekomendasi untuk perawat, dalam memberikan intervensi pada pasien diabetes melitus, hendaknya juga tetap memperhatikan faktor psikospiritual, sehingga intervensi yang diberikan bias lebih komprehensif, salah satunya dengan menganjurkan pasien yang beragama islam untuk melakukan dzikir dan doa, demikian juga de n gan pasien yang beragama lain dengan cara yang dianjurkan dalam agamanya. referensi al-banna, h. (2007). doa dan dzikir al-ma’tsurat sugra. surakarta : penerbit media insani. badan penelitian dan pengembangan kes eh atan kementrian kesehatan ri . (2013). riset kesehatan dasar. riskesdas. 126. canfield, n. (2016). dahsyatnya kekuatan berpikir positif. banana books. 32. dahlan, m. sopiyudin. (2014). statistik untuk kedokteran dan kesehatan. edisi 6. jakarta:epidemiologi. 14 indonesian journal of nursing practices 60 demspey, p. a. (2002). nursing research : text and work book (palupi widyastuti tran s ) . jakarta . egc. 92. departemen agama ri. (2009). al-qur’an dan terjemahannya. bandung : cv. media fitrah rabbani djaali, n.s. dan sappaile, nursiah. (2013). a systematic review : group counselling for older people with depression. 2nd international seminar on quality and affordable education (isqae 2013) dorland, w. a. n. (2002). kamus kedokteran dorland. (harawati hartono dkk, penerjemah) editor edisi bahasa indonesia, huriawati hartono dkk. ed.29. jakarta:egc. 588 (buku asli diterbitkan 2000). firdaus, a. (2013). hubungan lamanya menderita diabetes melitus tipe 2 terhadap tingkat depresi pada pasien poli penyakit dalam rsd dr. soebandi jember. karya tulis ilmiah strata satu. universitas jember, jember. garnita, dita. (2012). faktor risiko diabetes melitus di indonesia (analisa data sakerti 2007). karya tulis ilmiah strata satu. universitas indonesia. depok hanan, m. (2013). analisis faktor yang mempengaruhi kepatuhan minum obat pada pasien diabetes melitus di puskesmas bluto sumenep. jurnal kesehatan “wiraraja medika”. harista, r.a. (2016). perbedaan tingkat depresi pada penderita diabetes melitus tipe 2 antara pria dan wanita di puskesmas kedaton bandar lampung. karya tulis ilmiah strata satu. universitas lampung. international diabetes federation. (2015). idf diabetes atlas. 7th ed. 50-52. kusnanto. (2004). pengantar profesi dan praktik keperawatan profesional. jakarta: egc. 29. kuswandari, r.p. 2016. pengaruh dzikir untuk mengurangi skala nyeri pada ibu post sectio caesarea (sc).karya tulis ilmiah strata satu. universitas muhammadiyah yogyakarta. yogyakarta. notoatmodjo, s. (2012). metodologi penelitian kesehatan. jakarta: rineka cipta. hal 127. nursalam. (2008). konsep dan penerapan metodelogi penelitian ilmu keperawatan. jakarta : salemba medika. pangemanan d, mayulu n. (2014) analisis faktor resiko penyebab terjadinya diabetes melitus tipe 2 pada wanita usia produktif dipuskesmas wawonasa. jurnal e-biomedik. prasetyo, n. (2015). identifikasi advice drug reaction (adr) penggunaan obat antidepresan pada pasien depresi ra w a t jalan di rumah sakit jiwa daerah surakarta periode agustus tahun 2015. karya tulis ilmiah strata satu, universitas muhammadiyah surakarta, surakarta. purnamasari, d. (2010). metabolic syndrome. acta med indonesia, vol. 42. no.4 : 185186. jakarta ramdani, m. i. (2016). gambaran tingkat depres i pada pasien diabetus melitus tipe 2 di rumah sakit umum kardinah kota tegal. karya tulis ilmiah strata satu. uin syarif hidayatullah, jakarta. tombokan, v. , rattu, a. j. dan tilaar, ch. r. 2015. faktor-faktor yang berhubungan dengan kepatuhan berobat pasien diabetes melitus pada praktek dokter keluarga di kota tomohon. artikel penelitian. jikmu, vol. 5. no. 2, april 2015. undang-undang republik indonesia. (2014). tentang keperawatan nomor 38. world health organization. (2016). global report on diabetes. diakses pada 20 desember 2016, dari www.who.int. wulandari, f. (2013). efektifitas terapi dzikir dalam menurunkan stress. karya tulis ilmiah strata satu. uin sunan ampel, surabaya. http://www.inaactamedica.org/archives/2010/21063037.pdf http://www.who.int/ 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 indonesian journal of nursing practices 22 indonesian journal of nursing practices siti khuzaiyah1, milatun khanifah1, nur chabibah1 1 stikes muhammadiyah pakajangan pekalongan korespondensi: siti khuzaiyah email korespondensi: khuzaiyahpenulis@gmail.com evaluasi pencatatan & pemanfaatan buku kesehatan ibu dan anak (kia) oleh bidan, ibu dan keluarga info artikel online issn doi : : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.2175 abstrak angka kemati an ibu (aki) di indones i a s aat i ni mas i h ti nggi 359/100.kh. pel ayanan kes ehatan antenatal di fas i litas kes ehata n pemeri ntah maupun s was ta dan prakti k perorangan/kel ompok perl u di l aks anakan s ecara komprehens i f dan terpadu, mencakup upaya promoti f, preventi f, kurati f s ekal i gus rehabi l i tati ve. sal ah s atu i ns trument untuk menurunkan aki/akb adal ah buku kes ehatan ibu dan anak (kia). tuj uan penel i ti an i ni adal ah untuk mengetahui gambaran pemanfaatan buku kia ol eh i bu dan kel uarga di wi l ayah kerj a di nas kes ehatan kabupaten pekal o n ga n tahun 2016-2017. jeni s penel i ti an descriptive analytic dengan des ai n penel i ti an cross sectional. tehni k s ampl i ng dengan stratified random sampling dengan total s ampel 63. anal i s i s menggunakan analisis univariate. has i l penel i ti an i ni menunj ukkkan pemanfaatan buku kia menunj ukkan l ebi h dari s eparuh i bu kadang-kadang memanfaatkan buku kia (58,7%) dan 33,3 % i bu dan kel uarga embaca buku kia bers ama dengan bi dan. tenaga kes ehatan agar s el al u menggunkan buku k ia s ebagai medi a edukas i s ehi ngga i bu dan kel uarga termoti vas i untuk memanfaatkan buku kia s ecara l ebi h opti mal . kata kunci : pemanfaatan, buku kes ehatan ibu dan anak (kia), ibu dan kel uarga abstract. mortality mother rate (mmr) in indonesia in by 2012 is 359 / 100,000 kh. antenatal health services in public and private health facilities and individual / group practices need to be implemented comprehensively and integrated, including promotive, preventive, curative and rehabilitative efforts. one of the instruments to decrease mmr/imr is maternal and child health book (mch/kia book). the purpose of this research is to know the description of mch book recording and utilization by health officer and family in the working area of pekalongan regency health office 2016-2017. the study design was cross sectional. sampling technique with stratified random sampling with total sample 63. analysis using univariate analysis. the results of this study indicate that the use of mch books shows that more than half of mothers sometimes use the mch handbook (58.7%) and 33.3% of mothers and families read mailto:khuzaiyahpenulis@gmail.com 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/3667 vol. 2 no. 1 juni 2018 23 the mch handbook along with the midwife. health workers should always use the mch book as an educational medium so that mothers and families are motivated to use the mch handbook more optimally. keywords: utilization, maternal and child health book (mch), mother and family mukhripah i¹, dwi r pendahuluan angka kematian ibu (aki) di indonesia saat ini telah berhasil diturunkan dari 307/100.000 kelahiran hidup (kh) pada tahun 2002 menjadi 227/100.000 kh pada tahun 2007 (sdki, 2007). akan tetapi, aki kembali meningkat me njadi 359/100.000 kh pada tahun 2012 (sdki). faktor yang berkontribusi terhadap kematian ibu, secara garis besar dapat dikelompokkan menjadi penyebab langsung dan penyebab tidak langsung. penyebab langsung kematian ibu adalah faktor yang berhubungan dengan komplikasi kehamilan, persalinan dan nifas seperti perdarahan, preeklampsia/eklampsia, infeksi, persalinan macet dan abortus. penyebab tidak langsung kematian ibu adalah faktor-faktor yang memperberat keadaan ibu hamil seperti empat terlalu (te rl alu muda, terlalu tua, terlalu sering melahirkan dan terlalu dekat jarak kelahiran). penyebab lain yang mempersulit proses penanganan kedaruratan kehamilan, persalinan dan nifas seperti tiga terlambat (terlambat mengenali tanda bahaya dan mengambil keputusan, terl ambat mencapai fasilitas kesehatan dan terlambat dalam penanganan kedaruratan). faktor lain yang berpengaruh adalah ibu hamil yang menderita penyakit menular seperti malaria, hiv aids, tuberculosis, sifilis; penyakit tidak menular seperti hipertensi, diabetes mellitus, jantung, gangguan jiwa; maupun yang mengalami kekurangan gizi (kemenkes ri, 2013). untuk mengatasi permasalahan di atas, maka pelayanan kesehatan antenatal di fasilitas kesehatan pemerintah maupun swasta dan praktik perorangan/kelompok perlu dilaksanakan secara komprehensif dan terpadu, me ncakup upaya promotif, preventif, kuratif sekaligus rehabilitatif (kemenkes ri, 2013). untuk mendukung upaya promotif dan preventif, mak a kementrian kesehatan telah mengeluarkan berbagai instrumen kesehatan ibu dan anak, salah satu instrument yang digunakan adalah buku kesehata ibu dan anak instrumeninsturmen tersebut sudah didistribusikan ke fasilitas pelayanan kesehatan pemerintah di kabupaten pekalongan, akan tetapi sampai saat ini belum pernah dilakukan evaluasi terhadap pemanfaatan instrumen tersebut. melalui prose s evaluasi akan dapat diperoleh gambaran sejauh mana instrumen tersebut bermanfaat dan untuk menentukan program ke depan sehingga lebih sesuai dengan kondisi yang nyata terjadi di pelayan kesehatan dasar di wilayah kerja dinas kesehatan kabupaten pekalongan (dinkes kab. pekalongan, 2016). buku kia berisi informasi dan materi penyulu han tentang gizi dan kesehatan ibu dan anak, kartu ibu hamil, kms balita dan catatan pelayanan kesehatan ibu dan anak. buku kia disimpan di rumah dan dibawa setiap kali ibu atau anak datang ke tempat-tempat peayanan kesehatan di mana saja untuk mendapatkan pelayanan kia (sistiarini, dkk, 2014). fungsi buku kia merupakan sumber informasi kesehatan ibu dan anak, sebagai sarana pencatatan kesehatan ibu dan anak serta sebagai sarana untuk meningkatkan pengetahuan ibu mengenai kesehatan diri dan anaknya. pengisian buku kia seyogyanya memberikan pemahaman pada ibu tentang status kesehatan diri dan anaknya. catatan yang lengkap akan mendukung peningkatan pengetahuan ibu tentang kesehatan diri dan kesehatan anak-anak (avan, 2011). buku kia secara rutin digunakan oleh bidan dan klien saat melakukan pemeriksaan kesehatan. buku kia memuat banyak hal penting seputar kesehatan ibu dan anak, meliputi informasi dan pencatatan selama kehamilan, persalinan, nifas, bayi baru lahir, masa antara (kb) dan pertumbuhan serta perkembangan balita. s e lai n digunakan bidan untuk mendokumentasikan hasil pemeriksaan, buku kia juga dapat dimanfaatkan oleh klien dan keluarganya guna meningkatkan indonesian journal of nursing practices 24 pengetahuan ibu dan keluarga. pemanfaatan ini diharapkan dapat meningkatkan kesehatan ibu dan anak. namun hasil studi pendahuluan terhadap 10 ibu yang memiliki buku kia di kabupaten pekalongan, 7 orang (70%) mengatakan bahwa suami dan keluarga jarang ikut membaca buku kia. ada 27 puskesmas di wilayah kerja dinas kesehatan kabupaten pekalongan. diperlukan evaluasi yang merata, proporsional dan seimbang mengenai pencatatan dan pemanfaatan insturmen kia sehingga didapatkan gambaran nyata kondisi pelayanan d i fasilitas kesehatan pemerintah di kabupaten pekalongan. tujuan penelitian ini adalah untuk mengetahui gambaran pemanfaatan buku kia oleh ibu dan keluarga di wilayah kerja dinas kesehatan kabupaten pekalongan tahun 20162017. metode jenis penelitian descriptive analytic dengan desain penelitian cross sectional yakni dengan melihat secara spontanlitas jawaban dari responden saat penelitian dilakukan tentang pemanfaatan buku kia oleh ibu maupun anggo ta keluarga lainnya. instrumen dalam penelitian i n i mengunakan ceklist dengan skala likert. ceklist ini telah diuji validitas dan reabilitas pada studi pendahuluan yang telah dilaksanakan oleh peneliti pada pusksemas di kabupaten pekalongan. populasi pada penelitian ini adalah ibu yang memiliki balita. tehnik sampling dengan stritifeid random sampling peneliti melakukan teknik random sampling pertama pada populasi tempat penelitian yakni 27 puskesmas di kabupaten pekalongan dan didapatkan enam puskesmas yakni. puskesmas tirto i, wiradesa, doro ii, kajen ii, karangdadap dan kedungwuni ii. random yang ke dua dilaksanakan pada saat pengambilan sampel buku kia pada pasien yang datang ke posyandu atau datang ke puskesmas. sampel responden diambil berdasarkan kelipatan angka urutan datang. kriteria inklusi dalam penelitian ini adalah ibu yang memiliki anak balita dan membawa buku kia. didapatkan 63 responden yang memenuhi persyaratan rando m. metode pengumpulan data dilaksanakan den gan ijin bapeda dan dinas kabupaten pekalongan. kemutian tim mengirim tembusan dari bapeda ke masing-masing puskesmas yang telah di random menjadi tempat penelitian. pengambilan data dilaksanakan tanpa memberitahu bidan setempat akan kunjungan dari tim peneliti. data diambil spontanlitas saat pelaksanaan posyandu dan pada pemeriksaan balita di puskesmas. seluruh dokumentasi buku kia diambil secara analisis data menggunakan univariate untuk mengetah u i distribusi frekuensi data. hasil 1. gambaran waktu pertama mendapatkan buku kia tabel 1. distribusi frekuensi pemanfaatan buku kia pada aspek waktu pertama mendapatkan buku kia keterangan frekuensi persentase trimester 1 52 82.5 trimester 2 10 15.9 trimester 3 1 1.6 jumlah 63 100 tabel 1. menunjukkan bahwa sebagian besar i b u mendapatkan buku kia pada trimester i yaitu sebesar 82,5% dan hanya sebagian kecil yang mendapatkan buku kia di trimester iii yaitu 1,6%. hal ini memperlihatkan keerpaparan ibu hamil pada awal kehamilan dengan buku kia sangat tinggi dan memungkinkan pemanfataan buku kia secara maksimal di dalam kehamilan sampai dengan masa balita. 2. gambaran pemanfaatan buku kia sebagai bacaan ibu dan keluarga tabel 2. distribusi frekuensi pemanfaatan buku kia sebagai bacaan ibu dan keluarga keterangan frekuensi persentase tidak pernah 6 9.5 kadangkadang 37 58.7 sering 15 23.8 selalu 5 7.9 jumlah 63 100.0 tabel 2. menunjukkan bahwa lebih dari separuh ibu di wilayah kerja puskesmas kabupaten pekalongan kadang-kadang memanfaatkan b u k u vol. 2 no. 1 juni 2018 25 kia sebagai bacaan ibu dan keluarga yaitu sebesar 58,7%. hal ini memperlihatkan bahwa kebutuhan masyarakat terutama sasaran buku kia belum memanfaatkan buku kia secara maksimal. 3. gambaran pemanfaatan buku kia sebagai media bertanya tabel 3. distribusi frekuensi pemanfaatan buku kia sebagai media bertanya keterangan frekuensi persentase tidak pernah 19 30.2 kadangkadang 15 23.8 sering 10 15.9 selalu 19 30.2 jumlah 63 100.0 tabel 3. menunjukkan bahwa sebagian ibu di wilayah kerja puskesmas kabupaten pekalo n gan selalu memanfaatkan buku kia sebagai media bertanya kepada tenaga kesehatan atau kader yaitu sebesar 30,2% akan tetapi 30,2 % lainnya bahkan tidak pernah bertanya tentang hal-hal yang ada pada buku kia. hal ini menunjukkan ketidaktertarikan sasaran dalam membaca dan memanfaatkan buku kia. 4. gambaran pemanfaatan buku kia dalam peningkatan pengetahuan tabel 4. distribusi frekuensi pemanfaatan buku kia dalam peningkatan pengetahuan keterangan frekuensi persentase dibaca sendiri 22 34.9 dibaca bersama keluarga 11 17.5 dibaca bersama keluarga dan bidan 21 33.3 dibaca ibu dan bidan 9 14.3 jumlah 63 100.0 tabel 4. menunjukkan bahwa sebagi an kecil ibu di wilayah kerja puskesmas kabupaten pekalongan memanfaatkan buku kia sebagai sarana meningkatkan pengetahuan namun masih dibaca sendiri yaitu sebesar 34,9% dan 33,3 % dibaca ibu, keluarga bersama dengan bidan. artinya disinibidan sudah menf asilitasi untuk pemanfaatan buku kia dengan mengarahkan i b u dan keluarga dalam membaca buku kia meskipun belum secara optimal. 5. gambaran waktu pengembalian buku kia oleh bidan segera setelah dilakukan pemeriksaan tabel 5. distribusi frekuensi pengembalian bu k u kia oleh bidan segera setelah pemeriksaan keterangan frekuensi persentase tidak pernah 5 7.9 kadangkadang 6 9.5 sering 4 6.3 selalu 48 76.2 jumlah 63 100.0 tabel 5. menunjukkan bahwa sebagian besar bidan selalu mengembalikan buku kia se gera setelah melakukan pemeriksaan kepada ibu yaitu sebesar 76,2% sehingga dapat dimanfaatkan oleh ibu dan keluarga dirumah untuk peningkatan pengetahuan ibu dan keluarga tentang kesehatan ibu dan anak. pembahasan buku kia berisi informasi penting seputar kesehatan ibu dan anak. buku kia tidak hanya digunakan sebagai media pendokumentasian pelayanan kebidanan, tetapi juga dapat dimanfaatkan oleh ibu dan keluarga untuk meningkatkan pengetahuan tentang kesehatan ibu dan anak. buku kia biberikan ke sasaaran sebagai media untuk edukasi bagi bidan pada i b u dan keluarga dengan harapan ada peningkatan pengetahuan maupun sikap dengan adanya pola pemanfaatan buku kia sehingga sasaran dan keluarga dapat bersama-sama mewujudkan kesehatan ibu dan anak. pengetahuan akan mendasari seseorang dalam melakukan perubahan perilaku, sehingga perilaku yang dilakukan akan lebih langgeng daripada perilaku yang tidak didasari oleh pengetahuan (windiyanti, 2002). pengetahuan dapat diarti k an indonesian journal of nursing practices 26 tahu atau mengerti sesudah melihat (menyaksikan, mengalami atau diajar). sasaran yang memanfaatkan buku kia mempunyai pengetahuan yang baik. hasil penelitian menunjukkan bahwa ibu di wilayah kerja puskesmas kabupaten pekalo n gan telah memanfaatkan buku kia sebagai sarana meningkatkan pengetahuan baik oleh ibu maupun di baca bersama ibu, keluarga dan bid an (df:33,3%). hal ini memperlihatkan peran bidan sangat mendukung adanya pola pemanfaatan buku kia dalam meningkatkan pengetahuan ibu dan keluarga tentang kesehatanibu dan anak. fungsi buku kia merupakan sumber informasi kesehatan ibu dan anak, sebagai sarana pencatatan kesehatan ibu dan anak serta sebagai sarana untuk meningkatkan pengetahuan ibu mengenai kesehatan diri dan anaknya. pengis i an buku kia seyogyanya memberikan pemahaman pada ibu tentang status kesehatan diri dan anaknya. catatan yang lengkap akan menduk u n g peningkatan pengetahuan ibu tentang kesehatan diri dan kesehatan anak-anak (akhund & avan, 2011). sistiarini (2004) menyatakan bahwa kepemil ik an buku kia berhubungan dengan pengetahuan i b u tentang kesehatan ibu dan anak, pengetahuan ini berhubungan dengan intensitas membaca buku kia. ini diperlihatkan bahwa responden yang memiliki buku kia sebagian besar memiliki pengetahuan tinggi. nasril menambahkan bahw a ada hubungan bermakna antara pengetahuan responden tentang manfaat buku kia dengan kepatuhannya membawa buku kia ke tempat pelayanan kesehatan (muhammad am, 2012 dalam sistiarini, 2014). penelitian widagdo (2009) menegaskan bahwa salah satu aspek yang mempengaruhi pemanfaatan posyandu adalah pengetahuan ibu tentang kesehatan ibu dan anak (p value = 0,011; or=3,955). oleh karena itu perilaku ibu dan keluarga dalam pemanfaatan buku kia sangat mendukung perilaku ibu dan keluarga dalam perilaku pemanfaatan pada fasilitas kesehatan lainnya yang pada akhirnya mendukung kesehatan ibu dan anak. hasil penelitian menunjukkan bahwa hanya sebagian kecil ibu di wilayah kerja puskesmas kabupaten pekalongan yang selalu memanfaatkan buku kia sebagai media bertan y a kepada tenaga kesehatan atau kader yaitu sebesar 30,2%. keaktifan bertanya ini menunjukkan motivasi ibu dalam mewujudkan kesehatan dirinya sediri dan anaknya. rante, d k k (2007) menyatakan bahwa 69,2% persepsi ibu menyatakan bahwa kader menginformasikan pada para ibu untuk membaca buku kia. namu n , informasi pada buku kia tidak mengendap menjadi ingatan dan pengetahuan. penelitian terhadap waktu pertama mendapatkan buku kia menunjukkan bahwa sebagian besar ibu mendapatkan buku kia pada trimester i yaitu sebesar 82,5%. hal ini memperlihatkan bahwa bidan telah memediasi pemanfaatan buku kia sejak awal kehamilan sehingga ibu dan keluarga dapat memanfaatkan buku kia dimasa kehamilan sampai anaknya balita. penelitian terhadap waktu pengembalian buku kia oleh bidan menunjukkan bahwa sebagi an besar bidan selalu mengembalikan buku kia segera setelah melakukan pemeriksaan kepada ibu yaitu sebesar 76,2%. waktu pengembalian yang segera ini berhubungan dengan kepemilikan buku kia. pemanfaatan buku kia dapat diamati dari kepemilikan buku kia. ibu membawa buku kia ketika berkunjung ke fasilitas pelayanan kesehatan. kegiatan yang berhubungan pro gram kia telah menerima informasi dari penyedia layanan kesehatan yang menggunakan buku kia tersebut. selain itu, kemudahan ibu dalam memahami informasi kesehatan/pendidikan kesehatan menjadi determinan penting pengetahuan ibu (nur e, 2003). elly (2003) yang menyatakan bahwa ada hubungan bermakna antara motivasi dan pemanfaatan materi buku kia. demikian pula syamsudin (2002) mengungkapkan adanya hubungan motivasi dengan kinerja. sehingga kelengkapan pencatatan buku kia merupakan gambaran kinerja bidan serta memperlihatkan motivasi bidan dalam melakukan pencatatan dalam buku kia. vol. 2 no. 1 juni 2018 27 kesimpulan pada aspek pemanfaatan buku kia, sebagian besar ibu mendapatkan buku kia pada trimester pertama yaitu sebesar 82,5%, lebih dari separu h ibu di wilayah kerja puskesmas kabupaten pekalongan kadang-kadang memanfaatkan buku kia sebagai bacaan ibu dan keluarga yaitu sebesar 58,7%. sebagian ibu di wilayah kerja puskesmas kabupaten pekalongan selalu memanfaatkan buku kia sebagai media bertanya kepada tenaga kesehatan atau kader yaitu sebesar 30,2%. sebagian kecil ibu di wilayah kerja puskesmas kabupaten pekalongan memanfaatkan buku kia sebagai sarana meningkatkan pengetahuan namun masih dibaca dibaca sendiri yaitu sebesar 34,9%. sebagian besar bidan selalu mengembalikan buku kia segera setelah melakukan pemeriksaan kepada ibu yaitu sebesar 76,2%. pencatatan buku kia hendaknya ditingkatkan lagi agar pemantauan kesehatan ibu dan anak lebih baik. tenaga kesehatan agar lebih mendorong dan mendukung klien/ibu dan keluarga sehingga mereka dapat menafaatkan buku kia semaksimal mungkin. upaya ini diharapkan dapat berdampak pada peningkatan pengetahuan dan kesehatan ibu dan keluarga. ucapan terimakasih ucapan terimakasih kami sampaikan kepada seluruh pihak yang membantu kelancaran proses penelitian, terutama kepada dinas kesehatan kabupaten pekalongan yang telah memberikan dukungan dana dalam penelitian ini. referensi kementrian kesehatan ri. 2015. buku kesehatan ibu dan anak. jakarta akhund s, avan bi. development and pretestin g an information, education and communication (iec) focused antenatal care handbook in pakistan, journal of biomedical central. 2011;4:91 dinkes kab.pekalongan, 2016. wawancara bidang kesehatan keluarga sistiarini c, gamelia e. sari dyah up. 2014 i fungsi pemanfataan buku kia terhadap pengetahuan kesehatan ibu dan anak pad a ibu. kemas. jurnal kesehatan masyarakat nasional vol.8,no.8, mei 2014 (253-258) windiyanti, motivasi bidan dalam penggunaan buku kia di puskesmas tegalrejo yogyakarta, tesis, program pasca sarjana ugm, yogyakarta, indonesia, 2002 rante a, susilo w, faikah. studi deskriptif dan analisis faktor yang berpengaruh dalam tingkat pengetahuan kia pada ibu di puskesmas cakaranegara mataram. jurnal kesehatan prima. 2007; 1: 9384. widagdo l & husodo bt. 2009. pemanfaatan buku kia oleh kader posyandu, studi p ad a kader posyandu di wilayah kerja pusksemas kedungadem kabupaten bojonegoro. makara, kesehatan, vol.13, no.1, juni 2009: 39-47 nur e, werdiati k. pemanfatan buku kia sebagai materi penyuluhan dalam pelayanan antenatal oleh bidan puskesmas di kota bengkulu. jurnal manajemen pelayanan kesehatan. 2003; 6 (3). elly n, kristiani, werdati s. 2003. pemanfaatan buku kia sebagai materi penyuluhan dalam pelayanan ante natal oleh bidan puskesmas di kota bengkulu. jurnal manajemen pelayanan kesehatan vol.06/no.03/2003 (155-162) syamsudin. 2002. faktor internal dan eksternal yang berhubungan dengan kinerja bidan desa dalam pelayanan antenatal di kabupaten kota waringin barat. tesis. program pascasarjana universitas gadjah mada, yogyakarta 1 muhammadiyah journal of nursing abstract background. nicotine abstinence will lead nicotine withdrawal syndrome in somatic signs and aff ective signs. somatic signs such as body weight change. aff ective signs such as sign of anxiety. nicotine withdrawal syndrome will increasing the desire to use nicotine. delphinium grandifl orum is a plant with methyllcyaconitine (mla). methyllcyaconitine (mla) is antagonist competitive which block α7 nachrs. it will lowering the desire to use nicotine without induce nicotine withdrawal syndrome. objective. to know the eff ect of ethanolic extract delphinium grandifl orum in somatic signs and aff ective signs of nicotine withdrawal syndrome in sprague dawley female rats treated with oral nicotine. methods. this study was quasi experiment with pre and post control group design. rats were grouped into 4 groups. the groups are oo (control), no (nicotine+aquabides), nd 3 (nicotine+ d. grandifl orum 3 mg/kg), nd 6 (nicotine+ d. grandifl orum 6 mg/kg). nicotine was given ad libitum. nicotine was given via drinking water with a step wise increase of dosage every 4 days until 15 days. somatic signs and aff ective signs were observed during 24 hours period after abstinentia (16th and 20th days) on dark cycle. light cycle on 18.0006.00, dark cycle on 06.00-18.00. aff ective signs was observed with open spent time and open arm entries by elevated plus maze. result. there is no signifi cant diff erences between group for body weight, open spent time and open arm entries on day 16 and 20. conclution. there is have no eff ect of ethanolic extract delphinium grandifl orum and nicotine administration for somatic signs, aff ective signs of nicotine withdrawal syndrome in sprague dawley female rats. keywords. nicotine, nicotine withdrawal syndrome, somatic signs, aff ective signs. nurvita risdiana universitas muhammadiyah yogyakarta e-mail: nurvita.risdiana@gmail.com pengaruh pemeberian ekstrak etanol delphinium grandifl orum terhadap tanda somatik dan tanda afektif nicotine withdrawal syndrome pada tikus sprague dawley betina yang diberi nikotin peroral i. pendahuluan 1.1. latar belakang berhenti merokok sangat sulit dan merupakan suatu tantangan.(1) pada sekelompok orang yang berusaha berhenti merokok hanya 3% yang betul-betul berhasil berhenti dari kebiasaan merokok.(2) namun pada kasus lain lebih dari 80% yang berusaha untuk berhenti merokok pada akhirnya akan kembali merokok dalam hitungan bulan atau tahun.(2) sulitnya seseorang untuk berhenti merokok disebabkan karena adanya zat adiktif dalam rokok yang disebut sebagai nikotin. nikotin adalah zat psikoaktif yang bersifat adiksi.(3) nikotin merangsang pelepasan sebagian besar neurotransmiter ke otak(4) dan berinteraksi dengan nicotinic acetylcholine receptors (nachrs) pada sistem mesolimbik otak(5) khususnya di area tegmental ventral. (6) area tegmental ventral merupakan area di otak yang berperan dalam adiksi obat.(7) .interaksi antara nikotin dengan nachrs akan menyebabkan adiksi.(8) pemberian nikotin eksogen secara kronis akan menyebabkan interaksi antara nikotin dengan nachrs sehingga menyebabkan upregulation.(9) upregulation adalah suatu keadaan dimana reseptor mengalami perubahan jumlah dan fungsinya.(10) neuron dopaminergik akan meningkatkan neurotransmitt er lebih banyak disebabkan karena masuknya nikotin. peningkatan neurotransmitt er pada neuron dopaminergik akan meningkatkan dopamin sehingga perasaan menjadi tenang.(11) perasaan tenang tersebut sebagai efek terhadap masuknya nikotin. efek masuknya nikotin didalam tubuh akan menurunkan 2 muhammadiyah journal of nursing berat badan.(10) peningkatan neurotransmiter tersebut akan mengaktifk an binding site pada nachrs khususnya α7 nachrs(12), α4 nachrs dan β2 nachrs(13) alpha 7, α4 dan β2 nachrs berperan dalam pelepasan glutamat di area tegmental ventral.(6,13) akumulasi sistem dopamin pada mesencephalon menyebabkan ketergantungan nikotin. (14) akibatnya jika tidak menggunakan nikotin selama beberapa jam akan menyebabkan nicotine withdrawal syndrome.(15) tanda nicotine withdrawal syndrome berupa depresi, irritability, penurunan kognitif ringan dan gejala-gejala psikologis.(15) untuk mengatasi hal tersebut maka subjek akan termotivasi untuk menggunakan nikotin. sehingga beberapa orang mengalami kesulitan untuk menghentikan kebiasaan merokok. pada tikus, nicotine withdrawal syndrome ditandai dengan gejala terjadi peningkatan tanda somatik dan afektif yang tanda-tandanya sama seperti pada manusia.(10) tanda somatik dan afektif seperti perilaku kecemasan, peningkatan berat badan, penurunan sikap(10), konsentrasi(16) nikotin merupakan salah satu jenis obat yang sering digunakan oleh remaja.(16) (o’dell et al., 2004). selain itu remaja mempunyai keinginan menggunakan nikotin lebih tinggi. alpha 7 nachrs berperan dalam pengaturan kecemasan dan perilaku(17) sehingga pemberian antagonis tehadap reseptor nikotinik akan menurunkan nicotine withdrawal melalui fungsi otak secara signifi kan.(18) delphinium spp. adalah tanaman yang mengandung alkaloid berupa methyllcyaconitine (mla) bersifat antagonis kompetitif yang menghambat α7-, α6-, dan α3 nachrs.(19) delphinium spp. menyebabkan perubahan jumlah atau fungsi nachrs dan ditunjukkan dalam respon fi siologis pada tikus sebagai akibat perubahan fungsional pada respon agonis nachrs seperti nikotin .(20). delphinium spp. dapat digunakan sebagai terapi ketergantungan obat seperti morfi n.(21) nikotin mempunyai sifat yang sama dengan morfi n dalam menyebabkan adiksi dengan cara mengaktifk an nachrs pada area tegmental ventral(7) sehingga diharapkan dapat juga digunakan sebagai terapi adiksi nikotin. delphinium grandifl orum adalah salah satu spesies dari delphinium spp. yang mempunyai sifat yang sama sehingga diharapkan dapat membantu mengatasi ketergantungan nikotin. mla mempunyai efek memblok α7 nachrs tetapi tidak menyebabkan depresi karena dapat meningkatkan level dopamin di nucleus accumbens (nacc).(22) oleh karena itu mla dapat digunkan untuk terapi ketergantungan obat dengan sifatnya yang memblok α7 nachrs. (22) berdasarkan alasan di atas d. grandifl orum sebagai antagonis kompetitif α7 nachrs diharapkan dapat menjadi suatu alternatif terapi ketergantungan nikotin kepada masyarakat. d. grandifl orum diharapkan dapat menghambat α7 nachrs dan terjadi penurunan aktivasi α7 nachrs yang diakibatkan oleh nikotin tanpa menyebabkan terjadinya nicotine withdrawal syndrome.(21) berdasarkan uraian tersebut di atas penelitian ini bertujuan untuk mengetahui pengaruh pemberian ekstrak etanol d. grandifl orum terhadap tanda somatik dan tanda afektif nicotine withdrawal syndrome pada sprague dawley betina yang diberi nikotin peroral. 1.2. rumusan masalah pertanyaan penelitian ini adalah: bagaimanakah pengaruh pemberian ekstrak etanol delphi-nium grandifl o-rum terhadap tanda somatik dan tanda tikus sprague dawley betina yang diberi nikotin peroral? 1.3. tujuan penelitian mempelajari efek pemberian ekstrak etanol d. grandifl orum terhadap tanda somatik dan tanda afektif nicotine withdrawal syndrome pada tikus sprague dawley betina yang diberi nikotin peroral. 3 muhammadiyah journal of nursing ii. metodologi penelitian penelitian ini akan dilakukan dengan rancangan kuasi eksperimen dengan pre dan post control group design. sampel tikus remaja betina jenis sprague dawley usia ± 30-70 hari dengan berat 150-250 g. tikus dibagi menjadi 6 kelompok. kelompok oo (aquabidestilata peroral), no (nikotin + aquabidestilata peroral), nd 3 (nikotin + d. grandifl orum 3 mg/kg), nd 6 (nikotin + d. grandifl orum 6 mg/kg). seluruh tikus diadaptasikan terlebih dahulu selama 7 hari, selanjutnya tikus dirandom dan ditimbang. siklus hidup tikus dibuat fase gelap terang dengan siklus jam 06.00-18.00 merupakan fase gelap sedangkan jam 18.00-06.00 merupakan fase terang. makan dan minum ad libitum. pemberian nikotin peroral menggunakan air minum selama 15 hari dengan cara memberikan nicotine bitartate dyhidrate dilarutkan dalam h2o. nikotin tersebut diberikan secara peroral melalui air minum dengan dosis bertingkat dari 10, 20, 35, 50, 65, 80, 100, 125μg/ ml setiap 4 hari (rogers et al., 2008). setelah diberi nikotin peroral selama 15 hari, kemudian dilakukan pengukuran tanda somatik dan tanda afektif pada hari ke-16 pada fase gelap setelah 24 jam abstinensi nikotin. pada hari ke 16 setelah pengukuran tanda somatik dan tanda afektif dilanjutkan dengan pemberian nikotin peroral dengan ekstrak etanol d. grandifl orum sampai dengan hari ke19. pada hari ke20 pengukuran kembali tanda somatik dan tanda afektif. nicotine withdrawal syndrome yang diamati adalah tanda somatik dan tanda afektif. tanda somatik berupa perubahan berat badan (rafsanjani et al., 2012). tanda afektif berupa kecemasan yang diukur dengan menggunakan elevated plus maze. tanda kecemasan yang diukur meliputi open spent time dan open arm entries. tanda somatik dan tanda afektif nicotine withdrawal syndrome yang diukur dibandingkan antara sebelum dan sesudah pemberian ekstrak etanol d. grandifl orum. open spent time adalah waktu tikus tinggal didalam ruang terbuka dan dihitung dalam detik. semakin lama tikus tinggal di ruang terbuka menunjukkan tingkat kecemasannya semakin rendah sehingga persentase lebih tinggi menunjukkan kecemasan yang lebih rendah. persentase open spent time dihitung dengan rumus(23): waktu tinggal di ruang terbuka (detik) x 100% 300 detik open arm entries adalah frekuensi tikus masuk kedalam ruang terbuka. semakin sering masuk ke ruang terbuka kecemasannya semakin rendah. persentase open arm entries dihitung dengan rumus(23): frekuensi masuk ke ruang terbuka x 100% jumlah keluar masuk ruang tanda somatik berat badan hari ke-1, 16 dan 20 menurut uji shapiro–wilk menunjukkan distribusi data yang normal. selanjutnya dilakukan uji homogenitas levene. pada tanda somatik berat badan hari ke-16 dan 20 dilakukan uji statistik anova untuk mengetahui perbedaan antar kelompok dan uji paired t-test untuk mengetahui perbedaan pada kelompok yang sama setelah diberikan perlakuan. tanda afektif pada open spen time pada hari ke16 dan ke20 menurut uji shapiro–wilk menunjukkan distribusi data yang tidak normal. tanda afektif open spent time menggunakan uji kruskal wallis. tanda afektif pada open arm entries pada hari ke16 dan 20 menurut uji shapiro–wilk menunjukkan distribusi data yang tidak normal. tanda afektif open arm entries menggunakan uji kruskal wallis. 4 muhammadiyah journal of nursing iii. hasil penelitian dan pembahasan iii.1. tanda somatik pada tikus sprague dawley betina tanda somatik yang diamati pada tikus sprague dawley betina adalah perubahan berat badan. rerata berat badan tikus sprague dawley betina ditunjukkan pada tabel 1. berat badan tikus sprague dawley betina dikur pada hari ke-1, 16 dan hari ke20. pada hari ke-1, 16 dan hari ke-20 hasil uji statistik menunjukkan tidak ada perbedaan yang signifi kan antar kelompok dengan p= 0,65, p=0,50 dan p=0,61 (p>0,05). hasil uji statistik pada kelompok oo pada hari ke-16 dibandingkan dengan hari ke20 menunjukkan perbedaan yang signifi kan dengan p=0,03 (p<0,03). bb hari ke-20 menunjukkan rerata lebih tinggi dibandingkan dengan rerata hari ke-16 pada kelompok oo. hasil uji statistik antara kelompok menunjukkan hasil yang tidak signifi kan pada oo dibandingkan no, oo dibandingkan dengan nd 3, oo dibandingkan dengan nd 6, no dibandingkan dengan nd 3, no dibandingkan dengan nd 6, nd 3 dibandingkan dengan nd 6 (tabel 2). tabel 1. rerata ± sd berat badan tikus sprague dawley betina kelompok (n-6) berat badan (gram) hari ke-1 hari ke-16 hari ke-20 oo 197,5±29,96 198±24,99 203±23,86 no 211,5±8,34 109,75±9,03 210,75±10,46 nd 3 214,25±20,23 217±21,75 218,5±19,82 nd 6 210,75±15,06 214±12,72 217,5±16,19 p values 0,65 0,50 0,61 ket: oo : kontrol no : nikotin nd 3 : nikotin + d. grandifl orum dosis 3 mg/ kg bb nd 6 : kelompok nikotin + d. grandifl orum dosis 6 mg/ kg bb tabel 2. hasil uji statistik post hoc lsd pada berat badan tikus sprague dawley betina hari ke-16 dan 20 kelompok p value hari ke-16 p value hari ke-20 oo vs no 0,38 0,56 oo vs nd 3 0,16 0,25 oo vs nd 6 0,24 0,28 no vs nd 3 0,58 0,56 no vs nd 6 0,74 0,61 nd 3 vs nd 6 0,82 0,94 ket: oo : kelompok kontrol no : kelompok nikotin nd 3 kelompok nikotin + d. grandifl orum dosis 3 mg/ kg bb nd 6 : kelompok nikotin + d. grandifl orum dosis 6 mg/ kg bb iii.2. tanda afektif pada tikus sprague dawley betina iii.2.1. tanda afektif pada open spent time. rerata tanda afektif open spent time tikus sprague dawley betina hari ke-16 dan 20 ditunjukkan pada tabel 3. pada hari ke-16 hasil uji statistik menunjukkan perbedaan yang signifi kan dengan p=0,03 (p<0,05), sedangkan pada hari ke20 hasil uji statistik menunjukkan tidak ada perbedaan yang signifi kan dengan p=0,48. tabel 3. tanda afektif open spent time pada tikus sprague dawley betina kelompok (n=6) tanda afektif open spent time hari ke-16 hari ke-20 oo 12,51±13,52 12±14,88 no 9,45±7,78 0,01±2 nd 3 21,71±14,1 0,1±20 nd 6 0,18±0 0,16±20,3 p values 0,03 0,48 ket: oo : kelompok kontrol no : kelompok nikotin nd 3 : kelompok nikotin + d. grandifl orum dosis 3 mg/ kg bb 5 muhammadiyah journal of nursing nd 6 : kelompok nikotin + d. grandifl orum dosis 6 mg/ kg bb iii.2.2. tanda afektif pada open arm entires. rerata tanda afektif open arm entires tikus sprague dawley betina hari ke-16 dan 20 ditunjukkan pada tabel 4. pada hari ke-16 hasil uji statistik menunjukkan tidak ada perbedaan yang signifi kan dengan p=0,36 (p>0,05), sedangkan pada hari ke20 hasil uji statistik menunjukkan tidak ada perbedaan yang signifi kan dengan p=0,80. tabel 4. tanda afektif open arm entries pada tikus sprague dawley betina kelompok (n=6) tanda afektif open spent time hari ke-16 hari ke-20 oo 42,2±28,33 48,5±3 no 50,83±1,5 51,75±3,5 nd 3 49,6±2 51,5±3 nd 6 75±50 41,75±30,09 p values 0,36 0,80 ket: oo : kelompok kontrol no : kelompok nikotin nd 3 : kelompok nikotin + d. grandifl orum dosis 3 mg/ kg bb nd 6 : kelompok nikotin + d. grandifl orum dosis 6 mg/ kg bb iii.3. pembahasan nikotin merupakan zat adiksi dengan mempengaruhi neurotransmitt er sehingga terjadi upregulation.(9) pemberian nikotin kronis akan menghasilkan nicotine withdrawal syndrome. (16) nicotine withdrawal syndrome akan muncul setelah penghentian nikotin atau pemberian antagonis terhadap reseptor nikotinik asetilkholin sebagai akibat terhadap respon molekuler untuk mempertahankan nikotin didalam tubuh.(16) nicotine withdrawal syndrome berupa tanda somatik dan tanda afektif. tanda somatik berupa perubahan berat badan, sedangkan tanda afektif berupa tanda kecemasan yang diamati melalui open spent time dan open arm entries. pada penelitian ini tikus diadiksikan selama 15 hari dengan menggunakan nikotin peroral melalui air minum dan selanjutnya diberikan terapi menggunakan ekstrak etanol d. grandifl orum. iii.3.1. tanda somatik pada tikus sprague dawley betina. nikotin didalam tubuh akan mempengaruhi berat badan. pemberian nikotin kronis akan menekan nafsu makan sehingga berefek menurunkan berat badan.(16) namun, pada kondisi withdrawal atau pada saat penghentian nikotin akan muncul hiperfagi dan peningkatan berat badan.(24) pada penelitian ini hasil uji statistik terhadap berat badan antar kelompok pada hari ke-1 menunjukkan tidak ada perbedaan yang signifi kan dengan p=0,65 (p>0,05), demikian juga pada hari ke-16 dan 20 dengan p=0,50 dan p=0,61 (p>0,05). pemberian nikotin kronis pada penelitian ini tidak memberikan dampak pada perubahan berat badan. kelompok oo dibandingkan dengan kelompok no, nd 3 dan nd 6 juga tidak menunjukkan perbedaan yang signifi kan antara kelompok (tabel 2). penelitian penelitian lain menunjukkan bahwa pada kelompok tikus yang diberi nikotin akan terjadi peningkatan berat badan yang lebih rendah dibandingkan dengan kelompok tikus yang tidak diberikan nikotin. (25) sedangkan pada penelitian ini menunjukkan tidak ada perbedaan antar kelompok baik yang diberi nikotin ataupun tidak diberi nikotin. tanda somatik pada tikus remaja pada penelitian tertentu dari beberapa temuannya tidak terlalu tampak.(16) berat badan merupakan salah satu tanda somatik. pada penelitian ini menggunakan tikus remaja sehingga pada penelitian ini juga tidak tampak nicotine withdrawal syndrome pada berat badan dibuktikan dengan hasil uji statistik menunjukkan tidak ada perbedaan yang signifi kan antar kelompok. 6 muhammadiyah journal of nursing pada hari ke20 setelah pemberian ekstrak etanol d. grandifl orum menujukkan tidak ada perbedaan yang signifi kan antar kelompok. hal ini menunjukkan d. grandifl orum belum memberikan efek pada tikus sprague dawley betina terhadap tanda somatik nicotine withdrawal syndrome. mla tidak menimbulkan efek pada perubahan berat badan(26) sehingga hasilnya sama dengan hasil penelitian ini. delphinum grandifl orum mengandung mla sehingga pada penelitian ini tidak tampak tanda somatik berat badan pada tikus sprague dawley betina. iii.3.2. tanda afektif pada open spent time dan open arm entries. nikotin sebagai zat adiksi akan memberikan dampak positif berupa perasaan tenang. masuknya nikotin ke dalam plasma akan memberikan efek antidepresan.(27) pada kondisi abstinensi terhadap nikotin akan muncul nicotine withdrawal syndrome salah satunya adalah tanda afektif berupa kecemasan. tanda kecemasan pada diamati dengan menggunakan open spent time dan open arm entries. nicotine withdrawal akan menimbulkan kecemasan pada tikus dewasa, sedangkan pada tikus remaja tidak tampak adanya tanda kecemasan.(28) hal ini sesuai dengan penelitian ini bahwa tidak tampak tanda kecemasan pada pemberian nikotin hari ke-16 dengan hasil uji statistik tidak ada perbedaan yang signifi kan baik pada open spent time ataupun pada open arm entires (tabel 3 dan 4). pada hari ke-20 hasil uji statistik juga menunjukkan tidak ada perbedaan yang signifi kan (tabel 3 dan 4). hal ini dimungkinkan karena efek negatif dari nikotin yaitu berupa withdrawal syndrome pada remaja kurang sensitif sehingga tidak tampak jelas.(16) remaja mempunyai sensitivitas yang rendah terhadap depresi.(29) alasan tersebut menyebabkan efek negatif dari nikotin tampak kurang jelas. demikian juga dengan pemberian d. grandifl orum menunjukkan tidak ada perbedaan yang signifi kan. sistem kolinergik yang belum berkembang pada remaja dianggap sebagai alasan yang menyebabkan pemberian nikotin tidak begitu mempengaruhi nachrs.(16) demikian juga dengan pemberian d. grandifl orum belum memberikan efek terhadap nicotine withdrawal syndrome. dari penelitian ini d. grandifl orum sebagai antagonis terhadap α7 nachrs belum bisa mempengaruhi nachrs karena sistem kholinergik yang belum berkembang pada tikus remaja. iv. kesimpulan hasil dari penelitian ini tidak terdapat perbedaan yang signifi kan pada tanda somatik maupun tanda afektif nicotine withdrawal syndrome pada tikus sprague dawley betina yang diberi nikotin peroral. belum tampak manfaat pemberian ekstrak etanol d. grandifl orum pada tikus sprague dawley betina yang diberi nikotin peroral. v. daftar pustaka 1. balluz, l., ahluwalia, i.b., murphy, w., mokdad, a., giles, w., & harris, v.b., 2004. surveillance for certain heaslth behaviors among selected local areas—united states, behavioral risk factor surveillance system. mmwr cdc surveill. summ. 53:1-100. 2. benowitz , n.l., 2010. nicotine addiction. n. engl. j. med. 362(24):2295-2303. 3. bertrand, d., 2010. neurocircuitry of the nicotinic cholinergic system. dialogue. in. clin. neurosci. 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yulianiwinarti@gmail.com effectiveness of peer education method in increasing knowledge and attitude towards hiv/aids prevention among students in samarinda article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.32100 abstract background: the rise of hiv/aids cases on teenagers aged 15 to 24 years old has reached 25%. inadequate knowledge regarding hiv/aids has been particular issue contributing to the rise of the cases. objective: this study aims to find out the effectiveness of peer education methods on knowledge and attitudes regarding hiv/aids prevention in students of smk kesehatan in samarinda. method: this study is a quasi-experimental design with a nonequivalent control group of pre-test and post-test. the sample of the study was 60 students of smk kesehatan in samarinda, selected through purposive sampling, and it was divided into an experimental group that was exposed to the treatment of the peer education method, also, the other 30 students in the control group were only given a module. data analysis used paired t-test with a significant level of p = 0.05. result: the result found significant differences before and after intervention in intervention groups between pre and post-test of knowledge (t=-3.83, p= 0.01) and attitudes (t=-4.54, p=0.00). a significant increase in knowledge and attitudes in the treatment group was higher than the control group. conclusion: the peer education method is effective to increase the knowledge and positive attitudes of the students of smk kesehatan in samarinda. keywords: health education; peer education; prevention of hiv/aids introduction the spread of hiv/aids has increased rapidly, and it is proven by the data of the world health organization (2016) showing that there is a rise in the number of people living with hiv/aids (plwha) from the group of age less than 15 years old. fewer people died of hiv-related causes, with an estimated 1.1 million (range of 940,000–1.3 million) deaths in 2015; 43% from 2003, the date that treatment targets were first set. in 2015, new hiv infection was estimated at 2.1 million (range of 1.8–2.4 million). more than 2 million teenagers aged between 10 and 19 years old live with hiv/aids. the most dominant factors of this spread is the transmission through sexual intercourse, injected drugs, prenatal, and homosexual (kemenkes ri, 2013). the phenomenon of pre-marital sex has appeared amongst teenagers aged 10 to 24 years old, whether males and females (oktriyanto and alfiasari, 2019). the data from a forum of family planning (pkbi) samarinda revealed that 25% of teenagers aged 15-18 years old have conducted pre-marital sex. 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/3484 indonesian journal of nursing practices 106 research on basic health (2010) stated that most people aged 15-24 years old possess inadequate knowledge of maternity risks, fertility periods, and prevention of hiv/aids. the great efforts on socializing the danger of hiv/aids are not proven to be sufficient to raise the teenagers' knowledge about this disease. half of the citizens (57,5%) have heard about hiv/aids. nonetheless, this percentage does not guarantee that they know about hiv/aids comprehensively since there are only 11,4% who have comprehended the knowledge about the disease. an intensive and comprehensive effort on prevention, protection, and rehabilitation is necessary to be carried out. one of the initiatives that can be done is health education through the peer education method (adyani, muflih, and syafitri, 2019). get involved in social life is very important among the young people since in this pattern of intercommunication with their peer's teenagers development is influenced by their peers' behaviours to gain confidence (liu, zhao, chen, falk, and albarracín, 2017). the protection, prevention, and treatment of hiv/aids in this group intensively and comprehensively need to be done, and one of the efforts in the form of health education is through a peer education program. peer education is a strategy in which a person who has been trained from a group of targets that have a purpose as a link or networking system for their peers to effectively be able to encourage, support, and promote peer group in their healthy living. method the design of this research is a quasi-experimental study with the non-equivalent control group containing pre-test and post-test design. this study was carried out with two students group of smk kesehatan in samarinda. one group was given the education of hiv/aids through the peer education method, while the control group was assigned a module about the danger of hiv/aids to be read independently. this design was employed to see the effectiveness of the peer education method on the students' knowledge and attitudes towards the prevention of the hiv/aids spread. the sample of the study was 60 students of smk kesehatan in samarinda selected using purposive sampling. the sample was divided into the experimental group that was given the treatment of the peer education method and the control group that was only given a module. the first group was the first-year students of smk kesehatan in samarinda as the experimental group (30 students). the second group was the firstyear students of smk medika samarinda as the control group (30 students). the criteria of the subjects are: (1) male / female from the first year (2) unmarried (3) range of age between 16 and 18 years old (4) non-member of pik (center of counseling and information) from bkkbn samarinda (5) willing to participate in research. the dependent variables are students' knowledge and attitudes towards the prevention of the hiv/aids spread. the independent variable is the health education method or information communication and education using the peer education method regarding the prevention of hiv/aids. the instrument of the research is a questionnaire with close-ended questions to measure students' knowledge and attitudes. the data were analysed using paired t-test to find the different mean scores of pre-test, post-test one, and post-test two for all variables after the treatment for both control and experimental group. the decision of hypothesis testing is taken with a significant level of 5% or pvalue= 0.05. results the respondents in this research who are qualified for the criteria of inclusion in each group were 30 people. table 1 shows that most of the students in both groups were teenagers aged 15-17 years old, with a total number of 21 students (70%) in the experimental group and 19 students (63.3%) in the control group. females dominated both groups in terms of the number of students. meanwhile, in terms of origin, both groups showed various places, although students from samarinda dominated with total of 18 students (60%) in the experimental group and 23 students (76.7%) in the control group. since most of the respondents were from samarinda, in the category of place of living, most students lived with their parents, 17 students (56,7%) in the experimental group and 23 students (76.7%) in the control group. vol. 3 no. 2 december 2019 107 table 1. the characteristics of the respondents based on age, sex, origin, and place of living group characteristics intervention control n=30 % n=30 % age 15 years old 8 26.7 7 23.3 16 years old 17 years old 21 1 70.0 3.3 19 4 63.3 13.4 sex male 6 20.0 7 23.3 female 24 80.0 23 76.7 origin samarinda 18 60.0 23 76.7 kembang janggut tenggarong kutai timur 4 2 2 13.3 6.7 6.7 1 1 1 3.3 3.3 3.3 sanga-sanga 2 6.7 0 0 kota bangun kutai barat 1 1 3.3 3.3 0 4 0 13.3 place of living rent house with parents 6 17 20.0 56.7 1 23 3.3 76.7 with family 5 16.7 3 10.0 boarding house 2 6.7 3 10.0 the paired t-test analysis of students’ knowledge between the intervention and control group is shown in table 2. table 2. analysis of paired t-test on students’ knowledge of hiv/aids prevention (pre-test and posttest) knowledge mean (sd) mean differences (ci 95%) t p in te rv e n ti o n g ro u p posttest 1 with pre-test 26.17 (3.4) 23.47 (2.2) -2.70 (-4.13 – -1.26) -3.83 0.01* posttest 2 with pretest 27.00 (3.7) 23.47 (2.2) -3.53 (-5.13 – -1.93) -4.52 0.00* c o n tr o l g ro u p posttest 1 with pre-test 24.93 (2.7) 25.43 (4.0) 0.50 (-1.292.29) 0.56 0.57 posttest 2 with pretest 24.77 (2.6) 25.43 (4.0) 0.66 (-1.08 – 2.41) 0.77 0.44 *p =statististical significant α<0.5 the data on table 2 showed that there was a significant difference between before and after the treatment of the peer education method (t=7.33; p<0.05) to the experimental group. the data on the post-test (mean=26.17; d=3.4) were higher than the pre-test (mean=23.47; d=2,2). it means that the treatment of peer education is effective in increasing the students' knowledge of the danger of hiv/aids in intervention group. meanwhile, in the control group, in which students are only provided with a module of hiv/aids for self-reading, the statistical value did not show a significant difference between before and after the treatment (t = 0.16; p 0.57 > 0.05). to analyse the difference between the two groups before and after the treatment. an analysis was conducted to measure the pre-test and post-test using paired t-test analysis. the results are presented in table 3. table 3. analysis of paired t-test on students’ attitudes towards hiv/aids prevention (pre-test and posttest) attitudes mean (sd) mean differences (ci 95%) t p in te rv e n ti o n g ro u p posttest 1 with pre-test 82.47 (5.7) 76.80 (4.4) -5.6 (-8.21 -3.11) -4.54 0.00* posttest 2 with pretest 84.23 (6.1) 76.80 (4.4) -7.4 (-10.2 -4.61) -5.40 0.00* c o n tr o l g ro u p posttest 1 with pre-test 73.53 (4.6) 73.77 (4.9) 0.23 (-0.05-0.52) 1.6 0.10 posttest 2 with pretest 73.57 (4.3) 73.77 (4.9) 0.20 (-0.39.-0.79) 0.6 0.49 *p =statististical significant α < 0.5 based on table 3, the intervention group that was exposed to treatment through peer education method demonstrated a significant difference between before and after the treatment, in both phases of pretest-posttest 1 and pretest-posttest 2 (p-value< 0.05). the mean score of posttest 1 (mean= 82.47; 5.7) on the student's attitudes was higher than the pre-test indonesian journal of nursing practices 108 score (mean= 76.8; 4.4), and there was a difference of -5.6 between the pre-test and the posttest 1. the mean score of posttest 2 (mean= 84.23; 6.1) on the student's attitudes was higher than the pre-test score (mean= 76.8; 4.4), and there was a difference of -7.4 between the pre-test and the posttest 2. these statistical numbers show the empirical evidence of health education through the peer education method is effective in improving the students’ attitudes towards the prevention of hiv/aids. on the other hand, the data show that the students in the control group did not improve their attitudes towards the prevention of hiv/aids (p-value>0.05 in both pretest and posttest). the mean score of the posttest 1 (73.53; 4.6) was lower than the mean score of the pre-test(m= 76.8; 4.4). similarly, the mean score of posttest 2 was smaller than the pre-test. all things considered, providing a module of hiv/aids prevention for self-reading is not effective in improving the students' attitude in the control group. discussion based on the result of this research in table 2 and table 3, there was a significant increase in the students' knowledge and attitudes towards the prevention of hiv/aids from the experimental group. this increase is a result of health education that is given by a peer educator. with the peer education method, the teenagers are given the opportunity to develop their communication and interaction skills among themselves, especially matters that are related to the prevention of hiv/aids. according to jennings and protte (2014), this program can increase the students' knowledge and attitudes towards the prevention of youths' risky behaviours, including the spread of hiv/aids. health education through peer education is proven to be effective in helping young people to prevent hivrisk behaviours. many ways can be done to conduct health education, such as socialization at schools and certain institutions, displaying banners and posters, etc. however, from many methods that can be done, the peer-based education method is so far one of the most effective ways (ningrum and sumaryani, 2018). furthemore, the methods that are used by peer educators in delivering information are different from other conventional techniques. they had the freedom to express many things and able to discuss it. moreover, they could provide information about the danger and the prevention of hiv/aids in a more informal way. also, peer educators have known their friends very well. it gives them the advantage so that their friends will not hesitate to ask questions. a friendly atmosphere is also created during the process of delivering information since they know each other, and they are a group with small numbers. therefore, the delivery of information is conducted more effectively and more focused. a teenager may become an active agent in transferring knowledge about reproduction health and hiv/aids prevention. besides, they may become an alternative for the other teenagers to get the information so that they can develop their skills and knowledge to prevent hiv/aids (feith, gradvohl, füzi, darvay, krekó, and falus, 2018). the availability of the time that does not disturb the students/teenagers is also a factor that helps the students from the experimental group to develop their knowledge (fertman, and allensworth, 2016). the success of health education is determined by the strategies, methods and tools used to support the process of learning. some factors of the disastrous results from the control groups are lack of repetition from the source of the information and one-way communication, which makes it more difficult for the students to remember the information since they might store it in short-term memory. the increase of the knowledge from the experimental group is supported by choosing well-trained peers. criteria of peer educators who are recruited are according to his/her popularity among his/her friends and whether or not they fond of him/her (sun, miu, wong, tucker, and wong, 2018). a positive role model may enhance their self-confidence in developing their ability to deliver information so that a change can occur (mason-jones, 2011). based on the results of the statistical analysis in table 2 and table 3, the peer education method is empirically proven as an effective method to educate students of vocational high schools about hiv/aids from the experimental group. selecting a good peer educator and his/her characteristics are also very crucial since the peer educator has a vital role in helping attitude changes. according to ningrum and sumaryani (2018), the success of the educator to vol. 3 no. 2 december 2019 109 increase the students' attitudes relies on the recruitment process and the training process. the meeting frequency, relaxed delivery, and informal communicative delivery between the peer educators and the other students have supported the raise of positive attitudes. besides, peer educators and peer groups usually have known each other long before the treatment. this condition gives the advantage to the peer educator to create a friendly atmosphere so that the peer group might ask the question and discuss related topics without hesitation. in line with sarwono, s (2011) states that one may change by gaining information from the others through persuasion or social pressure. effective communication used by peer educators to an experimental group supports the increase of students' positive attitudes towards the prevention of the spread of hiv/aids (jenings and protte, 2014). peer educators may hold essential roles to improve the quality of delivery within the frame of health promotion, including the prevention of hiv/aids. according to maio, haddock, and verplanken (2018) stimulation is necessary before a change in someone's attitude has been made. this change cannot be reached unless there are supporting infrastructures and facilities to create health awareness. the information transfer conducted by a peer educator has become a guide for the peer groups to act, and the results show that the students from the experimental group had done better attitudes in hiv/aids prevention than ever before. health belief model (hbm) theory described that healthy lifestyle is determined by whether or not people: (1) see themselves at risk of health problems (2) see the problem as a serious matter (3) ensure that they will recover and get benefit from their effort of medication (4) recognize their needs to take action and the circumstances that may make their action slow. the education of health through peer educators can create a good impression for the peer groups since the information delivery process is usually not intimidating. therefore, they will be able to gain a better understanding regarding the danger of hiv/aids and its prevention as early as possible. the problems that are encountered by the subjects of the research can be diagnosed early when the peer educator is employed. it is due to the members of the peer group has more freedom to express themselves because the educator is their friend. hence, the subjects of the research from the experimental group have better knowledge and attitudes about hiv/aids prevention through peer educators (fertman, and allensworth, 2016). based on the analysis, non-significant change attitudes in the control group exist because the subjects do not have the opportunity to have a twoway communication since they read the module by themselves. they need to be highly committed to obtain more information from the module and reread the book. therefore, they are cannot develop their knowledge and attitudes about preventing hiv/aids as expected. also, the control group has a decreased score in the posttest compared with the score from the pre-test. it is due to less repetition done by the students in the process of reading the module so that the information they read usually be stored in the short-term memory (astari, & fitriyani, 2019). as a result, the students do not have an excellent comprehensive understanding about the prevention of hiv/aids. it is in line with the statement from kasih (2016) that the success of health education is also determined by the appropriate strategy, method, and tools which can support the success of the process of learning. ibrahim et al. (2012) stated that the improvement of students' knowledge and attitudes towards the prevention of hiv/aids can be developed through the continuous delivery of information. conclusion it can be concluded that the peer education method is effective in increasing the knowledge and positive attitudes of the students of smk kesehatan in samarinda. references adyani, s. a. m., muflih, m., & syafitri, e. n. (2019). kerentanan kehamilan remaja dan konseling sebaya: tinjauan teori. jurnal keperawatan respati yogyakarta, 6(1), 552557. astari, r., & fitriyani, e. (2019). pengaruh peer education terhadap pengetahuan dan sikap remaja tentang pencegahan hiv-aids di smk korpri majalengka. jurnal ilmu kesehatan bhakti husada: health sciences journal, 10(2), 143-152. depkes, r. i. (2013). riset kesehatan dasar. jakarta: badan penelitian dan pengembangan kesehatan kementrian kesehatan ri. indonesian journal of nursing practices 110 feith, h. j., gradvohl, e., füzi, r., darvay, s. m., krekó, i. b., & falus, a. (2018). health education– responsibility–changing attitude. a new pedagogical and methodological concept of peer education. acta universitatis sapientiae, social analysis, 8(1), 55-74. fertman, c. i., & allensworth, d. d. (2016). health promotion programs: from theory to practice. john wiley & sons ibrahim, n., rampal, l., jamil, z., & zain, a. m. (2012). effectiveness of peer-led education on knowledge, attitude and risk behavior practices related to hiv among students at a malaysian public university—a randomized controlled trial. preventive medicine, 55(5), 505-510. jennings, j. m., howard, s., & perotte, c. l. (2014). effects of a school-based sexuality education program on peer educators: the teen pep model. health education research, 29(2), 319-329. kasih, l. c. (2016). efektifitas peer education pada pengetahuan dan sikap siswa sma dalam pencegahan hiv/aids. jurnal ilmu keperawatan, 4(2), 26-33. kemenkes, r. i. (2013). laporan triwulan situasi perkembangan hiv/aids di indonesia. liu, j., zhao, s., chen, x., falk, e., & albarracín, d. (2017). the influence of peer behavior as a function of social and cultural closeness: a meta-analysis of normative influence on adolescent smoking initiation and continuation. psychological bulletin, 143(10), 1082. maio, g. r., haddock, g., & verplanken, b. (2018). the psychology of attitudes and attitude change. sage publications limited. mason-jones, a. j., flisher, a. j., & mathews, c. (2011). who are the peer educators? hiv prevention in south african schools. health education research, 26(3), 563-571. ningrum, s. a. w., & sumaryani, s. (2018). peer education prevents sexual risk behavior among adolescents in rural area. indonesian nursing journal of education and clinic (injec), 2(2), 193-199. oktriyanto, o., & alfiasari, a. (2019). dating and premarital sexual inisiation on adolescence in indonesia. kemas: jurnal kesehatan masyarakat, 15(1), 98-108. sarwono, s. w. (2011). psikologi remaja edisi revisi. jakarta: rajawali pers. sun, w. h., miu, h. y. h., wong, c. k. h., tucker, j. d., & wong, w. c. w. (2018). assessing participation and effectiveness of the peerled approach in youth sexual health education: systematic review and metaanalysis in more developed countries. the journal of sex research, 55(1), 31-44. world health organization. (2014). the global health sector strategy on hiv. indonesian journal of nursing practices 90 indonesian journal of nursing practices yuniar ika fajarini1, akbar amin abdullah1 1 department of nursing, stikes duta gama, jl.jogja-solo km.5, klaten. 57426 korespondensi: yuniar ika fajarini email korespondensi: yuniar007@gmail.com perangkat kesiapsiagaan bencana untuk wanita hamil dan pasca melahirkan info artikel online issn doi : : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.2284 abstrak latar belakang: letus an gunung berapi pada tahun 2010 meni ngkatkan kes adaran akan kebutuhan untuk mendi di k popul as i rentan dal am kes i aps iagaan bencana. wani ta dan bayinya teruta ma beri s i ko terkena bahaya karena bencana al am. penel i ti an s aa t i ni menunj ukkan bahwa popul as i rentan bi as a nya kurang s i a p untuk kej adi an bencana bes ar. tujuan: tuj uan dari penel i ti an i ni adal ah untuk mengetahui efekti vi tas dari i ntervens i pendi di kan s i ngkat yang di tuj ukan untuk meni ngkatkan ti ngkat kes i aps iagaan bencana dar i wani ta hami l d a n pas ca mel ahi rkan. metode: 30 wani ta hami l dan pa s ca mel ahi rkan di bagi menj adi kel ompok i ntervens i dan kel ompok kontrol . pretest di ukur dengan menggunakan i ns trumen kes i apan kel uarga, dan post-test di l akukan pada 30 hari pas ka-i ntervens i. skor di ni l ai berdas arkan j uml ah i t em yang berhas i l di sel es aikan pada i ns trumen kes i aps iagaan. hasil: perbedaan s i gni fi kan di temukan pada s kor pretest dan posttest pada kel uarga yang meneri ma i ntervens i (p = 0,000). skor posttest s ecara s i gni fi kan l ebi h ti nggi dari pada s kor pretest, menunj ukkan bahwa i ntervens i berhas i l meni ngkatkan ti ngkat kes i apan kel uarga untuk menghadapi bencana j angka pendek s ecara kes el uruhan pada popul as i i ni. kata kunci : letus an gunung berapi , kehami l an, pas ka mel ahi rkan, bencana abstract background: volcanic eruption in 2010 heightened awareness of the need to educate vulnerable populations on disaster preparedness. women and their infants are notably at risk for harm due to natural disasters. current research suggests that the vulnerable populations usually less prepared for a major disaster event. objective: the purpose of this study was to determine the shortterm effectiveness of a brief education intervention aimed at increasing levels of disaster preparedness of the pregnant and postpartum women. method: 30 pregnant and postpartum women assigned to control and intervention group families were surveyed prior to the intervention using instrument on family preparedness, and at 30 days post-intervention. a preparedness score was assigned to ea ch family based on the number of items completed on the preparedness instrument. 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/5278 vol. 2 no. 2 desember 2018 91 result: significant differences were found between preand posttest scores for families that received the intervention (p= 0.000). posttest scores were significantly higher than pretest scores, suggesting that the intervention was successful in increasing short-term overall levels of family disaster preparedness in this population . keywords: volcanic eruption, pregnant, post-partum, disaster pendahuluan bencana mengakibatkan kerusakan lingkungan, ekonomi, sosial dan infrastruktur perawatan kesehatan; menyebabkan hilangnya nyawa, dan memaksa individu dan masyarakat untuk bertahan dan menggunakan sumber daya mereka sendiri (who & icn, 2009). ibu hamil dan pascamelahirkan adalah populasi rentan yang membutuhkan perencanaan proaktif untuk memastikan bahwa kebutuhan mereka terpenuhi selama dan setelah bencana alam (acog, 2012). proses dalam kesiapsiagaan bencana mencakup (1) pemberitahuan tentang potensi bahaya di daerah, (2) membuat rencana komunikasi dan evakuasi, dan (3) menetapkan strategi dan seperangkat persediaan yang diperlukan untuk swasembada selama 3 hari pasca-bencana. kesiapsiagaan bencana merupakan upaya dari jaringan profesional kesehatan, organisasi dan komunitas (gnatt, 2011; rebmann, english, & carrico, 2007; bond, beckstrand, & heise, 2009; daugherty & blome, 2009; landry & stockton, 2008). kesiapsiagaan pribadi adalah masalah yang signifikan, tidak hanya untuk individu akan tetapi juga sebagai unsur respon masyarakat, dikarenakan anggota masyarakat sering bertindak sebagai orang pertama yang membantu komunitas asal mereka, bahkan ketika tidak ada pelatihan formal atau sumber daya pendukung dari luar (adams & canclini, 2008). meskipun 10 tahun berlalu sejak erupsi gunung merapi, sedikit yang telah dilakukan untuk meningkatkan kesiapsiagaan bencana untuk wanita hamil dan pasca-melahirkan dan keluarga mereka. identifikasi topik yang bersangkutan diperlukan untuk pembuatan program pendidikan untuk meningkatkan kesadaran dan kesiapan untuk populasi yang rentan ini. obstetricians and gynecologists (acog, 2012) mendukung kesiapsiagaan bencana, mengakui bahwa wanita hamil dan bayi berisiko bahaya yang ditimbulkan dari bencana alam karena kurangnya sumber daya, akses terbatas ke perawatan medis, dan karena ibu hamil serta bayi akan lebih sensitif terhadap paparan toksin (acog, 2012; kirsi & kirsi, 2011). harville, xiong, dan buekens (2011) melakukan tinjauan sistematis dari 49 studi peer-review tentang bencana dan kesehatan perinatal dan didapatkan hasil bahwa populasi ini rentan cedera, kekerasan, dampak ekonomi, gangguan medis, dan tekanan mental selama dan setelah bencan a alam. perawat memainkan peran penting dalam mendidik populasi rentan ini untuk menghadapi potensi bencana alam. asosiasi kesehatan obstetri dan keperawatan neonatal perempuan (awhonn, 2012) merekomendasikan bahwa peran perawat harus mencakup pendidikan untuk keluarga dengan ibu hamil dan pasca-melahirkan, keterlibatan dengan perencanaan darurat dalam keluarga hamil dan pasca-melahirkan, keterlibatan dalam perencanaan darurat pada rumah sakit dan masyarakat, menjadi relawan dengan perencanaan dan tanggap darurat, dan memasukkan perencanaan darurat bencana ke dalam kurikulum keperawatan. pendidikan persalinan juga bisa memainkan peran penting dalam mendidik wanita hami l d an pasca-melahirkan serta keluarga mereka dalam kesiapsiagaan bencana alam. (dewald & fountain, 2006; ewing, buchholtz, & rotanz, 2008; giarratano et al., 2010). edukasi yang dapat diajarkan meliputi persiapan kit darurat yang mencakup pasokan makanan dan air 3 hari, persediaan obat-obatan, barang-barang perawatan pribadi dan bayi, persediaan keselamatan, elektronik (lampu senter, radio, ponsel dengan pengisi daya, dan tambahan baterai), dan dokumen penti ng, seperti nomor telepon darurat. metode penelitian ini menggunakan de sain kuasi eksperimental dengan pendekatan non indonesian journal of nursing practices 92 equivalent control-group yaitu penelitian yang dilakukan pada dua atau lebih kelompok yang diukur sebelum dan sesudah perlakuan. penelitian dilaksanakan di wilayah kerja puskesmas kemalang kabupaten klaten dimana secara letak geografis tempat tersebut dekat dengan gunung merapi. teknik pengambilan sampel pada penelitian ini ada dengan cara menggunakan non probability sampling dengan jenis purpossive sampling. sampel terdiri d ari 30 orang yang merupakan ibu hami l dan post partum yang terpilih sebagai responden penelitian berdasarkan kriteria inklusi dan di b agi menjadi kelompok eksperimen dan kelompok kontrol. kriteria inklusi adalah ibu hamil trimester ketiga atau ibu post partum 15 hari pertama, belum pernah mendapatkan pelatihan serupa dan bersedia untuk mengikuti jalan nya penelitian dari awal sampai akhir. cara pengendalian variabel pengganggu yaitu dengan memilih responden sesuai dengan kriteria inklusi penelitian, hal ini dilakukan dengan cara memberikan kuesioner kepada calon re s p o n d en pada saat studi pendahuluan, dengan cara ini diharapkan variabel pengganggu dapat dikendalikan dan tidak me ngganggu jalannya penelitian. kelompok eksperimen berjumlah 15 ibu hamil dan post partum, kelompok kontrol berjumlah 15 ibu hamil dan post partum. responden dipilih berdasarkan nomor urut menjadi responden, responden nomor urut pertama sampai 15 dimasukkan kedalam kelompok intervensi dan nomor urut 16 sampai 30 dimasukkan kedalam kelompok kontrol. sebelum dilaksanakan penelitian, terlebih dahulu peneliti memberikan informed consent untuk menjelaskan maksud dan tujuan dari penelitian yang akan dilaksanakan. informed consent tersebut harus diisi oleh partisipan baik bers ed ia mengikuti kegiatan penelitian ataupun tidak bersedia. responden mempunyai hak meminta bahwa data yang diberikan harus dirahasiakan, untuk itu perlu adanya tanpa nama ( anonymity) dan rahasia (confidentiality). penelitian ini benar benar menjaga kerahasiaan responden dengan tidak meminta responden untuk mencantu mk an nama namun hanya mencantumkan tanda tangan atau inisial nama pada lembar persetujuan menjadi partisipan. kelompok intervensi akan menerima intervensi berupa pendidikan kesehatan bersama item insentif, yang terdiri dari leaflet, perangkat bencana pribadi termasuk diantaranya handout dan lembar checklist kit untuk bertahan selama 72 jam setelah bencana. kelompok kontrol hanya diberikan lembar checklist kit untuk bertahan selama 72 jam setelah bencana. 30 hari setelah intervensi peserta yang menyelesai kan pretest dan menyelesaikan intervensi dihubungi untuk dilakukan posttest. responden dihubungi melalu i nomor telepon yang telah mereka cantumkan pada survei awal. intervensi. pretest pada responden dilakukan dengan mengisi lembar kuesioner yang telah disediakan. pendidikan kesehatan diberikan oleh salah satu penel iti d an termasuk diskusi 10–20 menit tentang dampak bencana, kesiapsiagaan bencana, serta lembar informasi darurat untuk ibu hamil dan post partum. intervensi terdiri dari unsur-unsur yang peneliti rasakan penting untuk memberdayakan klien untuk terlibat dalam perilaku kesiapsiagaan. responden diminta untuk menyelesaik an s u rv ei pra-intervensi yang diadaptasi dari survei kesiapan keadaan darurat di rumah (blessman et al., 2007), yang digunakan untuk menilai tingkat kesiapsiagaan bencana sebelum menerima intervensi. kuesioner pada penelitian ini dimodifikasi dari 21 item pertanyaan menjadi 15 pertanyaan. 15 i te m yang berkaitan langsung dengan kegiatan kesiapsiagaan seperti “apakah anda memiliki persediaan p3k?, "dan" apakah anda memiliki 3 galon air yang tersimpan untuk persediaan?” lima item (11, 12, 15, 16, 17 dan 18 pada kuesioner asli telah dihapus) kemudian satu ite m ditambahkan untuk mencerminkan tugas yang disarankan untuk keluarga dengan ibu hamil atau post partum untuk kebutuhan pe rawatan kesehatan khusus; para peserta diberi skor kesiapan berdasarkan jumlah item kesiapsiagaa n yang berhasil diselesaikan dengan rentang kemungkinan 0-15 (butir 16 tidak dimasukkan vol. 2 no. 2 desember 2018 93 dalam skor kesiapan karena hanya berisi informasi untuk menghasilkan detail pada item sebelumnya). analisa yang digunakan pada penelitian ini adalah menggunakan uji tdependen dan t-independen. hasil tabel 1. homogenitas karakteristik responden pada kelompok eksperimen dan kelompok kontrol berdasarkan tabel 1. hasil uji statistik menggunakan uji kolmogorov-smirnov untuk melihat homogenitas antara kelompok eksperimen dan kelompok kontrol. hasil yang didapatkan adalah antara kelompok eksperimen dan kelompok kontrol tidak ada perbedaan yang signifikan dengan p value > 0,05. hal ini berarti karakteristik responden antara kelompok eksperimen dan kelompok kontrol adalah homogen. tabel 2. kesiapan dan pengetahuan ibu hamil dan post partum pada kelompok eksperimen sebelum dan sesudah diberikan pendidikan kesehatan tabel 2. menunjukkan hasil uji statistik didapatkan mean sesudah diberikan pendidikan kesehatan pada kelompok eksperimen lebih rendah pada saat pretest yaitu sebesar 56,23 dengan standar deviasi 8,87 daripada saat posttest yaitu sebesar 83,92 dengan standar deviasi 12,12. hasil analisa diperoleh p value= 0,000 (p<0,05), berarti ada perbedaan yang signifikan rata-rata sebelum dan sesudah diberikan pendidikan kesehatan pada kelompok eksperimen. tabel 3. perbedaan kesiapan pada kelompok eksperimen dan kelompok kontrol sesudah diberikan pendidikan kesehatan hasil analisa diperoleh p value (0,000) < α (0,05), maka ho ditolak dan ha diterima. sehingga dapat disimpulkan ada perbedaan yang si gnifikan antara rata-rata kesiapan ibu hamil sesudah diberikan pendidikan kesehatan pada kelompok eksperimen. karakteri s ti k kel ompok kel ompok eks peri men kontrol p value (n = 15) (n = 15) n % n % mul ti para 3 20,0 6 40,0 0,925 nul i para 2 13,3 1 6,7 pri mi para 10 66,7 8 53,3 pekerj aan wi ras wasta 1 6,7 1 6,7 0,999 ibu rumah 13 86,7 11 73,3 tangga 0 0 1 6,7 pedagang 1 6,7 2 13,3 lai n-l ai n pendi di kan sd 2 13,3 7 46,7 0,999 smp 3 20,0 6 40,0 sma 10 66,7 2 6,7 pt 0 0 2 13,3 indonesian journal of nursing practices 94 pembahasan ada perbedaan yang signifikan dari hasil pretest dan posttest. hasil dari pengisian kuesioner kesiapan didapatkan bahwa dari total 30 responden, kurang dari sepertiga responden melaporkan memiliki rencana komunikasi darurat keluarga yang tertulis jelas (12,2%) atau tempat pertemuan di luar lingkungan jika mereka terpisah (24,4%). barang-barang lainnya termasuk memiliki kit persediaan darurat (24,4%), pasokan air selama 3 hari (18,5%), dan salinan rencana medis darurat (27,3%). setelah dilakukan pendidikan kesehatan hasil post test meningkat menjadi rata-rata lebih dari 50% p ad a setiap item pada kelompok intervensi. para pemangku kepentingan dan keluarga, perlu dimasukkan dalam perencanaan kesiapsiagaan bencana. penelitian ini mendukung pengembangan program pendidikan bencana yang menargetkan keluarga ibu hamil dan pas ca melahirkan. perawat perlu untuk mengembangkan pelati han yang dibutuhkan. topik-topik harus fleksibel, ringkas, dan akurat sehingga dapat disesuaikan dengan perbedaan karakteristik tempat tinggal dan budaya setempat. handout dengan gambar dapat digunakan sehingga dapat berfungsi un tu k mengilustrasikan kemungkinan-kemungkinan yang terjadi pada subyek penelitian seperti komplikasi, mengenali perdarahan pasca persalinan, dan menyusui atau relaktasi pada saat terjadinya bencana. pendidikan kesehatan h aru s dapat membuat keluarga lebih sadar akan bencana alam dan apa yang dapat mereka lakukan untuk mempersiapkan. dengan memberikan mereka pendidikan dan handout penting untuk meningkatkan keamanan dan sumber daya mereka selama bencana. checklist keluarga untuk menjaga keluarga dan rumah aman juga akan bermanfaat. yasunari (2011) menyarankan bahwa wanita hamil akan dapat menerima pendidikan ini ketika mereka melihat bahwa bencana dapat mempengaruhi keluarga mereka. persediaan untuk perlengkapan kelahiran darurat pada saat bencana perlu dipersiapkan oleh keluarga seperti apa yang ada dalam daftar yang kemungkinan besar mereka miliki dan apa yang dapat mereka lakukan. penting bagi perawat untuk membantu keluarga memprioritaskan barang-barang yang paling penting dan ekonomis. kesimpulan intervensi berhasil meningkatkan tingkat kesiapan keluarga dalam menghadapi bencana, terutama untuk ibu hamil dan post partum. informasi ini sangat penting untuk dibagikan dengan para relawan dan pemerintah di tingkat lokal dan nasional. lembaga-lembaga tersebut dapat memberikan bantuan dalam mempersiapkan perangkat kesiapsiagaan bencana bagi keluarga yang kurang mampu untuk menyediakan persediaan yang diperlukan. pendanaan hibah dan dan penelitian untuk kesiapsiagaan bencana bagi keluarga yang hamil dan setelah melahirkan sangat diperlukan. referensi american congress of obstetricians and gynecologists (acog). (2010). preparing for disasters: perspectives on women. obstetrics & gynecology, 115(6), 13391342. american red cross. (n.d.) prepare for disasters before they strike: build a disaster supply kit. retrieved from http://www.nddh.org/cpca/planning_and_prepar edness/individual_and_family_prepare d ness/home_disaster_supplies/build-akit.pdf association of women’s health obstetrics and neonatal nurses (awhonn). (2012). th e role of the nurse in emergency preparedness. nursing for women's health, 16(2), 170-172. doi:10.1111/j.1751-486x.2012.01726.x blackwood, b., albarran, j. w., & latour, j. m. (2011). research priorities of adult intensive care nurses in 20 european countries: a delphi study. journal of advanced nursing, 67(3), 550-562. doi:10.1111/j.1365-2648.2010.05512.x vol. 2 no. 2 desember 2018 95 comrey, a. l., & lee, h. b. (2013). a first course in factor analysis. hoboken: nj:taylor & francis. department of homeland security. (n.d.). plan and prepare for disasters. retrieved from http://www.dhs.gov/topic/plan-andprepare-disasters dewald, l., & fountain, l. (2006). ask an expert. introducing emergency preparedness in childbirth education classes. journal of perinatal education, 15(1), 49-51. emergency preparedness for childbirth. (2011). journal of midwifery & women’s health, 56(2), 185-186. doi:10.1111/j.15422011.2010.00020.x ewing, b., buchholtz, s., & rotanz, r. (2008). assisting pregnant women to prepare f o r disaster. mcn: the american journal of maternal child nursing, 33(2), 98-103. federal emergency management agency (fema). (2008). national response framework. retrieved from http://www.fema.gov/pdf/emergency/nr f/nrf-core.pdf vol. 2 no. 2 desember 2018 61 indonesian journal of nursing practices erni yuniati akademi keperaw atan setih setio, muara bungo, 37211 indonesia korespondensi: erni yuniati email: up2m_akperss@yahoo.com sandplay mempengaruhi perkembangan motorik halus anak usia prasekolah info artikel online issn doi : : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.2280 abstrak latar belakang: menurut who, 5-25% anak us i a pras ekol ah mengal ami gangguan perkembangan motori k hal us . perkembangan motori k hal us anak s alah s atunya di pengaruhi ol eh penggunaan al at permai nan edukati f. terdapat j eni s permai nan edukati f yang di gunakan dal am mens ti mul us perkembangan motori k hal us anak di antaranya adalah pas ir (sandplay). namun s ayangnya di l apangan , kegi atan yang dapat mens ti mul us perkembangan motori k hal us anak mas i h bel um di l akukan dengan adekuat, dal am hal i ni frekuens i nya mas i h kurang dari yang di gunakan. sehi ngga perkembangan motori k hal us anak menj adi kurang opti mal . tujuan: tuj uan penel i ti an i ni untuk mengetahui pengaruh penggunaan al at permai nan edukati f j eni s pas i r (sandplay) terhadap perkembangan motori k hal us anak us i a prasekol ah di taman kanakkanak at taqwa mekars ari , ci mahi jawa barat. metode: penel i ti an i ni menggunakan metode penel i ti an quasi experiment design dengan rancangan pretest dan posttest. tekni k pengambi l an s ampel menggunakan purposive sampling s ej uml ah 17 res ponden kel ompok i ntervens i permai nan edukati f j eni s pas i r (sandplay). cara pengumpul an data menggunakan kui s i oner dan dengan cara obs ervas i . peni l ai an menggunakan l embar i ns trumen denver ii yang di ambi l as pek pengukuran motori k hal us . anal i s a data yang di gunakan adal ah uj i t 2 s ampel dependen dan uj i t 2 s ampel i ndependen untuk bi vari at. hasil: penel i ti an membukti kan bahwa terdapat pengaruh i ntervensi permai nan edukati f j eni s pas i r (sandplay) terhadap perkembangan motori k hal us anak us i a pras ekolah. berdas arka n hasil p en el i ti a n , untuk mens ti mul us perkembangan motori k hal us anak, agar di l akukan dengan menambah frekuens i permai nan, dapat menggunakan pas i r (sandplay). kata kunci : perkembangan motori k hal us , s ti mul us sandplay. abstract background: according to who, 5-25% of preschool aged children experience impaired smooth motor development. fine motor development of the child one of them influenced by the use of educational game tools. there are types of educational games used in stimulating smooth motor development of children such as sand (sandplay). but unfortunately in the field, activities that can stimulate the smooth motor development of children are still not done adequately, in this case the frequency is still less than that used. so the smooth motor development of the child becomes less than optimal. mailto:muda101180@gmail.com 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/4079 indonesian journal of nursing practices 62 objective: the purpose of this research is to know the effect of using sand game of sandblast (sandplay) to the fine motor development of preschool age children in kindergarten at taqwa mekarsari, cimahi, west java. method: this research uses quasi experiment design method with pretest and posttest design. the sampling technique used purposive sampling of 17 respondents of intervention group of educational game of sand (sandplay) type. assessment using the denver ii instrument sheet taken on the fine motor measurement aspect. data analysis used is t test of 2 dependent samples and t test 2 independent samples for bivariate. result: the result of the research shows that there is an influence o f sandplay game education to the development of fine motor of children. based on the results of research, to stimulate the smooth motor development of children, to be done by increasing the frequency of the game, can use sand (sandplay). keywords : development of fine motor, sandplay stimulus mukhripah i¹, dwi r pendahuluan seorang anak dapat mengalami keterlambatan perkembangan pada hanya satu ranah perkembangan saja, tetapi dapat pula di lebih dari satu ranah perkembangan. masalah ranah perkembangan yang sering terjadi pada anak usia dini/ prasekolah adalah perke mbangan motorik halus. dampak yang terjadi apabila kurangnya pencegahan gangguan perkembangan motorik halus pada anak akan menyebabkan perkembangannya tidak sesuai dengan umur, misalnya pada anak prasekolah seharusnya sudah mampu dalam hal motorik halus te tapi jika ada penyimpangan anak hanya mampu untuk melaksanakan tahap perkembangan motorik halus dibawah usia perkembangannya (sa’amah, 2012). sebagai contoh pada anak usia prasekolah anak belum mampu melakukan tugas perkembangan sesuai dengan usianya yaitu memegang krayon dengan benar. solusi yang dapat dilakukan untuk mencegah terjadinya gangguan perkembangan motorik halus pada anak yaitu dengan melakukan deteksi dini tumbuh kembang anak dan skrining serta orang tua memberikan stimulasi lebih awal (sa’amah, 2012). motorik halus merupakan aspek yang berhubungan dengan kemampuan anak untuk mengamati sesuatu. motorik halus merupakan kegiatan melakukan gerakan yang melibatkan bagian-bagian tubuh tertentu saja dan dilak u kan otot-otot kecil, tetapi memerlukan koordinasi yang cermat. misalnya kemampuan untuk menggambar dan memegang sesuatu benda. world health organizations (who, 2009), melaporkan bahwa 5-25% dari anak-anak usia prasekolah menderita disfungsi otak minor, termasuk gangguan perkembangan motorik halus. data menunjukkan bahwa 0,4 juta atau sekitar 16% usia prasekolah di indonesia mengalami gangguan perkembangan. hal ini terjadi dipicu oleh kurangnya deteksi dini dan kurangnya stimulasi yang diberikan untuk mendukung perkembangan motorik halus. anak usia prasekolah adalah anak usia 3-6 tahun yang belum menempuh sekolah dasar. pend apat lain mengemukakan bahwa usia 4-6 tahun disebut dengan anak usia prasekolah yang merupakan bagian dari anak usia dini yang berada pada rentang usia lahir sampai 6 tahun dan fase ini merupakan usia emas (golden age). untuk mengetahui tahap perkembangan anak diperlukan deteksi dini tumbuh kembang (ddtk). deteksi dini pada anak prasekolah dilakukan dengan menggunakan kuisioner pra skrining perkembangan (kpsp)/ ddst. kpsp/ ddst dapat dilakukan oleh tenaga kesehatan (dokter, bidan dan perawat) sesuai dengan standar yang ada. vol. 2 no. 2 desember 2018 63 faktor yang mempengaruhi perkembangan anak usia prasekolah salah satunya adalah bermain. bermain adalah cara yang paling berharga, melalui bermain, anak akan menggunakan sensor motorik atau fungsionalnya. bermain pasir d ap at mengasah keterampilan motorik halus dengan melatih gerakan otot-otot jari, dan syaraf taktil anak, pergelangan tangan yang membutuhkan koordinasi mata dan tangan, kecepatan, ketepata n telapak dan jari yang sangat diperlukan untuk mengembangkan kemampuan menulis permulaan pada anak usia prasekolah (rubianti, 2013). hasil penelitian rufaida (2013), tentang penerapan bermain pasir untuk meningkatkan kemampuan motorik halus pada anak kelomp o k a tk yunior surabaya menunjukkan bahwa penerapan bermain pasir telah mampu meningkatkan kemampuan motorik halus. fenomena saat ini, pada tahun pertama, sering kali tenaga kesehatan dan orang tua lebih memfokuskan pada perkembangan motorik kasar saja. hal ini menyebabkan perkembangan motorik yang dianggap normal tersebut dengan suatu harapan yang semu terhadap kemampuan intelektual anak. padahal perkembangan motorik halus merupakan indikator yang lebih baik (l e bi h dapat menilai kemampuan motorik anak) daripada motorik kasar, dalam diagnosis gangguan motorik pada anak. taman kanak-kanak (tk) at taqwa, dari jumlah anak yaitu 85 orang, terdapat sekitar 40% anak belum dapat melaksanakan tugas perkembangan sesuai dengan usianya pada aspek motorik halus . masih terdapatnya data dan hambatan tersebut, perlu dilakukan pengembangan terhadap kemampuan motorik halus anak agar memiliki kemampuan motorik halus yang lebih baik. berdasarkan latar belakang di atas, maka rumusan masalah dalam penelitian ini adalah pengaruh penggunaan alat permainan edukatif jenis pasir (sandplay) terhadap perkembangan motorik halus anak usia prasekolah di taman kanak-kanak at taqwa mekarsari, cimahi jawa barat. tujuan penelitian ini adalah untuk mengetahui pengaruh penggunaan alat permainan edukatif jenis pasir (sandplay) terhadap perkembangan motorik halus anak usia praskekolah. di taman kanak-kanak at taqwa mekarsari, cimahi jawa barat. metode penelitian ini menggunakan rancangan penelitian quasi eksperimen dengan menggunakan desain pretest dan posttest. untuk mengukur pretest dan posttest menggunakan uji t dimana uji t 2 sampel dependen digunakan untuk melihat apakah ada pengaruh pretest dan posttest pada kelompok intervensi yang diberikan permainan pasir (sandplay). populasi pada penelitian ini adalah anak usia prasekolah tk at taqwa mekarsari cimahi berjumlah 85 orang. teknik pengambilan samp e l dalam penelitian ini menggunakan purpossive sampling yaitu metode pemilihan sampel yang dilakukan berdasarkan maksud atau tujuan tertentu yang ditentukan oleh peneliti. sampel dalam penelitian ini adalah anak prasekolah di tk at taqwa dengan kriteria inklusi. berdasarkan perhitungan sampel minimal menurut sugiyono (2012) dan berdasarkan perhitungan rumus sampel maka didapatkan sampel yaitu 17 orang diberikan perlakuan permainan pasir ( sandp la y) . penelitian dilakukan selama 1 (satu) bulan , y ai tu bulan april 2016, penilaian menggunakan lembar kuisioner biodata anak usia prasekolah, le mb ar/ instrumen untuk melihat perkembangan motorik halus anak prasekolah (modifikasi dari denver ii aspek motorik halus) dan prosedur penggunaan alat permainan edukatif pasir (sandplay). anali sa data yang digunakan adalah analisa univariat d an bivariate dengan uji t-test. hasil rerata perkembangan motorik halus anak sebelum dan setelah diberikan permainan edukatif jenis pasir (sandplay) tabel 1. rerata perkembangan motorik halus anak sebelum dan setelah diberikan permainan edukatif jenis pasir (sandplay) variabel mean sd minimalmaksimal 95%ci pretest 3,35 0,493 3-4 3,103,61 posttest 1,94 0,659 1-3 1,602,28 indonesian journal of nursing practices 64 berdasarkan tabel 1 dengan memperhatikan hasil pada pretest dan posttest intervensi permainan edukatif jenis pasir (sandplay) didapatkan nilai rata-rata pretest 3,35, (95% ci = 3,10-3,61) dengan sd 0,493, nilai pretest terendah 3 dan tertingi 4. dari hasil estimasi intervensi disimpulkan bahwa 95% diyakini bahwa rerata perubahan perkembangan motorik halus anak sebelum intervensi permainan edukatif jenis pasir (sandplay) adalah antara 3,10 sampai dengan 3,61. sedangkan pada hasil posttest intervensi permainan edukatif jenis pasir ( sandplay) didapatkan nilai rata-rata posttest 1,94, (95% ci = 1,60-2,28) dengan sd 0,659, nilai posttest terendah 1 dan tertinggi 3. dari hasil estimasi intervensi disimpulkan bahwa 95% diyakini bahwa rata-rata posttest perkembangan moto ri k halus anak dengan kelompok intervensi permainan edukatif jenis pasir (sandplay) ad al ah antara 1,60 sampai dengan 2,28. dari hasil estimasi interval disimpulkan bahwa 95% diyakini selisih rerata peningkatan perkembangan motorik halus anak sebelum dan setelah intervensi permainan edukatif jenis pasir (sandplay) ad al ah antara 1,5 sampai dengan 1,33. analisis pengaruh penggunaan alat permainan edukatif jenis pasir (sandplay) terhadap perkembangan motorik halus anak usia prasekolah tabel 2. hasil analisis pengaruh penggunaan alat permainan edukatif jenis pasir (sandplay) terhadap perkembangan motorik halus variabel mean sd se p value n pretest 3,35 0,493 0,119 0,0001 17 posttest 1,94 0,659 0,160 0,0001 17 berdasarkan tabel 2 menunjukkan bahwa hasil uji t 2 sampel dependen intervensi permainan edukatif jenis pasir (sandplay), dari hasil analisa “paired sample statistic” terlihat perbedaan nilai p yang dapat dilihat pada kolom sig (2-tailed). jika nilai p < 0,05 maka kesimpulannya yaitu ada perbedaan yang signifikan rata-rata pretest dan posttest. berdasarkan tabel 3.3 didapatkan bahwa rata-rata perkembangan motorik halus sebelum dilakukan permainan edukatif jenis pasir (sandplay) atau pretest adalah 3,35 dengan standar deviasi 0,493. setelah dilakukan permainan edukatif jenis pasir ( sandplay) atau posttest, didapatkan rata-rata perkembangan motorik halus adalah 1,94 dengan standar deviasi 0,659. terlihat bahwa mean perbedaan antara pretest dan posttest adalah 1,41 dengan standar deviasi 0,712. hasil uji statistik didapatkan nilai p = 0,0001 maka dapat disimpulkan ada perbedaan yang signifikan rata-rata motorik halus sebelum dan setelah dilakukan permainan edukatif jenis pasir (sandplay). pembahasan rerata perkembangan motorik halus anak sebelum dan setelah dilakukan permainan edukatif jenis pasir (sandplay) dari hasil penelitian didapatkan hasil bahwa selisih rerata peningkatan perkembangan motorik halus sebelum dan setelah dilakukan intervensi permainan edukatif jenis pasir (sandplay) yaitu antara 1,5 sampai dengan 1,33. kelompok intervensi pasir (sandplay) berjumlah 17 orang terdiri dari 8 orang laki-laki dan 9 orang perempuan, didapatkan bahwa sebagian besar anak sebelum diberikan permainan edukatif jeni s pasir (sandplay), motorik halusnya sedang yaitu 11 responden (64,7%), selebihnya adalah 6 (35,3%) responden memiliki perkembangan motorik halus rendah. kemudian setelah dilakukan intervensi permainan edukatif jenis pasir (sandplay) didapatkan bahwa sebagian besar anak motorik halusnya dalam kriteria tinggi yaitu 10 (58,8%) responden, kemudian anak dengan perkembangan motorik halus sangat tinggi yaitu 4 (23,5) responden dan selebihnya adalah 3 (17,6%) responden memiliki perkembangan motorik halus sedang. berdasarkan penelitian rufaida (2013), yang menyatakan bahwa dalam kegiatan bermain pasir di tekankan pada keterampilan menggunakan jari jemari tangan dan gerakan pergelangan tangan yang tepat. perkembangan motorik halus terjadi ketika anak bermain pasir basah, anak membuat gambar-gambar diatas pasir, menulis dengan jarinya, maupun dengan kayu/ranting diatas pasir, mencetak telapak tangan dipasir, mencetak pasir dengan berbagai bentuk, membuat istana dari pasir, membuat terowongan dari pasir. vol. 2 no. 2 desember 2018 65 sejalan dengan hasil penelitian ini, bahwa bermain pasir (sandplay) dapat menstimulasi atau meningkatkan kemampuan motorik halus anak. hal ini dikarenakan anak diberikan stimulus bermain pasir secara terus-menerus dan teratur, dimana dalam bermain pasir merup ak an kegiatan anak melakukan eksplorasi sensori motor yang dapat merangsang perkembangan motorik halus. hasil penelitian ini sesuai dengan teori yang diungkapkan, bahwa anak yang banyak mendapat stimulasi akan lebih cepat berkembang dari p ada anak yang kurang atau bahkan tidak mendapat stimulasi. perkembangan motorik halus dapat dikembangkan dengan bermain yang melatih koordinasi otot-otot tangan dalam beraktivitas seperti bermain pasir (sandplay). sejalan dengan teori yang menjelaskan bahwa agar proses belajar mengajar dapat mempero l eh hasil optimal, sebaiknya siswa diajak untuk memanfaatkan semua alat inderanya. bagaimana kita berupaya untuk menampilkan rangsangan (stimulus) yang dapat diproses dengan berbagai indera. semakin banyak alat indera yang digunakan untuk menerima dan mengolah informasi semakin besar kemungkinan info rmasi tersebut dimengerti dan dapat dipertahankan dalam ingatan. pengaruh penggunaan alat permainan edukatif jenis pasir (sandplay) terhadap perkembangan motorik halus anak dari hasil penelitian didapatkan hasil bahwa rata rata perkembangan motorik halus sebelum dilakukan permainan edukatif jenis pasir (sandplay) adalah 3,35. setelah dilakukan permainan edukatif jenis pasir (sanplay), didapatkan rata-rata perkembangan motorik halus adalah 1,94. terlihat bahwa meanq perbedaan antara sebelum dan setelah dilakukan intervensi permainan edukatif jenis pasir (sandplay) adalah 1,41. hasil uji statistik didapatkan nilai p = 0,0001 maka dapat disimpulkan ada perbedaan yang signifikan rata rata motorik halus sebelum dan setelah dilakukan permainan edukatif jenis pasir (sandplay). berdasarkan penelitian menyatakan bahwa peningkatan perkembangan motorik halus anak sebelum dan setelah diberikan stimulus dikarenakan stimulus yang diberikan secara sering dan teratur akan diterima oleh panca indra dan selanjutnya akan disampaikan ke otak. otak maupun panca indra anak yang belum mencapai tingkat perkembangan yang optimal, pemberian stimulus tersebut merupakan pelajaran yang baru. hal ini akan memicu otak untuk belajar, menganalisa, memahami dan memberikan respon yang tepat terhadap stimulus yang diberikan. sejalan dengan hasil penelitian ini terlihat bah w a terjadi peningkatan rata-rata dari sebelum dilakukan intervensi permainan menjadi meningkat setelah dilakukan intervensi permainan pasir (sandplay). pemberian sti mu lu s permainan pasir (sandplay) yang dilakukan secara terus-menerus pada anak usia prasekolah membantu merangsang kemampuan motorik halus anak. karena pada anak usia prasekolah yang sering diberikan stimulus dengan permainan edukatif salah satunya adalah pasir, anak akan merasa senang dan dapat berimajinasi dengan permainannya. pada saat bermain pasir, anak akan melibatkan otot-otot kecil, jari-jemari tangan serta koordinasi mata dan tangan yang sangat bermanfaat dalam menstimulus perkembangan motorik halus anak. hasil peneitian ini selaras dengan penelitian rufaida (2013) yang menjelaskan bahwa ada pengaruh bermain pasir terhadap perkembangan motorik halus anak. hal ini dikarenakan pembelajaran melalui pemanfaatan bermain pasir ini, yang diimplementasikan melalui aktivitas membuat coretan diatas pasir, menggambar bentuk binatang diatas pasir, mencetak model benda diatas pasir, mend oro n g anak menjadi aktif dan senang untuk menciptakan model-model mainan sesuai imajinasi, serta melatih otot-otot kecil, jari-jemari anak, melatih anak dalam koordinasi mata dan tangan yang dapat merangsang perkembangan motorik halus. hasil penelitian ini sesuai dengan teori adriana (2011), mendukung bahwa pemberian stimulus sebaiknya dilakukan setiap kali ada kesempatan berinteraksi dengan anak. semakin sering dan teratur rangsangan yang diterima, maka semak i n kuat hubungan antar sel-sel otak tersebut. indonesian journal of nursing practices 66 hasil penelitian ini didukung oleh teori yang menyatakan bahwa karakteristik anak usia prasekolah yaitu rasa ingin tahu yang kuat terhadap banyak hal (anak cenderung memperhatikan dan mempertanyakan berbagai hal yang sempat dilihat dan didengarnya terutama terhadap hal-hal baru), eksplorati f d an berjiwa petualang (anak terdorong oleh rasa ingin tahu yang kuat dan senang mencoba), senang dan kaya akan fantasi (anak senang dengan halhal yang imajinatif). kesimpulan terjadi peningkatan perkembangan motorik halus yang signifikan, hal ini terlihat dari peningkatan rata-rata kemampuan motorik halus anak, nilai rata-rata sebelum diberikan permainan edukatif jenis pasir (sandplay) menjadi meningkat sete lah diberikan permainan edukatif jenis pasir (sandplay). terdapat perbedaan yang signifikan rata-rata pretest dan posttest yaitu terjadi perubahan peningkatan perkembangan motorik halus anak setelah diberikan intervensi permainan e d u k atif jenis pasir (sandplay). dengan hasil tersebut maka dapat disimpulkan bahwa permainan jenis pasir (sandplay) sangat bermanfaat dan sangat aman diberikan kepada anak usia prasekolah untuk menstimulasi perkembangan motorik halus. ucapan terimakasih peneliti menyampaikan ucapan terimakasih kepada seluruh dosen stikes jenderal achmad yani, pihak-pihak yang ikut terlibat dalam penelitian ini antara lain kepala sekolah, guru dan siswa yang menjadi responden di taman kanak-kanak at taqwa mekarsari yang telah memberikan kesempatan dan membantu baik secara langsung maupun tidak langsung dalam melakukan penelitian ini. referensi adriana, d. (2011). tumbuh kembang & terapi bermain pada anak. jakarta: salemba medika. indrianawati, f., dan hasibuan, r. pengaruh aktivitas bermain pasir terhadap kemampuan sosio-emosional anak kelompok b di tk anissa bangah, gedangan-sidoarjo. kementrian kesehatan r.i. (2010). pedoman pelaksanaan stimulasi, deteksi dan interven si dini tumbuh kembang anak di tingkat pelayanan kesehatan dasar. indonesia sehat 2010, bakti husada. kuet, c.t. (2014). penggunaan terapi bermain pasir dalam menangani masalah perhubungan sosial antara rakan dan ahli keluarga murid tahun tiga. jurnal penyelidikan tindakan ipgk bl. 8. nirmalasari, d., mulyani, b., & utami, b. (2013). studi komparasi penggunaan media mind map dan crossword puzzle pada metode proyek ditinjau dari pada materi pokok sistem koloid kelas xi semester genap sma n 1 banyudono tahun pelajaran 2012 / 2013, 2(4), 110–117. rubianti, r., thamrin, m., dan yuniarni, d. (2013) . peningkatan keterampilan sosial melalui permainan pada anak usia 4-5 tahun, universitas tanjungpura, pontianak. 3. rufaida, n., dan reza, m. (2013). penerapan bermain pasir untuk meningkatkan kemampuan motorik halus pada anak kelompok a tk yunior surabaya. sa’amah,u(2012).tersedia http://umisaamah.blogspot.co.id/2012/07/pe ndekatan-dan-metode-pembelajarandi_07.html, diakses 07 maret 2016. shariat, a., ghamarani, a., yarmohammadian, a . , dan sharifi, t. (2014). effectiveness of sandtherapy on the attenuation of separation anxiety signs in pre-school children. international journal of kinesiology & sports science, 3 (1), 3. sugiyono. (2014). statistik untuk penelitian. bandung: alfabeta cv. suwariyah, p. (2013). test perkembangan bayi/ anak, menggunakan denver development screening test (ddst). jakarta: cv. trans i n f o media. tiara dwi yunianti, antarini idriansari, b. m. g. (2012). pengaruh metode glenn doman terhadap perkembangan bahasa dan kogni ti f anak usia prasekolah di tk ladas berendai prambuluh. saudi med j, 33, 3–8. https://doi.org/10.1073/pnas.0703993104 vol. 2 no. 2 desember 2018 67 yanti, fridalni, dan n. (2009). hubungan stimulasi terhadap perkembangan motorik halus anak prasekolah usia (3-5 tahun) di paud al mubaraqah ampang kecamatan kuranji tahun 2011. mercubaktijaya, 1. vol. 1 no. 3 desember 2017 101 indonesian journal of nursing practices emi nurlaela1, lia dwi prafitri1, dan syavira nooryana1 1 stikes muhammadiyah pekajangan pekalongan, jaw a tengah, indonesia e-mail: nurlaela_stikespkj@yahoo.co.id kepuasan ibu dalam melakukan massage bayi di wilayah puskesmas buaran kabupaten pekalongan info artikel masuk revisi diterima doi number : : 10 september 2017 : 20 november 2017 : 30 novermber 2017 : 10.18196/ijnp.1367 abstrak massage bayi merupakan ungkapan kas i h s ayang s eorang i bu mel alui s entuhan. kepuas an i bu akan tercapai apabila dapat mel akukan massage bayi s endi ri s ehi ngga menambah hubungan kas i h s ayang dan kedekatan antara i bu dan bayi . tuj uan penel i ti an i ni mengetahui gambaran kepuasan i bu dal am mel akukan massage bayi . penel i ti an i ni merupaka n penel i tian kuanti tati f j eni s des kri pti f. tekni k pengambi l an s ampel yai tu accidental sampling s ebanyak 43 res ponden. anal i s is uni vari at untuk mendes kri ps i kan kepuas an i bu dal am mel akukan massage bayi . ibu yang memi l i ki ti ngkat kepuas an rendah s ebes ar 39,5%, s edangkan i bu yang memi l i ki ti ngkat kepuas an ti nggi s ebes ar 60,5%. has i l anal i s is data di dapatkan bahwa i bu yang mel akukan massage s ecara mandi ri pada bayi, kemudi an di ukur ti ngkat kepuas annya s ebagi an bes ar i bu meras akan puas yai tu di tunj ukkan dengan i bu yang meras a s enang dan bayi yang nyaman s aat di pi j at s erta di aj ak berkomuni kas i ol eh i bu. bagi tenaga kes ehatan untuk meni ngkatkan pel ayanan dan pendampi ngan untuk memberi kan pel ati han kepada i bu untuk mel akukan mas s age bayi s ehi ngga maki n banyak i bu yang terampi l s erta memfas i l i tas i s arana dan pras arana untuk memberi kan pel ayanan dan pendampi ngan dal am pel ati han kepada ibu untuk mas s age bayi . kata kunci : kepuas an ibu, massage bayi abstract baby massage is the expression of a mother's affection through touch. maternal satisfaction will be achieved if you can do your own baby massage so as to increase the relationship of affection and closeness between mother and baby. the purpose of this stud y to know the descriptrion of maternal satisfaction in giving baby massage. this research is a descriptiv e quantitative research. the sampling technique in this study is accidental sampling counted 43 respondents. the univariate analysis to describe maternal satisfaction in infant massage. mothers who have a low satisfaction rate of 39.5%, while mothers who have a high satisfaction rate of 60.5%. the results of data analysis found that the mother who performs the massage independently in infants, then measu red the level of satisfaction most of the mothers feel satisfied that is shown with a happy mother and a comfortable baby when massaged and invited to communicate by the mother. health workers suggested to improve services and assistance to provide the training for mothers to practice baby massage so that increase skilled mothers and facilitate the tools and infrastructu re to provide services and assistance in training for the mother to massage the baby. keywords: satisfaction, baby massage mailto:nurlaela_stikespkj@yahoo.co.id1 indonesian journal of nursing practices 102 pendahuluan pijat telah digunakan untuk pengobatan dan menjadi bagian rutin perawatan bayi selama ratusan tahun di banyak kebudayaan dan salah satu teknik terapi tertua di dunia. pijat telah menjadi komponen pengembangan perawatan suportif. pijat bayi sebagai bentuk pengobatan alternatif menjadi semakin popular karena kesederhanaan, efektifitas biaya, mudah dipelajari dan dapat dilakukan di rumah oleh keluarga (pitre, 2012). pijat bayi dapat meningkatkan ikatan kasih sayang antara anak dengan orang tua, karena itu pijat bayi sebaiknya dilakukan oleh orang tua bayi (serrano, doren dan wilson, 2010). orang tua yang memijat anaknya dapat merangsang perkembangan koneksi antara sel – sel saraf otak bayi yang akan membentuk dasar untuk berfikir, merasakan dan belajar. selai n itu pijat dapat membantu bayi yang rewel sehingga dapat tidur dengan nyenyak dan dapat mengurangi penyakit, termasuk sakit perut. pijat bayi dapat digolongkan sebagai aplikasi stimulasi sentuhan (maharani, 2009). ibu adalah orang tua paling dekat dengan bayi, dimana pijatan ibu kepada bayinya adalah sapuan lembut pengikat jalinan kasih sayang. kulit ibu adalah kulit yang paling awal dikenali oleh bayi. sentuhan dan pijatan yang diberikan ibu adalah bentuk komunikasi yang dapat membangun kedekatan ibu dengan bayi dengan menggabungkan kontak mata, senyuman, ekspresi wajah. jika stimulasi sering diberikan, maka hubungan kasih sayang ibu dan bayi secara timbal balik akan semakin kuat, sehingga membuat kepuasan tersendiri kepada ibu saat melakukan massage pada bayinya (irva, hasanah, dan wofers, 2014). langkah awal yang dilakukan oleh para ibu untuk memperkecil resiko ataupun komplikasi pijat bayi, hendaklah orang tua jeli dalam memilih praktisi pijat untuk bayinya. apabila ibu belum mengerti tentang cara memijat bayi yang benar sebaiknya ibu mencari informasi melalui media yang membahas tentang pijat bayi yang benar serta diharapkan memberikan informasi pada ibu, selanjutnya ibu mengaplikasikan sendiri. di indonesia pelaksanaan pijat bayi di masyarakat desa masih dipegang perannya oleh dukun bayi. selama ini, pemijatan tidak hanya dilakukan pada saat bayi sehat, tetapi juga pada bayi sakit atau rewel dan sudah menjadi rutinitas perawatan bayi setelah lahir (aminati, 2013). tujuan penelitian ini adalah mengetahui gambaran kepuasan ibu dalam melakukan massage pada bayinya di wilayah puskesmas buaran kabupaten pekalongan. metode penelitian ini merupakan penelitian kuantitatif jenis deskriptif dimana peneliti mencari gambaran kepuasan ibu dalam melakukan massage bayi. penelitian yang dilakukan ini, menggunakan kuesioner yang telah dilakukan uji validitas dan reliabilitas. instrument penelitian berupa kuesioner tersebut yang telah dilakukan uji validitas dan reliabilitas. teknik pengambilan sampel yaitu accidental sampling di desa watusalam, wonoyoso, dan simbang kulon kemudian melakukan informed consent kepada ibu yang mempunyai bayi, melakukan praktek massage bayi kemudian dengan membagikan kuesioner kepuasan. analisis yang digunakan dalam penelitian ini adalah analisis univariat, untuk mendeskripsikan variabel kepuasan ibu dalam melakukan massage bayi yang disajikan dalam bentuk distribusi frekuensi. hasil penelitian ini melibatkan 40 orang responden dan mayoritas berusia 20-35 tahun. pendidikan responden mayoritas adalah pendidikan dasar dengan jumlah 32 orang. pekerjaan responden mayoritas tidak bekerja dengan jumlah 32 orang dan paritas responden mayoritas adalah multiparitas dengan jumlah 31 orang. karakteristik responden disajikan pada tabel 1. vol. 1 no. 3 desember 2017 103 tabel 1.karakteristik responden karakteristik jumlah (n) persentase (%) umur 20-35 tahun > 35 tahun 40 3 93 7 pendidikan pendi di kan das ar pendi di kan menengah danti nggi 32 11 74,4 25,6 pekerjaan ti dak bekerj a bekerj a 32 11 74,4 25,6 paritas pri mi paritas mul ti pari tas 12 31 27,9 72,1 kepuasan ibu dalam melakukan massage bayi terdiri dari dua tingkatan. kepuasan tinggi ibu dalam melakukan massage bayi berjumlah 26 orang. kepuasan ibu dalam melakukan massage bayi dapat dilihat pada tabel 2. tabel 2. kepuasan ibu dalam melakukan massage bayi kepuasan jumlah (n) persentase (%) kepuas an rendah 17 39,5 kepuas an ti nggi 26 60,5 nilai mean pada penelitian ini adalah 1,4 dengan nilai sd yaitu 0,495. pembahasan kepuasan ibu setelah melakukan massage bayi ditandai dengan ibu merasa senang dan bangga karena bisa melakukan massage bayi sendiri, tidak perlu bantuan dari dukun bayi lagi. kepuasan adalah tingkat perasaan seseorang setelah membandingkan kinerja atau hasil yang dirasakannya dengan harapan (kotler, 2008). hasil penelitian didapatkan sebagian besar (60,55) memiliki kepuasan tinggi setelah melakukan massage bayi di wilayah kerja puskesmas buaran kabupaten pekalongan. ibu merasa puas setelah dapat melakukan tiap gerakan massage bayi, merasa menjadi lebih dekat dengan bayinya, ibu juga menyampaikan bahwa bayi menjadi lebih nyenyak saat tidur. sedangkan ibu yang mempunyai kepuasan rendah disebabkan karena mereka menyatakan bahwa kurang percaya diri dan merasa takut untuk melakukan massage bayinya sendiri karena tindakan tersebut pada umumnya dilakukan oleh dukun bayi. menurut pernyataan salah seorang responden, di lingkungannya mereka memijatkan bayinya ke dukun bayi dikarenakan sudah merupakan hal yang umum dilakukan. hasil dari wawancara dengan responden menunjukkan bahwa keseluruhan ibu sebelumnya memijatkan bayi ke dukun bayi. dukun bayi merupakan tokoh kunci di dalam masyarakat yang berpotensi untuk meningkatkan kesehatan ibu dan bayinya. akan tetapi, perlu disadari bahwa peran dan pengaruh dukun bayi sangat bervariasi sesuai dengan kultur yang berlaku disuatu tempat. pada beberapa kultur, dukun bayi paling banyak adalah seorang wanita yang memiliki pengaruh besar di masyarakat (who, 2009). indonesian journal of nursing practices 104 dukun bayi yang berada di wilayah kerja puskesmas buaran hampir semua belum mendapatkan pelatihan dari tim kesehatan atau puskesmas, dukun bayi tersebut melakukan pijat bayi hanya berdasarkan pengetahuan dan pengalamannya sendiri. meskipun massage bayi mempunyai manfaat yang sangat besar bagi bayi, namun kenyataannya banyak ibu yang tidak mau melakukan massage pada bayinya dengan alasan tidak sempat, malas serta adanya rasa takut. hal ini menunjukkan dukun bayi yang berada di wilayah kerja puskesmas buaran masih memiliki peran yang penting dalan massage bayi. hal tersebut sesuai dengan hasil penelitian septia (2017), perilaku ibu dalam memijatkan bayi ke dukun bayi dipengaruhi oleh beberapa faktor yaitu, sumber informasi tentang pijat bayi, tempat pemijatan bayi, waktu memijatkan bayi, usia bayi, keadaan bayi, frekuensi ibu memijatkan bayi, persiapan yang dilakukan ibu saat bayinya dipijat, aktifitas yang dilakukan ibu saat bayinya dipijat, kondisi khusus bayi dipijat, aktifitas ibu setelah dilakukan pijat bayi. selain hal tersebut dia atas, faktor lain yang tidak dikendalikan dan dapat mempengaruhi kepuasan dalam melakukan massage bayi adalah pendidikan, pekerjaan, pengetahuan, sikap, paritas, ketersediaan fasilitas serta perilaku atau para petugas kesehatan. selain itu, usia mempengaruhi terhadap daya tangkap dan pola pikir seseorang. semakin bertambah usia akan semakin berkembang pula daya tangkap dan pola pikirnya, sehingga pengetahuan yang diperolehnya semakin membaik. pada usia muda, individu akan lebih berperan aktif dalam masyarakat dan kehidupan sosial serta lebih banyak melakukan persiapan demi suksesnya upaya menyesuaikan diri menuju usia tua, selain itu orang usia muda akan lebih banyak menggunakan banyak waktu untuk membaca. kemampuan intelektual, pemecahan masalah, dan kemampuan verbal dilaporkan hampir tidak ada penurunan pada usia ini (meliono, 2007dalam nuraeni 2015). berdasarkan asumsi penelitian dari nuraeni (2015) didapatkan bahwa walaupun usia ibu sebagain besar berada pada kategori dewasa awal (25-35 tahun), namun masih banyak ibu pada kategori dewasa akhir yang belum mengerti tentang pijat bayi sehingga dapat disimpulkan bahwa ibu dengan usia dewasa awal lebih banyak yang memiliki pengetahuan yang baik. peningkatan pengetahuan tidak mutlak diperoleh di pendidikan formal, akan tetapi juga dapat diperoleh pada pendidikan non formal. pengetahuan seseorang tentang sesuatu obyek juga mengandung dua aspek yaitu aspek positif dan negatif. kedua aspek inilah yang akhirnya akan menentukan sikap seseorang terhadap obyek tertentu. semakin banyak aspek positif dari obyek yang diketahui, akan menumbuhkan sikap makin positif terhadap obyek tersebut (meliono, 2007 dalam nuraeni, 2015). hasil penelitian nuraeni (2015) menyatakan, semakin tinggi pendidikan ibu maka semakin baik pengetahuan ibu tentang pijat bayi, pendidikan sangat mendukung karena pendidikan dikendalikan oleh peneliti yaitu minimal smp, sehingga pada saat penelitian sebagian besar ibuibu sangat antusias dalam mengikuti pelatihan pijat bayi ini. hal ini disebabkan karena tingkat pendidikan ibu sangat mempengaruhi pola pikir dan informasi yang diterima oleh ibu khususunya tentang pijat bayi. tingkat pendidikan ibu yang sebagian besar hanya kategori menengah keatas tentunya membuat akses informasi yang diterima ibu juga terbatas, yang berakibat pada rendahnya pengetahuan ibu tentang pijat bayi, maka dapat disimpulkan bahwa semakin tinggi tingkat pendidikan di dusun pranti responden aktif dan pernah terpapar dalam kegiatan sosial yang dilaksanakan di dusun pranti ibu dengan pendidikan menengah keatas banyak yang pengetahuannya tinggi dibanding dengan pengetahuan yang rendah. hasil penelitian kusbiantoro (2014) bahwa sebagian besar perilaku ibu kurang dalam melaksanakan pijat bayi, hal ini bisa di pengaruhi oleh faktor pendidikan ibu yang sebagian besar ibu berpendidikan slta/sma sehingga ibu masih sedikit sulit mencerna atau menerima informasi dan pada akhirnya makin berkurang pula perilaku dalam melaksanakan pijat bayi. selain itu faktor vol. 1 no. 3 desember 2017 105 umur sangatlah berpengaruh bagi seseorang dalam melakukan atau bersikap terhadap sesuatu termasuk dalam melaksanakan pijat bayi. hasil penelitian menunjukkan bahwa sebagian besar ibu berumur 21-30 tahun. ibu yang berada dalam umur tersebut tergolong umur yang sudah matang sehingga mudah untuk memperoleh informasi. hasil penelitian lestari (2015) menyatakan bahwa tinggi rendahnya keterampilan memijat bayi seseorang tidak selalu dipengaruhi oleh paritas yaitu primipara ataupun multipara. hal ini disebabkan semakin berkembangnya ilmu pengetahuan dan teknologi, sehingga seorang ibu baik primipara ataupun multipara sama-sama dapat meningkatkan pengetahuan dan keterampilan yang dalam hal ini adalah keterampilan memijat bayi. ibu yang kurang memiliki aktivitas khususnya dalam bekerja, sehingga meskipun waktu ibu cukup lama, akan tetapi ibu merasa bosan dan tidak harus segera mengerjakan pekerjaan yang lain sehingga tingkat kepuasan ibu tinggi. ibu multiparitas lebih merasa puas setelah melakukan massage bayi dikarenakan ibu multiparitas sudah mempunyai pengalaman pada saat mempunyai anak yang sebelumnya. keterbatasan dalam penelitian ini yaitu pengumpulan data menggunakan kuesioner, dimana responden akan lebih cenderung memberi jawaban yang ditambah dengan sikap dan harapan pribadi, sehingga lebih bersifat subyektif serta belum tentu menggambarkan keadaan sebenarnya yang dialami responden. penelitian ini hanya dilakukan pada ibu yang memiliki bayi dengan jumlah responden 43 sehingga hasil penelitian ini tidak dapat dige neralisasikan untuk populasi yang lain. kesimpulan hasil penelitian menunjukkan tingkat kepuasan ibu setelah melakukan massage bayi yaitu ibu yang memiliki tingkat kepuasan tinggi sebanyak 26 orang (60,5%), sedangkan ibu yang memiliki tingkat kepuasan rendah sebanyak 17 orang (39,5%). bagi tenaga kesehatan diharapkan dapat mengusahakan peningkatan pelayanan dan pendampingan untuk memberikan pelatihan kepada ibu yang mempunyai bayi untuk melakukan massage bayi sehingga makin banyak ibu yang terampil dalam melakukan massage bayi serta bagi puskesmas supaya dapat memfasilitasi sarana dan prasarana bidan untuk memberikan pelayanan dan pendampingan dalam pelatihan kepada ibu yang mempunyai bayi untuk melakukan massage bayi. ucapan terima kasih penelitian ini terlaksana atas kesempatan dan fasilitas dari sekolah tinggi ilmu kesehatan muhammadiyah pekajangan pekalongan dan bantuan dari berbagai pihak. disampaikan terima kasih kepada ketua stikes muhammadiyah pekajangan pekalongan, ketua lppm, kepala puskesmas buaran, bidan desa puskesmas buaran, dan para responden atas kerja sama dan bantuannya. referensi aminarti, dini. (2013). pijat dan senam untuk bayi & balita, cetakan ke-1. yogyakarta: brilliant books. irva, s., hasanah, o., dan woferst, r. (2014). pengaruh terapi pijat terhadap peningkatan berat badan bayi. jom psik. 1 (2). kotler, p. (2008). marketing management: analysis, planning, implementation and control, (8th edn). new jersey: prentice hall international. inc. kusbiantoro, d. (2014). perilaku pijat bayi berhubungan dengan pengetahuan dan dukungan keluarga. jurnal surya, 03 (19), 1 – 7. lestari, i. (2015). pengaruh penyuluhan dengan menggunakan metode demonstrasi dan bedside teaching terhadap keterampilan ibu melakukan pijat bayi di tinjau dari paritas. jurnal kesehatan samodra ilmu, 06 (02), 106 – 114. maharani, sabrina. (2009). pijat dan senam sehat untuk bayi. jogjakarta: kata hati. indonesian journal of nursing practices 106 nuraeni. (2015). pengaruh pelatihan pijat bayi terhadap keterampilan ibu melakukan pijat bayi di posyandu nusa indah dusun pranti pundong bantul yogyakarya. naskah publikasi. diperoleh dari http://digilib.unisayogya.ac.id/671/1/nurae ni_201410104090_naskah%20publikasi.p df pitre, s. (2012). effect of massage on physiological and behaviorral parameters among low birth weight bebies. international. journal of sciene and research (ijsr), 3 (5), 474–487. septia, p.a. (2017). gambaran pola perilaku ibu dalam memijatkan bayi ke dukun bayi di kelurahan karang tengah kecamatan sragen. naskah publikasi ums. diperoleh dari http://eprints.ums.ac.id/54839/12/naskah %20publikasi.pdf serrano, doren dan wilson. (2010). teaching chilean mothers to massage their full -term infants: effects on maternal breast-feeding and infant weight gain at age 2 and 4 months. journal of perinatal & neonatal nursing, 24 (2), 72 – 81. who. (2009) perawatan ibu & bayi pedoman praktis. jakarta: egc. http://digilib.unisayogya.ac.id/671/1/nuraeni_201410104090_naskah%20publikasi.pdf http://digilib.unisayogya.ac.id/671/1/nuraeni_201410104090_naskah%20publikasi.pdf http://digilib.unisayogya.ac.id/671/1/nuraeni_201410104090_naskah%20publikasi.pdf http://eprints.ums.ac.id/54839/12/naskah%20publikasi.pdf http://eprints.ums.ac.id/54839/12/naskah%20publikasi.pdf 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. vol. 2 no. 2 desember 2018 83 indonesian journal of nursing practices nabilah siregar braw ijaya university, indonesia korespondensi: nabilah siregar email: nabilahsiregar92@gmail.com pedriatric population in disaster: how should we care for them? info artikel online issn doi : : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.2283 abstract background: disaster might cause many impacts for vulnerable people, especially children (pediatric population). objective: this paper aims to explain how should nurse do in caring for children in disaster management. method: this review is conducted by searching many literatures from science direct, proquest, pubmed, and google scholar about children and care for pediatric population. result: management for children in disaster should consider to many important things, such as: physical condition, psychology, development and behavior. health practitioner include nurse should care for and involve families, consider to physica l and psychological need and protect children from exploitation or any harms to prevent post traumatic distress syndrome (ptsd) in disaster management. nurse should pay more attention for children as a unique vulnerable population by considering all aspects of pediatric and involve their families in disaster management. keywords: pediatric, disaster, care introduction morbidity and mortality rate in the world al w ay s increase due to many emergency cases that occurred in hospital or pre hospital setting, include disaster. disaster as an event that cau s e d of natural or social factors, might cause many negative effects such as economical aspect, health disorder and many victims include children or pediatric population. in the world, about 50% of all disaster victims are children ( cooper et.al., 2014). meanwhile, indonesia is also a country that has a high risk to get many kind of natural disasters, because indonesia located in pacific ring of fire. many health problems could occu r as impact of disaster like tsunami, or vulcano eruption that occurred recently and cause respiratory problem such as acute respiratory tract infection (puspnegoro & sujudi, 2016). infant and children are vulnerable population because of many reasons include less of preparedness of health practitioners especially to treat or care for them during disaster (drayna et.al., 2012). in united states, 25% children under 18 years old were disaster victims. so, pediatric population should get special attention, becau se of many factors, such as: physiologic, development, behavior, and mental health of children, especially in disaster preparedness planning (blake & blowers, 2018). health practitioners should remember that children have not ability to save themselves during disaster because of unability in motoric and cognitive to make a decision for their lives (emergency medical service for children, 2016). in pre hospital setting, children’s needs are depend on their parents. in almost cases, children who were separated from their parents would have mentally disorder. so health practitioners include nurse should involve their parents and care for them based on nursing care guideline, not only in pre hospital but also in hospital setting to fulfill their needs. they also 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/5185 indonesian journal of nursing practices 84 should give rapid response to disaster. consider to many pediatric population as disaster victi ms , hospital also plays important roles based on hospital disaster plan to treat the children (national association pediatric of nurse practitioners, 2011). many pediatric population in disaster victims might not get appropriate care, so morbidity an d mortality rates could increase. one of the facto rs that could affect it is less of nursing care preparedness to the children. those are basic and be reason for author to explore and describe aspects about caring for them. this review is conducted to explain how should nurse do in caring for children in disaster management. methods this literature review is conducted by searching many literatures from science direct, proquest, pubmed, and google scholar about children and care for pediatric population. criteria for the literatures are 1) explain related to the topic about pediatric care in disaster management, 2) articles exist in 10 years recently (2008-2018). the process of searching was conducted on june to july 2018, by using keywords: pediatric in disaster, children in disaster, pediatric care in nursing disaster management, pre hospital care for children in disaster, and in-hospital care for children in disaster. finally, 11 review articles and one book were used in this review. the process of searching literature is described by using prisma chart on chart 1. chart 1. flow chart of literature searching and selection results and discussion the results of searching about fourty articles about pediatric care in disaster management were found, but only 11 review articles and one book from science direct, pubmed, and google scholar are used in this review after screening, eligibility and include processing. many disasters in the world have caused many pediatric victims. in 2005, hurricane katrina had caused victims with pediatric as the most population among disaster victims include newborn. a hospital near the disaster si te received and stabilized 122 infants (orlando,et.al., 2010). not only that, indonesia also is one of many countries with high risk to have many disasters have caused many pediatri c victims. because of indonesia located in ring of fire lane so makes many natural disasters could occur, like tsunami, eruption, and other disasters. in 2013, eruption of sinabung mountain in north sumatera occurred and caused 2,856 records after dup licates removed (n = 38) dup licated record (n = 2) records identified through database searching: science direct (n = 20), proquest (5), pubm ed (n = 4), google scholar (n= 11) s cr e e n in g in cl u d e e li g ib il it y id e n ti fi ca ti o n records screened (n = 38) full-text articles assessed for eligibility (n = 38) ) full-text articles excluded (n = 26) with reasons: not fulfill the criterion literature review (n = 11 articles) and 1 book vol. 2 no. 2 desember 2018 85 children with all education levels (elementary, junior and senior high school) were evacuated (nugroho, 2013). most of evacuees include children had various health problems such as: acute respiratory tract infection (39.1%), gastritis (16%), conjungtivitis (12.4%), diarrhea (4.9%), and skin diseases (0.7%) (pakpahan, 2016). weiner (2009) said that the proportion and severity of illness or injury in pediatric victims are dependent on location, time and type of disaster. they are more likely be victims when they are o n the site of disaster like school hostage or bombing in school area or daycare cente r. disaster that occures in school time for children to study also results more proportion of them as victims. type of disaster like tsunami in 2004 in indian ocean results more victims of pediatric population than hurricane in katrina because th e power of ocean wave to sweep away them include health practitioners. in other hand, th e re were still many health practitioners to help children as victim of this type of disaster. most o f children have less ability to escape and protect themselves. national association of pediatric nurse practitioners (2011) explained that pediatric population is one of many vulnerable populations because they live dependently to their parents, not only physic but also psychologic. they also have not had physical capacities and ability in taking decision to save and protect themselves. moreover, health practitioner should consider to charachteristic of children such as: physiology anatomy (small body size and fewer body fat, fewer blood volume, thinner skin, and lower immune system), physical and emotional dependent, and development (drayna et.al., 2012). rapid minute volume, large and permeable body skin make them susceptible to be exposured and get debris or other negative effects from biological, toxic or chemical materials (american academy of pediatrics, 2015). in addition, children would have many pro b l e ms during or post disaster. during disaster, care providers should pay more attention about shelter, diapers, formula, foods or other suppl i es that appropriate to their age. their immune systems are lower than adults because children especially infants and children under five years have not perfect or mature immunity. some of them might not get complete immunization als o . so, children are more likely to get infection f ro m disaster, like outbreak or hazardous environments. children tend to get malnutritio n easier in pre, during, and post disaster phase, dehydration, and multiple injury easier than adults (weiner, 2009). children also might need medication with age-appropriate dosage, h e al th equipments, and care delivery more intensive than adults. after disaster, chidren would have other problems that are long-terms effects of disaster such as post traumatic stress disorde r o r behavioral problems. because of those conditions and reunification as an issue in disaster, so emergency practitioners should coordinate and strive to take them back to their parents or guardians as soon as possible (cornette & so, 2011). considering to children’ characteristics, health practitioners should have knowledge and skill about caring for pediatric population in disaster, whether in pre hospital or in-hospital setting, and use health equipments and medication appropriately (bouton & becker, 2016). world health organization and international coun ci l o f nursing (2009) said that nurses’ competencies i n caring for vulnerable people include pediatric population are: a) identify vulnerable group, their responses and needs; b) create environment that help them to live with their functions as pos s i b le as they can; c) advocate vulnerable population; d) identify resources to help them; e) caring for vulnerable population (pediatric); f) co l l ab o rate with other health organization to help complete vulnerable people needs (children’ needs). health providers especially nurse have importan t rule to treat them, care and help to address needs and save children, especially pay a s p e ci al attention in their physical, mentally or psychological needs. so. when caring for pediatric population in disaster, nurse shoul d : a) understand about emergency planning in caring during disaster; b) use and supply medical equipments according to the age and body size; c) understand about medication using based on dosage for children; d) do triage for childre n an d their families; e) do physical and psychological indonesian journal of nursing practices 86 care; f) provide stabil and safety environment f o r children and their families in recovery phase; g) collaborate with other professional health te am to construct infrastructure in community and support for long term care based on childrens’ needs (national association of pediatric nurse practitioners, 2011). pediatric also could get exploitation or sexual abuse by adults, so they would get post traumatic distress syndrome (ptsd) (bouton & becker, 2016). kar (2009) also said that ptsd occurred about 5–43% in pediatric population after disaster. children especially pre school children usually get anxiety. so, rapid initial screening about syndrome and psychologic in children or their parents is needed. interve nti on that health practitioners include nurse could do when caring pediatric population in disaste r are : a) communicate and support children, and ap p l y family context approach in order to understand their conditions; b) psychotherapy could be applied by playing or art activities, and give a chance for them to tell something or someone that they love; c) post disaster consultation to help communication between children and th e i r families or society; d) cognitive behavior therapy, to children or teenagers; e) emotional first aid technique to clarify the facts, to normalize childrens’ reactions, and to teach about problem solving; f) group therapy; g) playing therapy like story telling and draw i n g; h ) involve childrens’ parents or families (psychoeducation); i) refer patients or victi ms to secondary health care; and j) medication using like antidepressant for victim with convulsive or other serious conditions. in addition, health providers include nurse should have a good disaster plan and preparedness to address many problems that might be occurred in children. comprehensive disaster plan not only in pre hospital (site or community) but also inhospital are needed to give immediate and appropriate response as disaster management. organized plan and system with trained pediatric health providers and pediatric nurses, and health related technologies should be prepared before disaster occurred for better pediatric disaster management. pre hospital and hospital reponse could be correlated. pediatric victims must be transferred to hospitals that have complete and good equipment and staff for pediatric care (weiner, 2009). because of distinctive physical, development, and psychological aspects of children, it is important to have disaster plan for pediatric population (burke et.al., 2010). furthermore, drayna et.al., (2012) and new york city health (2008) described manythings that should be considered in caring for pediatric victims in hospital based on hospital guideline for pediatric preparedness: a) activate the hospital disaster plan; b) do appropriate pediatric triage: jumpstart algorithm on disaster site, a rapid visual assessment and more detailed triage assessment in hospital, include mentally status assessment based on their developments; c) decontamination according to pediatric age groups, and caregiver should use personal protective equipment; d) provide adequate nutrition based on age and condition of childre n ; e) hospital should prepare surgeon and surgery related equipment with appropriate size, and patient bed at intensive care unit and surgery room; f) it is recommended to hospital to build an information and family support center in disaster plan to address psychosocial problem and give family-centered pediatric care; g) prevent or control infection between infected children and their caregivers; h) supply medications to children with emergency condition, sufficient and use exact dosage for children; i) care for physical need but also mental or psychosocial in children and their caregivers pre, during, and post disaster; j) save children from kidnapping or any harm, transport victim inter and intra hospital to appropriate room and supported by staff and equipments; k) staff or care giver, doctor and nurse identification and development, with experience and skill in pediatric care; and l) conduct training for caregiver about trauma life support and emergency care in children. moreover, orlando et.al. (2010) explained that pediatric nursing care in hospital according to disaster management phases are: a) mitigation: nurses play important roles such as identify s af e location or evacuation, design and planning for vol. 2 no. 2 desember 2018 87 care unit like perinatal or pediatric unit; b) preparedness: nurses’roles in this phase are to be involved in personal development of disaster plan, identify option of caring by family, self preparedness by education and training to give high standard care as what victims need; c) response: nurses have roles to assess, triage, physical and mental monitoring to patient (victim) that still survive, give appropriate care, evacuation children, infant and their mothers, communicate and transfer or discharge patient appropriately; and d) recovery: nurses with hospital party to anticipate emergency medical care for routin care to children and their mothers in community, coordination and collaborate wi th health care in community about shelter, food supply; and mental care of children and their families. blake and bowers (2018) also said that considered to unique needs in pediatric population or adolescents such as physical, psychological, development and behavior require health practitioner include nurse to pay particular attention fo them in disaster and emergency preparedness planning. unfortunately, a study in 2015 said that only 47% of all hospitals had disaster plan for pediatric population. not only hospital near the disaster site, but stakeholders in community have to prepare such a system-based approach by coordinating with other community partners. country with stakeholders, departement of health, emergency medical service, hospital whether pediatric hospital or other hospitals, pediatric experts and surge capacity involved and work together in disaster management or preparedness plan. emergency or disaster preparedness and response plan for pediatric should be applied sustainably and integrated with all local or regional health care systems. a special guideline or standard and training for addressing pediatric needs is required in comprehensive disaster plan. even in this crises situation, registered or advanced pediatric n u rs e must be involved and play important roles in disaster plan and preparedness. pediatric nurse should understand all about children, work together, provide communication and coordination with other local community health care or providers, school, church or other worship places to strengthen disaster preparedness. pediatric nurses also play a rol e as advocator for pediatric victims by motivating or ensuring policymaker about how crucial a legislation for pediatric in disaster is. health policy regarding to unique characteristic and long-term impact of disaster to all aspects of children is needed to help providers to recogn i z e and address their needs. furthermore, caring for vulnerable population include children has a main goal to make them less of vulnerable, be safe and resilient. to achieve this goal, national commission on children and disaster (2010) made 11 categories as recommendation to achieve the goal and improve preparedness, response and recovery for pediatric in disaster. those categories are: a) integration, means disaster management activities especially meet pediatric’s needs should integrated with inter and intra governmental; b) mental health, means integrate activities i n care for mental and behavioral health of children with trained or expert psychological or mental professionals, public health or other related professionals whether in preparedness an d p o s t disaster. the activities like training program or counseling; c) child physical health and trau ma, are health care consider to pediatric medical n appropriate dosage and administration, conducted by clinical trained health profesio n als about pediatric care, formal pediatric care system should be established in regional country to support pediatric surge, critical or intensive care for children. mental health support is also needed to recover and support restorating of children; d) emergency medical service and pediatric transport, describe that emergency medical service in regional or country is require d to improve the capability to transport and treat children during pre hospital setting, and emergency transport should be sufficient; e) disaster case management, means that holistic service with standard and appropriate resources are required in disaster case management to address the needs of children and their fami l ies ; f) child care and early education, this recommendation said that disaster preparednes s and plan should be improved i n caring for children, planning of evacuation, relocation, shelter, and reunification between children and their families should be prepared promptly; g) elementary and secondary education, are needed to support collaboration and coordination with indonesian journal of nursing practices 88 emergency providers, so teachers should be certified in this area and situation; h) child welfare and juvenile justice, that welfare and justice agencies are needed to support preparedness and recovery rapidly and mini miz e the impact of disaster to children; i) sheltering include service and supplies; j) housing; and k) evacuation, include reunification between children and their families after disaster (wizemann et.al., 2014). conclusions health practitioners especially nurse should pay more attention for children as a unique vulnerable population, and consider all aspects of them in disaster management. physical, pshycological, development, behavior and also their families should be considered by nurse in caring for them. not only addressing pediatrics need, but nurse also playing a role to advocate them to policymakers about providing special standard or regulation for pediatric in disaster. nurse worked in taking care children with local government, department of health and other related-parties in community. references american academy of pediatrics. (2015). ensuring the health of children in disasters. pediatrics, 136(5). doi: 10.1542/peds.2015-3112 blake, n., & bowers, e.k.f. (2018). disaster preparedness: meeting the needs of children. journal of pediatric health care, 32(2), 207-210. doi: 10.1016/j.pedhc.2017.12.003. bouten, m., & becker, b.m. (2016). children and disaster. ciottene's disaster medication (second edition) (pp. 53-59). burke, r.v., iverson, e., goodhue, c.j., neches, r., & upperman, j.s. (2010). disaster and mass casualty events in the pediatric population. seminars in pediatric surgery, 19, 265-270. doi: 10.1053/j.sempedsurg.2010.06.003 cooper, l., guan, h., hernandez, a.a..o., gallardo, b.l., rivera, g., wathen, g., shulman, b., & berman, s. . (2014). pediatrics in disasters evaluation of a global training program. advances in pediatrics. doi: 10.1016/j.yapd.2014.03.003. cornette, e.c. & so, a.p. (2011). children and disaster planning: the national commission on children and disaster's findings and recommendations. journal of emergency management, 9(2). doi: 10.5055/jem.2011.0049. drayna, p.c., hansen, a., boggs, r., & locklair, m.r. (2012). disaster management and emergency preparedness for children and youth with special health care needs. division of pediatric emergency medication, 13(2). emergency medical service for children. (2016). addressing the needs of children in disaster preparedness exercises 2nd edition. retrieved from www.stritch.luc.edu/emsc. kar, n. (2009). psychological impact of disasters on children: review of assessment and interventions. world journal of pediatrics, 5(1). doi: 10.1007/s12519009-0001-x. national association of pediatric nurse. (2011). pediatric nurse practitioners role in disasters involving children. journal of pediatric health care, 25(4), 9a-10a. doi: 10.1016/j.pedhc.2011.03.004. new york city health. (2008). children in disasters: hospital guidelines for pediatric preparedness. the centers of bioterrorism preparedness planning pediatric task force (3rd ed.) nugroho, s.p. (2013). 2.586 anak pengungsi sinabung tetap bersekolah. retrieved from https://www.bnpb.go.id/2-856anak-pengungsi-sinabung-tetapbersekolah. vol. 2 no. 2 desember 2018 89 orlando, s., danna, d., giarratano, g., prepas, r. , & johnson, c.b. (2010). perinatal considerations in the hospital disaster management process. jognn, 39(4), 468479. doi: 10.1111/j.15526909.2010.01158.x. pakpahan, lisbeth. (2016). kesiapan manajemen rumah sakit umum kabanjahe dalam penanganan korban bencana erupsi gunung sinabung di kabupaten karo provinsi sumatera utara tahun 2013. repository institusi universitas sumatera utara. retrived from http://repository.usu.ac.id/handle/12345 6789/61723. pusponegoro, a.d., & sujudi, a. (2016). kegawatdaruratan dan bencana: solusi dan petunjuk teknis penanggulangan medik dan kesehatan. jakarta timur: pt. rayana komunikasindo. weiner, d.l. (2009). lessons learned from disaster affecting children. 10(3). wizemann, t., reeve, m., & altevogt, b. (2014). preparedness, response, and recovery considerations for children and families: workshop summary. united states: the national academics press. world health organization and international council of nursing. (2009). icn framework of disaster nursing competencies. http://repository.usu.ac.id/handle/123456789/61723 http://repository.usu.ac.id/handle/123456789/61723 vol. 2 no. 2 desember 2018 77 indonesian journal of nursing practices isytiaroh stikes muhammadiyah pekajangan pekalongan indonesia korespondensi: isytiaroh email: isytiaroh@stikesmuh-pkj.ac.id myths and failure of exclusive breastfeeding: study in buaran community health center pekalongan regency central java info artikel online issn doi : : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.2282 abstract background: fai l ure of excl us i ve breas tfeedi ng i s s ti l l hi gh i n pekal ongan regency, central java indones i a. the one of reas ondue to the exi s ti ng myth about breas t mi l k and breas tfeedi ng acti vi ty i n s oci ety cul ture. objective: thi s s tudy ai med to determi ne the rel ati ons hi p between myth about breas tfeedi ng and fai l ure of excl us i ve breas tfeedi ng. method: thi s cros s -s ecti onal s tudy des i gn conducted among 151 mothers wi th i nfant 6-12 month age whi ch s el ected by cl us ter s ampl i ng, i n buaran communi ty heal th center i n pekal ongan regency central java indones i a, from january to may 2017. an i ns trument us ed was a ques ti onnai re devel oped by the res eacher. result: the res ul ts s howed 70.1% parti ci pants fai l ed excl us i ve breas tfeedi ng, 56.9% of them bel i eved negati ve myths about excl us i ve breas tfeedi ng by p = 0.001 (95% ci: 1,757 -8,057). the characteri s ti c of parti ci pants was i n reproducti ve age (81,5%), mul ti parous (71,5%), unempl oyed (70,9%), and from extended fami l y (66,9%). mos t of the parti ci pants had a vagi nal del i very (86,8%). there was as i gni fi cant rel ati ons hi p between myths about breas tfeedi ng and fai l ure of excl us i ve breas tfeedi ng. breas tfeedi ng educati on s houl d del i ver i n communi ty-bas ed, i n terms of growi ng breas tfeedi ng cul ture, i n indones i an s oci ety. keywords: cul ture; excl us i ve breas tfeedi ng; myth introduction breastfeeding is the most ideal and valuable food for growing infant since it suffices nutritional requirements by adequately and inappropriate manner. exclusive breastfeeding for the first six months of baby’s life followed by adequate and safe complementary foods, with continued breastfeeding up to two years isneededfor optimized baby health (world health organisation, 2013). the set target of exclusive breastfeeding by nutrition and maternal and child health program in indonesia,is 50% with the initiation of early breastfeeding in newborns by 50% (indonesian ministry of health, 2015). the target set based on many benefits of breastfeeding, for both mother and baby.stuebe(2009)explained the benefits of breastfeeding such as having immunityfor infection protectionthat babies will get immunoglobulin that will protect babies fro m infection, babies are better protected from otitis media, respiratory, diarrhea and other gastrointestinal diseases, avoiding juvenile diabetic disease, lymphoma, obesity, hypertension and some other diseases. while the mother will avoid post-birth bleeding d u e to weak uterine contractions, breast cancer risk, and obesity. 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/5097 indonesian journal of nursing practices 78 in fact, the benefits of breastmilk and doing breastfeeding very much for babies and mothers have not been able to increase coverage of breastfeeding in infants, especially exclusive breastfeeding target. nationally, the coverage of exclusive breastfeeding in indonesia until 6 months of 2016 was 29.5% and central java province was 42.7% (indonesian ministry of health, 2017). the pekalongan regency as one of the districts in central java has exclusive breastfeeding coverage of 30.3% by 2015. the latest data in february 2016 was that the lowest exclusive breastfeeding coverage i s at community health centers in buaranpekalongan regency with a percentage ranged from 14.22% (departement of health pekalongan regency, 2016). this is the lowest coverage in pekalongan regency. one of the reasons for the exclusion of exclusive breastfeeding targeting is due to incorrect myths about breast milk and doing breastfeeding that still exists in society (eram, 2017). some myths that develop in society, among others, are colostrum should not be given to newborns because it can cause babies stomach ache, newborns need additional food to be big fast because breast milk alone is not enough. myths are either mythical or religious (susantina & purnomo, 2013). they explain the definitions of myths and religions are associated with the presence of the belief in the existence of supernatural forces above human strength.the myth can also be interpreted as the assumption of a thing that developed in the society without the true nature of the truthbut believed to be something obeyed. blumenberg (2003 as cited in morales 2013) explain about myths too, myths are stories that have a high degree of constancy in their narrative core and also some margins of variation. in addition, i n t h e reality of the world and the human, myths also express the complexity inherent. improper myths about breast milk and breastfeeding also occur in pekalongan district. preliminary studies conducted on some breastfeeding mothers showed that still the myths that breastfeeding mothers believe. the mythsare that the baby is born to need to eat so must be fed (foods such as bananas and rice are crushed), breastfeeding moth e rs cannot eat when it's night so that the body is not overweight, babies who cry continues to mean less milk so it needs to be fed infant formula quiet. the myth is growing in the community and is believed to be true by breastfeeding mothers, especially if nursing mothers live a house with parents, then the myth is getting thicker and should be run by nursing mothers. this phenomenon is an attraction for researchers to examine the topic of myth and exclusive lecture. methods the study design used cross sectional study of 151 mothers with infant 6-12 month age. in buaran community health center as the coverage of exclusive breast the lowest coverage of exclusive breastfeeding in pekalongan regency in 2016 (14.22%). a cluster sampling design was used to select populations. the studi was conducted in buaran community health center in pekalongan regency central java indonesia from january to may 2017.the inclusion criteria included mother who has infant aged 6-12 months, no complications that affect breastfeeding, and living with their husbands or relatives. the exclusion criteria were mother that delivere d baby with congenital defects and infant having illness which interferes with successful breastfeeding. freguency distributions, and cross-tabulations were used to describe the variable of the study. the study used confidence interval 95%. the instrument used in this study was a questionnaire prepared by the researcher. this questionnaire were consists of demographical data (age, parity, educatio n al level, employment status, type of family, an d mode of delivery), failure of exclusiv e breastfeeding and myths about breastfeeding. vol. 2 no. 2 desember 2018 79 the consten of questionnaire failure of exclusive breastfeeding is one question. the question is whether the baby has received other than breastmilk, such as liquids or solids with the exception of drops or syrups consisting of vitamins, mineral supp lemen ts , or medicines during the first months delivery . the guttman scale used to categorize data. i f participans answered “yes” (noted to 1), th e n failure of exclusive breastfeeding, but if answered “no”, then not failure of exclusive breastfeeding (noted to 0). the other content questionnaire are myths about breastfeeding. the guttman scale us e d to categorize data. the choises for answering questionnaire devided into believed (noted to 1) and not believed (noted to 0). if participan t answer at least one believe from questionnaire, it means that they believ e th e myth. the questions involved whether the mother has believe and do that believe, namely 1). breastfeeding mothers should n o t eat fish, meat, chicken eggs; 2). breastcolored milk (colostrum) is stale breast milk so it should not be given to the baby; 3). breastfeeding mothers should not eat when it was late; 4). breastfeeding can change the shape and size of the breasts and can cau s i n g disturbance body image; 5). babies who given formula-fed will sleep long and calm than those fed breast milk; 6). a baby who asks f o r breastfeeding continues means less breast milk so formula milk is required; 7). the quality of formula milk is the same as breast milk so formula-fed is not problem for the babies; 8). newborns should be fed like bananas or liquid food to be calm. researchers also conducted interviews to explore other myths about breastfeeding. data collection including basic demographic (mother age, parity, educational level, employment status, type of family, and mo d e of delivery), and myths about breastfeeding are independent variable. dependent variabel is failure of exclusive breastfeeding. data was entered in ms excel and analyzed using statistical package for social sciences (spss) software version 11.5. chi square test was used to find out the association of myth s an d failure exclusive breastfeeding. results table 1 shows the characteristics of the participants. there are 151 mothers participated in this study. almost participants were in reproductive age (n=121; 81.5%), multiparous (n=108; 71.5%), and unemployed (n=107; 70.9%). the majority type of family were low educational level (n=96; 63.6%) an d type of family was extended family (n=101; 66.9%). the majority mode of delivery was vaginal (n=131; 86.8%). table1. sosiodemographic characteristic participants characteristics summary (n=151) percentage mother age category (i n year) ˃ 20 20 – 35 < 35 0 121 28 0 81.5 18.5 pari ty nul l i parous mul typaraous 43 108 28.5 71.5 educati onal level low mi dl e-hi gher 96 55 63.6 36.4 empl oyment s tatus empl oyed unempl oyed 44 107 29.1 70.9 type of fami l y nucl ear extended 50 101 33.1 66.9 mode of del i very ces arean secti on vagi nal 20 131 13.2 86.8 indonesian journal of nursing practices 80 table 2.distribution of participans based on the breastfeeding myths andfailure exclusive breastfeeding vari abl e excl us i ve breas tfeedi ng total 95% ci p val ue fai l ed succed n % n % n % breas tfeedi ng myths not bel i eve 20 13.2 21 14 41 27.2 1.757-8.057 .001 bel i eve 86 56.9 24 15.9 110 72.8 106 70.1 46 29.9 151 100 the table 2. showed a total of 106 (70.1%) failed exclusive breastfeeding. a total of 56.9% of paticipants believed the negative myths about exclusive breastfeeding with p= .001 (95% ci: 1.757-8.057). discussion analysis bivariate showed most respondents who believed in negative myths and failed to exclusive breastfeeding were 86 (56.9%) and who gave exclusive breastfeeding were 24 (15.9%). p v al u e was 0.001 (95% ci 1.757-8.057). this result indicates a relationship between negative my th s about breastfeeding and exclusive breastfeed in g failure. the results of this study showed that myths are believed to affect a person's behavior. morales (2013) said myths is a direct link with culture practices, and an important part in cultural competences and represent a significant development in daily life. in breastfeeding mothers, myths thrive from generation to generation so that breastfeeding mothers will b e frightened if they do not do. especially if the mother live together in a house with her parents , parents will influence based on past breastfeeding experience, although the knowledge of the myth cannot be proven. breastfeeding decisions also were based on the influences of exposure to formula milkcommercials. a qualitative study in indonesia by marzuki et al (2014) to elucidate the factors that influence mothers’ choices for infant feeding. the result study finding reasons mother to introduce additional milk formula. the most frequent reasons for mothers to introduce additional mi l k formula or food were the perception of an inadequate milk supply, infant dissatisfaction or fussiness after feeding.they believed that b re as t milk alone was insufficient for their infants and the babies crying and fussiness were con s i de red to be signs of hunger so food was introduced to calm them. this result is similar to eram's (2017) study. eram's a riview articlestudy showed an incorrect myth about breastfeeding to be one of the factors causing exclusive breastfeeding failure. these myths include colostrum should not be given to the baby, the mother should not breastfeed if infected, the baby needs water beside breast milk, the pregnant mother should stop breastfeeding, the nipple should be clean ed every time before the baby suckles, no safe drugs are given to breastfeeding mothers, the amount of breast milk production depends on the s i z e o f the breast, the baby needs sweet water before the first feed. the result study kamath et al (2016) also showe d that the advantages of breast milk were in poor perceptions among 188 indian mother, with respect to nutritive value, immune effect, and disease protection (n=188). among of them had discontinuation of breastfeeding in previous child if their baby had sikcness, such as diarrhea and vomiting. the quality of mother perception on breastmilk around 37.3% (71 mothers) opined that it is nutritious, an equal number were non committal, and one-fourth of the mothers disagreed with its nutritious aspect. interestingly, majority og the mother felt that breastmilk is healthy for baby (181; 96.3%), breast milk can protects babies from diseases 32 (17%). almo s t a half (n=93, 49.4%) of the mothers agreed that breast milk would encourage bonding attachment mothers and their babies. vol. 2 no. 2 desember 2018 81 socio-cultural factors affect the breastfeeding too (wanjohi, et al 2017). socially and culturally, breastfeeding mothers learn and observe breastfeeding practices by older parents, grandmothers or older women in their communities. this kind of learning model is carried out from generation to generation and is firmly rooted in people who are less exposed to the development of science, especially in traditional societies. this practice will be detrimental if there is a misperception about breastfeeding. the madhavi and manikyamba studies (2016) also identified the reasons for exclusive breastfeeding failure including misperceptions about exclusive breastfeeding with a perce n tage of 35.52% of 2000 respondents. the same study, yaqub and gul (2013) discovered the reasons of failure of exclusive breastfeeding were insufficient milk production in 289 (93.2%), working mother in 13 (4.2%) mothers, illness of baby in 2 (.65%), illness of mother in 6 (1.9%) cases. the study showed mothers perseption about insufficient milk production dominant factor cause failure of exclusive breastfeeding. study in nyanmar by thet et al (2016) showed partisipants had high levels of knowledge about exclusive breastfeeding, but low adherence. o n e of the primary barriers to exclusive breastfeeding was that mothers, husbands, and grandmothers believed that exclusive breastfeeding was not sufficient for babies and solid foods and water were necessary. water and mashed up rice w e re commonly introduced before 6 months of age. false perseption or negative myths can breastfeeding failed programs. qualitative result study heidari, et al (2016) were identified three main categories barriers to breastfeeding promotion. there were "incompetency of breastfeeding services", "mother’s inadequate breastfeeding self-efficacy" and "family’s neglect to breast milk." the cause of three main categories bariers f rom the participants are inadequate performance of bab y friendly hospital, failure of prenatal centers in teaching skills to mothers and families, and inadequate support for nursing women after delivery had caused breastfeeding damage. heidari, et al (2016) giving advice to overcome the barriers to breastfeeding promotion, examples supportive and educational programs should be provided for all individuals invol ve d i n breastfeeding including mothers, families and health workers. the limitation of this study is the way to built a questionnaire by researcher was form emp i ri cal fact. therefore the result of theis study may not be generalized to another comunity with different culture. conclusion the conclusion of the study is there is a negati v e mythic relationship about breastfeeding with exclusive breastfeeding failure. negative my th ic in this study is beliets about breast milk and breastfeeding that cannot be verified by scien ce . this study recommends the importance of education on exclusive breastfeeding in terms o f the growing culture in indonesian society acknowledgement we gratefully thanks for stikes muhammadiyah pekajangan pekalongan, particularly dr nur i z z ah m.kes, nuniek nizmah sp.kmb, firman faradisi, msn and windha widyastuti, msn for their support and corrected english text. we also gratefully thanks for dewi puspita as editor ijnp umy. references departement of health in pekalongan regency (dinas kesehatan kabupaten pekalongan).(2016). exclusive breastfeeding coverage in pekalongan regency. pekalongan indonesia : departament of health in pekalongan regency . eram,u. (2017). a riview article : myths, beliefs and malpractices relating to breastfeeding and complementary feeding practices. international journal of pharmaceutical science invention, 6.(i), 14-16. heidari, z., keshvari, m., kohan, s. (2016). breastfeeding promotion, challenges and barriers: a qualitative research. international journal pediatrics. 4(5), 1687-95. indonesian journal of nursing practices 82 indonesian ministry of health (kemenkes ri). (2015). stategic planning indonesian ministry of health in 2015-2019. retrived from http://www.depkes.go.id/resources/dow nload/info-publik/renstra-2015.pdf indonesian ministry of health (kemenkes ri). (2017). indonesian healthprofile 2016. retrieved from http://www.depkes.go.id/resources/dow nload/pusdatin/profil-kesehatanindonesia/profil-kesehatan-indonesia2016.pdf kamath, s. p., garg, d., khan, m. k., jain, a., & baliga, b. s. (2016). perceptions and practices regarding breastfeeding amo n g postnatal women at a district tertiary referral government hospital in southern india. scientifica, 2016, 1-6, retrieved from. http://doi.org/10.1155/2016/5430164 morales, s.s. (2013). myth and the construction of meaning in mediated culture. an internationaljournal of pure communication inquiry, 1(2), 33-43. retrieved from http://komejournal.com/files/3solamoral esabstract.pdf madhavi, n., & manikyamba, d. (2016). evaluation of factors responsible for failure of exclusive breastfeeding for firs t 6 months-hospital based study. international journal of contemporary medical research, 3(6), 1701-1704. marzuki, n.s., yohmi, e., nainggolan, e., hegar, b., oswari, h., nyoman, g.a., partiwi. (2014). breastfeeding practices in mothers: a qualitative study. paediatrica indonesiana, 54 (1), 35-41. stuebe, a. (2009). the risks of not breastfeedin g for mothers and infants. reviews in obstetrics and gynecology, 2(4), 222–231 thet, m. m., khaing, e. e., diamond-smith, n., sudhinaraset, m., o.s., &aung, t. (2016). barriers to exclusive breastfeeding in th e ayeyarwaddy region in myanmar: qualitative findings from mothers, grandmothers, and husbands. appetite, 96, 62-69. doi:10.1016/j.appet.2015.08.044 world health organization. (2013). global strategy for infant and young child feeding. retrieve from http://www.who.int/nutrition/publicati o ns/gs infant feeding text eng.pdf wanjohi, m., griffiths, p., wekesah, f., muriuki, p., muhia, n., musoke, r. n.,kimani murage, e.w. (2016). sociocultural factors influencing breastfeeding practices in two slums in nairobi, kenya. international breastfeeding journal, 12(5), 92-97. retrieved from http://doi.org/10.1186/s13006-0160092-7. yaqub, a. & gul, s. (2013). reason for failure of exclusive breastfeeding in children less than six mother of age. journal of ayub medical collage abbottabad, 25(1-2), 165-167. retrieved from http://www.ayubmed.edu.pk/jamc/251/asma yaqub.pdf http://www.depkes.go.id/resources/download/pusdatin/profil-%20kesehatan-indonesia/profil-kesehatan-indonesia-2016.pdf http://www.depkes.go.id/resources/download/pusdatin/profil-%20kesehatan-indonesia/profil-kesehatan-indonesia-2016.pdf http://www.depkes.go.id/resources/download/pusdatin/profil-%20kesehatan-indonesia/profil-kesehatan-indonesia-2016.pdf http://www.depkes.go.id/resources/download/pusdatin/profil-%20kesehatan-indonesia/profil-kesehatan-indonesia-2016.pdf http://doi.org/10.1155/2016/5430164 http://www.who.int/nutrition/publications/gs%20infant%20feeding%20text%20eng.pdf http://www.who.int/nutrition/publications/gs%20infant%20feeding%20text%20eng.pdf http://doi.org/10.1186/s13006-016-0092-7 http://doi.org/10.1186/s13006-016-0092-7 http://www.ayubmed.edu.pk/jamc/25-1/asma%20yaqub.pdf http://www.ayubmed.edu.pk/jamc/25-1/asma%20yaqub.pdf vol. 3 no. 2 december 2019 75 ijnp (indonesian journal of nursing practices) vol 3 no 2 december 2019 : 75-81 belet lydia ingrit1 1universitas pelita harapan corresponding author: belet lydia ingrit email: lydia_inggrid@yahoo.com the application of levine’s and kolcaba’s theories in the nursing care of patients with the third stadium of cervical cancer article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.3296 abstract background: cervical cancer was the second leading cause of cancer in indonesia. new cases of cervical cancer are found in indonesia each year. objective: this study aims to describe an application of levine’s conservation nursing theory and kolcaba’s comfort theory in a patient with the third stadium of cervical cancer. method: the method used in this study was a narrative of a case report in one patient with the third stadium of cervical cancer at the hospital in central jakarta. she is 44 years old, who has been diagnosed since october 2017. she experienced nausea and vomiting a week before she was hospitalized and had a history of vaginal discharge ever since nine months ago. levine’s conservation interventions were provided to maintain energy, improve adaptability, improve standard comfort, educate, and provide comfort. results: the result showed that the patient was able to adapt to the condition of the illness and obtained a sense of comfort during hospitalization. therefore, levin's conservation theory and kolcaba's comfort theory can be applied in performing nursing care in patients with cervical cancer. conclusion: the three stages of kolkaba's comfort intervention can improve patient comfort not only physically but also psychologically during treatment. keywords: cervical cancer, kolcaba’s comfort, levine’s conservation, nursing care introduction the prevalence of cancer incidence in the world still has the highest rank after cardiovascular disease and becomes the leading cause of death. the total number of patients of cancer today in the world is 32.4 million and 52% of them are suffered by many women (international agency for cancer research, 2014). in southeast asia, the incidence of cervical cancer accounts for 20-30% of all cancers (bal, goyal, suri & mohi, 2012). according to the data revealed by the ministry of health of the republic of indonesia (2015), in 2013, cervical cancer was the highest prevalence in indonesia by 0.8% (98,692 cases). twenty-one thousand new cases of cervical cancer are found in indonesia each year and continue to increase (afiyanti & pratiwi, 2017). cervical cancer is one of the diseases that currently becomes a health concern throughout the world, especially in developing countries. the cancer is a malignancy from the cervix that is caused by infection with the human papilloma virus (hpv). approximately 70% of cervical cancer cases worldwide are caused by hpv types 16 and 18. in general, precancerous lesions have not shown symptoms. however, when it becomes invasive cancer, the most common symptoms are bleeding during sexual intercourse, unstoppable bleeding, and excessive vaginal discharge. the risk factors for cervical cancer are sexual activity at a young age, sexual intercourse with multiple partners, smoking, multiple children, low socioeconomics, use of birth control pills, sexually transmitted diseases, and immune disorders (national committee of cancer management, 2014). 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/4670 indonesian journal of nursing practices 76 cervical cancer can cause problems such as morbidity, suffering, death, and financial problems for the family. therefore, it is important to conduct early prevention for women in cervical cancer. nurses, as part of the health workers, have a role in providing comprehensive nursing care to patients with cervical cancer. this case study report aims to describe the result of nursing care to the patient with cervical cancer using levin's conservation theory and kolcaba’s comfort theory. in this case, the patient examined was in the third stadium of cervical cancer. levin focuses on improving the adaptability to environmental change and maintaining the integrity of individuals either physically, personally, or socially by using conservation principles. meanwhile, the need for comfortable feeling is viewed from the context of a holistic comfort, which consists of four aspects, namely physical, psychospiritual, environment and social, with three levels of comfort namely relief, ease, and transcendence (tomey & alligood, 2006). the first steps in nursing assessment with levin's conservation theory are an observation of pain response, viewing medical reports on patient status, and a diagnostic examination result to find out patient’s needs. the assessment also includes assessing internal and external environmental changes that encompass four conservation principles namely energy conservation, structural integrity, personal integrity, and social integrity (alligood, 2014). the second step is to formulate tropicognosis. tropicognosis is a nurse decision based on the consideration of factors affecting the health condition of cervical cancer patients. the third stage is to make a hypothesis, often referred to as a nursing diagnosis. the fourth stage is intervention and then evaluation. the whole attainment is that patient is able to adapt to changes that occur to the four principles of levin’s conservation. assessment of the four comfort aspects includes physical, psychospiritual, environmental, and social contexts. each context is categorized into the level of comfort, which encompasses relief defined as a state in which comfort is reduced, ease defined as the loss of specific discomfort, and transcendence defined as reinforcing and reminding nurses not to give up in helping patients and their families to improve their comfort. the context of comfort as a holistic experience is considered based on four aspects, such as physical, psychospiritual, environmental and social (tomey & alligood, 2006). method the method used in this article was a narrative of a case report in one patient who suffers from the third stadium of cervical cancer in the inpatient ward at the hospital in central jakarta. the investigation was carried out by using the nursing care approach adopting levin’s nursing theory of conservation and kolcaba’s comfort theory from the assessment stage until the evaluation stage. the subject investigated is, mrs. esh (44 years), p2a0, medically diagnosed with the third stadium of cervical cancer since october 2017 with a bilateral post of nephrostomy admitted from the hospital since 02 november 2017. mrs. esh is a sundanese and muslim housewife with two children, who has married once for 15 years. her last formal education background is elementary school. the history of contraceptive use is a three-month contraceptive for 17 years and pills for four years. the obstetric history of menarche is 15 years, and the menstrual cycle is regular and does not feel pain during the menstruation. the patient said that she still had menstruation periods and she never had an iva test. the frequent symptoms that the patient felt were nausea and vomiting one week before being hospitalized. another complaint was vaginal discharge since nine months ago although there was no bleeding. however, every time she had sexual intercourse, she got bleeding. the patient had also lost weight during the last two months as much as 7 kg. nausea and vomiting were felt the last week before she got hospitalized. the loss of appetite and bowel complaints were not found as a problem but the urination issue was a problem as the patient urinated just a little over two days before being hospitalized. the patient used bilateral nephrostomy to help urinating because she had difficulty in it. the use of nephrostomy caused pain to the patient that she felt pain from the abdomen spreading until the waist. she said that the pain scale was 10 out of 10, so it is categorized as a heavy pain to her. the pain made vol. 3 no. 2 december 2019 77 the patient have no passion and was unable to perform activities independently. the patient seemed to be uncommunicative, moody and she stated that the illness was a test from god. the results of vital observation signs obtained blood pressure 117/80 mmhg, pulse 76 times per minute, breathing 18 times per minute, temperature 360 c, and 99 percent oxygen saturation. assessment for conservation energy was carried out by collecting the data from the subjective and objective aspects. subjective data is an assessment result from complaints or patient’s perceptions of her health status (dinarti & mulyanti, 2017). in this case, the patient said that she had no appetite and felt frequent nausea. it was observed from the portion of her leftover food. since she had been sick, she revealed that she had lost weight from 55 kg to 48 kg, and based on the observation, the patient looked thinner. according to the laboratory test, the result showed that the patients' hemoglobin was below the normal value that was 7 gr/dl. that was one of the reasons why the patient looked pale. furthermore, based on ecog performance status, the patient was in the third grade. she had limited movement and self-care ability, confined to bed or chair more than 50% of her waking hours (ecogacrin, 2018). the integrity structural conservation assessment showed that the patient looked pale and the conjunctiva looked anemic. besides that, the patient also looked jaundice in the sclera area, dry lips, cyanotic, capillary refill time more than 3 seconds, extremities in cold feeling, and skin turgor elastic. there was no edema and no enlargement either in the neck or in the axilla. the patient had bilateral post-nephrostomy procedures before medical diagnose such as aki (acute kidney injury). aki became the previous complaint where the patient had difficulties in urine issues. the result of the assessment on the conservation of personal integrity shows that the patient surrendered for her disease. the patient also hoped that the treatment conducted could provide healing. meanwhile, the result of the conservation assessment on social integrity shows that the patient tended to be calm, was able to work together with any action provided by the health team. however, the patient is more likely to be moody and rarely communicated with others in her room. on the other hand, there are four parts of the comfort measurement standard according to kolcaba assessment. there is physical comfort which includes psychological and behavioral and emotional comfort which includes sociocultural, spiritual, and environmental comforts. data objective from physical and physiological assessment aspects showed that the patient complained about discomfort such as pain in the surgery location (procedure of nephrostomy), and also her nausea and the absence of appetite so that she had lost weight during the illness. based on the psychospiritual aspect, the patient stated that the illness was the experience for her life, and a test from god so that she could only surrender, accept, and try to recover her health. nurses and other health workers provided mental support such as listening to patient complaints, providing positive advice, empathy, and information support such as explaining nursing or medical procedure, and also providing health education. the social factor of the nearest person is very meaningful for the patient, especially the patient's mother who waited for the patient every day in the hospital and helped the patient's activity. there is no cultural prohibition for a patient undergoing treatment at the hospital. support from health workers and family and spiritual aspects by facilitating the patient to pray, helped to make decision making and giving a caring attitude toward the patient. based on the environmental comfort assessment, the patient was in a fully furnished room with six-bed capacity, one air conditioner, one ventilated door, and the patient's position were located near the windows. results nursing diagnosis according to levin and kolkaba’s assessment theory to this patient were: 1) conservation disorders of structural integrity such as tissue perfusion associated with a decrease in oxygen supply, 2) discomfort such as pain related to nephrostomy wound surgical incision, 3) less nutrition for body's needs due to inadequate intake, 4) conservation disorder of structural integrity such as a change of elimination pattern associated with infiltration of cancer in urinary tract, 5) anxiety indonesian journal of nursing practices 78 associated with a lack of knowledge about disease and treatment procedures. upon finding the nursing diagnosis, the next step was to make several goals from each diagnosis. they are as follow: 1) conservation disorders of structural integrity, such as tissue perfusion resolved with the result of the criteria. the criteria were vital signs within normal limits that the patient does not look weak, capillary refill time was less than 3 seconds, and extremities felt warm and no visible cyanosis. interventions of structural integrity conservation disorders of tissue perfusion were by observing vital signs, especially blood pressure and pulse, observing the capillary refill time and nail bed color, observing circulation status, encouraging patients for bed rest and collaboration in transfusion therapy, laboratory examination (hemoglobin), and oxygen therapy if necessary. 2) the patient's pain decreased with the result criteria of vital signs within normal limits. the patient revealed that the pain was controlled, decreased and that she looked calm and could perform a relaxation technique and distraction appropriately as an indication of a pain-control. the nursing intervention was to examine the history of pain, the area of the pain, frequency, duration, intensity, and scale, by giving necessary comfort measures such as relaxation, distraction, imagination or soft massage, observing and monitoring vital signs, providing a comfortable position and doing a collaboration in giving analgetic medicine. 3) the patient's nutritional status could be maintained with several criteria to meet the needs of the body. the outcomes of the criteria were patients were able to consume portions of food, there was no conjunctiva anemic, the weight was normal, and hemoglobin values were within normal limits. interventions for energy conservation disorders were such as fewer nutrients than the body's needs assessed the nutritional status of the patients, measuring weight as indicated, motivating patients to eat high-calorie and high-protein foods, monitoring daily food input, and encouraging patients to eat small portions but often. 4. the diagnosis of nursing for conservation disorder of structural integrity included a change of elimination pattern. the aim was that the elimination pattern returns to normal (adequately) with expected outcome criteria. the outcome criteria were incontinence urine resolved. interventions for conservation of structural integration are such as changes in the pattern of elimination which observed urine output, observed the urine color and the presence of an abnormal odor, provided fluid enhancement and fluid intake, observed the vital signs, peripheral pulse, capillary refill time, and did collaboration in the examination laboratory (urea and creatinine). 5. nursing diagnosis with the patient's anxiety could be reduced with the patient's outcome criteria. the outcome criteria were patient stated that anxiety diminishes or disappears. furthermore, other criteria are safety, and a comfortable environment for the patient and that patient looks relaxed. in addition, the patient gets accurate information and support from the nearest relative, like husband and other family members. interventions for discomfort problems include anxiety are such as motivating the patient to express her thoughts and her feelings, providing an open environment, maintaining effective communication by caring for the patient, and helping the patient or the nearest person in recognizing and clarifying fear. a communicative therapist must conduct five nursing diagnoses with several interventions for each diagnosis and that it can heal the patient and accept her condition with the illness. upon conducting the intervention, the next step for the nurse is to make an evaluation. evaluation is carried out every day after implementation. it is conducted by asking the patient’s complaints (subjective data) and evaluation with observation and secondary data from laboratory results or medical records (objective data). in terms of this case, the evaluation from each diagnosis is that the five nursing problems are partially resolved so that further interventions are needed to improve the patient's condition. discussions cervical cancer is a malignancy from the cervix caused by infection with human papillomavirus vol. 3 no. 2 december 2019 79 (national committee of cancer management, 2014). national committee of cancer management (2014) also stated that hpv types 16 and 18 are the leading causes in 70% of cases of cervical cancer in the world. national committee of cancer management (2014), also reveals that the risk factors for cervical cancer are sexual activity at a young age, sexual intercourse with multiple partners, smoking, multiple children, low socioeconomic, use of birth control pills, sexually transmitted diseases, and immune disorders. it indicates that there are several risk factors for cervical cancer. it is in line with the research conducted by hidayat, hasibuan & fitriyati (2013), stating that the number of parity influenced the incidence of cervical cancer. in this case, mrs.esh (44 years old) is a woman and a housewife. nursing care did to her includes many aspects, from assessment to evaluation. then, levin’s conservation theory and kolkaba’s comfort theory start with an assessment of subjective or objective data collection. the subjective and objective data results are the basis for the interventions. implementation is given under the planning or intervention. evaluation is obtained based on the result from subjective and objective data of the patient after implementation is given. interventions are given under levin's conservation principles and kolkaba's comfort in five nursing issues experienced by patients during hospitality. structural integrity conservation disorders are such as tissue perfusion resolved by nursing independent interventions. in this case, it is conducted by monitoring vital signs, checking capillary refill time, nailing bed colors, and observing patient circulation status. therefore, it can conserve tissue structures that can help adequate tissue perfusion. meanwhile, the nursing collaboration intervention is conducted by giving the therapy of transfusion prc. post-transfusion hemoglobin in patients increases after the prc of 500 cc. it is relevant to the final report from fitriani, setyowati & afiyanti (2016), who said that levine’s conservation theory could be applied to cervical cancer patients with bleeding. nursing care for supporting perfusion encourages the patient to take a rest. the purpose is to reduce oxygen needs, so the oxygen in the body can be prioritized to important organs. the next nursing problem is a sense of comfort. the evaluation found was that patients said the pain had been reduced, but the problem for nausea and appetite complaints still existed even though the portion of food eaten had increased. in terms of the problem of the elimination pattern, the patient has been assisted by using nephrostomy, but the nurse's independent actions are still required in monitoring urine output /production, fluid balance, urine color, and turbidity. national cancer management committee (2014) stated that treatment for cervical cancer in the third stadium with ckd (chronic kidney disease) is with nephrostomy or (if needed) with hemodialysis while other treatments are chemoradiation and radiation. not only physic, but psychology also becomes the problem of the patient. it is proved by the result showing that the patient experienced the nursing problem of anxiety. it is supported by qualitative research conducted by yolanda and karwur (2013), revealing that 60 % of patients with cervical cancer have a level of anxiety. in this case, the anxiety has been reduced by the independent actions of nurses in giving information. the information is related to nursing caring during the patient’s hospitality. in relation to this, the profile of the patient, in this case, is a 44-year older woman with a 15-year marriage history. it is a risk factor for patients with cervical cancer. besides the history of marriage at a young age, being at the age of over 35 years old also has a risk factor for the occurrence of cervical cancer (diananda, 2007). it is supported by the research conducted by herlana, nur, & purbaningsih (2017), stating that the highest frequency of cervical cancer is at the age of more than 35 years old with parity of more than three children. cervical cancer can be effectively prevented by hpv vaccination, but this is influenced by family support and patients’ knowledge levels. according to a study by sari & syahrul (2014), the knowledge levels affect a person to take hpv vaccination in adult women. in this case, mrs.esh only graduated from elementary school, and she never took an iva test. besides that, the history of contraceptive use is also a risk factor for cervical cancer. in the case of mrs. esh, she had a history of injecting contraceptive use for 17 years indonesian journal of nursing practices 80 and birth control pills for four years. it indicates that contraceptive use is the leading risk factor for cervical cancer. furthermore, mrs. esh (47 years) also had a vaginal discharge history for nine months. it smelt and flowed like water. the disease process made her body had weight loss. the patient had drastic weight loss during the last two months of 7kg. the patient also feels the experience of related pain. on the other hand, anemia also becomes a significant problem in cervical cancer. the patient came to the hospital with a history of anemia. hemoglobin on the first day in the hospital was below a normal value that was less than 12g/dl. the patient was diagnosed with the status of anemia because the hemoglobin is just 7gr/dl. upon being given 500cc transfusion, the hemoglobin level raised until 12gr/dl. therefore, the nurses can apply levin’s conservation theory to resolve the tissue perfusion problem caused by bleeding or anemia with a hemoglobin level below normal values. a collaboration with other health services by giving a packed red cell transfusion can help improve the patient's health status. in addition, the independent intervention from nurses in helping the patient's daily activities can conserve the energy of the patient. another nursing problem that can be solved by using levin's conservation theory is a disorder of nutrition fulfillment. it is a condition when the nutrition portion is less than the body requirements associated with inadequate intake characterized by nausea and anorexia. in addition, kolkaba’s comfort theory can be used to solve nursing diagnoses for discomforts such as pain related to nephrostomy wound surgical incision and tissue necrosis of the cervix due to cervical cancer. there are no bowel complaints, but there is a problem in secrete urine. the patient just had anuria over two days before being hospitalized. therefore, levin's conservation nursing theory, especially on the principle of conservation of structural integrity and energy conservation, is needed in this nursing problem. the intervention given directly to the patient is to achieve the wholistic care and improve adaptation. levin’s hypothesis is a nursing intervention provided by the direct care provider because the nurse directly provides nursing care independently or collaboratively with other health teams such as the nutrition and medical team. wuriningsih (2016) stated that the application of levin’s conservation nursing theory could help maternity nurses to be able to do holistic, active, and independent awareness of caring in patients with cervical cancer. in this case, the patient with the third stadium of cervical cancer feels discomfort not only physically but also psychospiritual, environmental, and social. physical discomfort is caused by the presence of cervical cancer itself with the suppression of cancer cells in the tissues of nerve cells that cause the patient to feel pain. in addition, the installation of catheters and nephrostomy also makes discomfort in the patient. other discomforts may also be due to bleeding or vaginal discharge, discomfort in the case of urination, discomfort with a crowded environment, or discomfort with the surrounding environment. psychospiritual discomfort is also felt because the cervical cancer process makes patients anxious from the treatment process and despair in undergoing the disease. meanwhile, environmental discomfort is influenced by the atmosphere of a treatment room that is not supportive of being able to get rest well. convenience or comfort feeling is a holistic phenomenon and is a basic need of every human. therefore, nursing interventions are needed to solve the discomfort and improve comfort in patients. there are three steps in kolkaba’s comfort intervention. the first step is standard comfort, such as maintaining hemostasis and pain control; the second step is by coaching (coaching and training). coaching is giving education to patients to relieve her anxiety, provide information, listen, and help plan recovery, and the last one is the third step that is a comfort for the soul as a soul-soothing act, such as massage or guided imagery. besides that, support from the couple (husband) is also a comfort for the patient so that the anxiety can be reduced. furthermore, health education about the disease and its treatment can help to reduce patient’s anxiety due to lack of information and her disease. massage and guided imagery can help the patient vol. 3 no. 2 december 2019 81 reduce her pain. a soothing touch can provide comfort for cervical cancer patients. this massage action is a nurse's independent intervention as a part of collaborative intervention with analgesic granting such as duragesic patch. conclusions patients with the third stadium of cervical cancer are advanced-stage cancer patients who require comprehensive maternity care both physically and psychologically. therefore, the application of levin’s conservation model and kolkaba's comfort theory is necessary. the nursing theory uses four principles of levin’s conservation and kolkaba’s comfort model to provide support for patient adaptation in the healing process. by conserving structural integrity and energy conservation, patients can solve the problems. furthermore, the three stages of kolkaba's comfort intervention can improve patient comfort not only physically but also psychologically during treatment. references afiyati, y & pratiwi, a. 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(2013). tingkat kecemasan pasien kanker serviks pada golongan ekonomi rendah yang mengikuti program kemoterapi di rsud dr. moewardi. sains medika, 5 (2), 68-81. https://ecog-acrin.org/resources/ecog-performance-status https://ecog-acrin.org/resources/ecog-performance-status https://ecog-acrin.org/resources/ecog-performance-status vol. 1 no. 3 desember 2017 107 indonesian journal of nursing practices wiwiek retti andriani1, elsye maria rosa2, moh. afandi2 1 akper ponorogo 2 universitas muhammadiyah yogyakarta email: rereqoe@gmail.com peningkatan capaian k ompetensi k ognitif mahasiswa akper pemkab ponorogo deng an penerapan peer-assisted (pal) info artikel masuk revisi diterima doi number : : 25 juli 2017 : 10 november 2017 : 30 novermber 2017 : 10.18196/ijnp.1368 abstrak pros es pembel aj aran yang di tekankan s aat i ni adal ah student centered learning yang memberi kan kes empatan mahas i s wa untuk membangun s endi ri pengetahuannya s ehi ngga akan memperol eh pemahaman mendal am. sal ah s atu pembel aj ara n i novati f dengan s trategi student centered learning yai tu peer-assisted learning (tutor s ebaya). metode pal mampu meni ngkatkan pemahaman (s ecara kogni ti f) pada tutor dan tutees, di karenakan kons ep-kons ep dapat di j el as kan s ecara s ederhana dengan menggunakan bahas a yang pal i ng mudah di fahami dan s es uai dengan l evel mahas i s wa. kons ep i ni di kenal s ebagai kons ep kes el aras an kogni ti f (cognitive congruence). tuj uan penel i ti an i ni adal ah menganal i s i s penerapan metode peer-assisted learning (pal) dal am meni ngkatkan pencapai an kompetens i kogni ti f mahas i s wa. penel i ti an i ni menggunakan des ai n quasy experiment dengan rancangan pre and post-test with control group design. tehni k s ampl i ng menggunakan simple random sampling, dengan s ampel s ej uml ah 60 mahas i s wa s emes ter empat yang terbagi menj adi dua kel ompok perl akuan dan kontrol . ins trumen penel i ti an menggunakan multiple choice question. data di anal isis menggunakan t-tes t, dengan α = 0.05. has i l uj i s tati sti k menunj ukkan bahwa rata -rata ni lai pre-tes t dan pos t-tes t mengal ami perubahan s i gni fi kan (p val ue 0.000). ni l ai rata -rata pre-tes t (42,40) termas uk dal am kategori ti dak kompeten s edangkan ni l ai rata -rata pos t-tes t (84,27) s ehi ngga termas uk dal am kategori kompeten. sedan gkan pada kel ompok kontrol s ebel um perl akuan ni l ai mean (40,67) termas uk dal am kategori ti dak kompeten. setel ah mendapatkan i ntervens i non -pal, ni l ai mean meni ngkat menj adi (69,60) termas uk kategori ti dak kompeten. penerapan peer-assisted learning berpengaruh s i gni fi kan untuk meni ngkatkan kompetens i kogni ti f mahas i s wa. kata kunci: apl i kas i , peer-assisted learning (pal), kompetens i kogni ti f. abstract the learning process that is emphasized today is student centered learning, this learning provides an opportunity student to build their own knowledge so that gain a deep understanding. one of innovative learning with student centered learning strategy is peer-assisted learning (peer tutor). the pal method is able to improve understanding (cognitively) on tutor and tutees, as concepts can be explained simply by using the easiest language to understand and match the student level. this concepts is know as the concept of cognitive alignment (cognitive congruence). the aim of the research is to analyze the application of pal method to increase the achievement of students’ competency. the research used quasi-experimental design, pre and post-test plan with mailto:rereqoe@gmail.com indonesian journal of nursing practices 108 control group design. the sampling technique was simple random sampling. the samples were currently fourth semester students, 60 students were divided in 2 groups, treatment group and control group. the instrument was multiple choice questions for cognitive competency evaluation and checklist for psychomotor competency and affective evaluation. data were analyzed by using t-test, with 0.05 degree of significance. the result showed that the average value of pre-test and post-test examination experiencing significant changes (p=0.000). the average value of pre-test (42.40) was categorized incompetence, while the average value of post-test (84.27) was classified as competence. whereas in control group before implementation of pal the mean value was 40.67. it was classified as incompetence. after pal intervention it increased into 69.60 or categorized as competence. it was concluded that there was significant influence of pal application to improve students’ cognitive competence. keywords: applications, peer-assisted learning (pal), cognitive competence pendahuluan kurikulum pendidikan saat ini mengarah pada pendekatan kompetensi. mahasiswa dituntut untuk menguasai ilmu pengetahuan, attitude, juga keterampilan klinik (mulder, 2006). kurikulum pendidikan saat ini mengamanahkan perubahan pendekatan pembelajaran teacher centered learning ke metode student centered learning. metode belajar yang lebih menekank an pada keaktifan mahasiswa, saat ini mulai b an y ak digunakan untuk lebih mendorong partisipasi aktif dan berpikir kreatif. metode pembelajaran yang diterapkan di lingkungan akper pemkab ponorogo sebagian besar cenderung pada pembelajaran yang bersifat konvensional (teacher centered learning). hal ini menjadikan mahasiswa pasif, cenderung hanya mendengar, komunikasi satu arah, tidak ada diskusi dengan teman terkait materi yang harus dikuasai. diperlukan adanya metode pembelajaran yang membuat mahasiswa berinteraksi dengan teman dan aktif diskusi untuk mengasah kemampuan berfikir kritis. ladyshewsky (2000, dalam tice, 2014) menyatakan bahwa pembelajaran kooperatif merupakan strategi yang baik untuk meningkatkan hasil pendidikan dan sangat berguna untuk mengembangkan kompetensi siswa. salah satu metode yang di tawarkan adalah peer-assisted learning (pal) (stone, cooper, & cant, 2013). peer-assisted learning (pal) merupakan salah satu metode atau strategi pembelajaran yang bersifat student center learning karena dianggap sebagai suatu metode pembelajaran kolaboratif, kooperatif dan memberikan manfaat secara akademik bagi mahasiswa (santee & garavalia, 2006; secomb j, 2008; yu et al., 2011). menurut tice (2014) salah satu dasar teoritis untuk semua jenis peer teaching dan learning adalah cooperative learning. perspektif yang mengarahkan penelitian dan pengembangan cooperative learning adalah interaksi sosial, perkembangan kognitif dan teori teori perilaku belajar. penggunaan pal dalam program pendidikan kesehatan medis, keperawatan, terapi fisik, terapi okupasi, obat-obatan, pelatihan atletik, dan pendidikan tinggi, merupakan strategi pendidikan yang tepat digunakan karena menawarkan agar siswa aktif berpartisipasi (henning, weidner, & mellisa, 2008). asistensi atau yang disebut juga peer assisted learning (pal) adalah suatu kegiatan pembelajaran dimana perolehan ilmu berasal dari rekan yang derajatnya sama dengan peserta yang menerima ilmu (topping, 1996). metode pal ini dapat menggunakan mahasiswa sebaya pada satu tahun angkatan yang sama (peer-) maupun pada tahun angkatan yang berbeda namun tidak berjauhan ( near-peer), dalam satu jenjang pendidikan yang setara (misalnya diploma), maupun lintas jenjang, dalam vol. 1 no. 3 desember 2017 109 satu institusi pendidikan maupun lintas institusi (topping, 1996). peer-assisted learning merupakan salah satu implementasi pembelajaran dalam kelompok kecil yang bermanfaat untuk mengembangkan keterampilan berkomunikasi, pengembangan kompetensi intelektual dan professional, dan pengemban gan kepribadian mahasiswa (brown & atkins, 2002). metode peer-assisted learning (pal) terbukti memberikan manfaat secara akademik bagi mahasiswa pengajar (tutor) maupun peserta (tutees) (yu, et al., 2011). manfaat bagi mahasiswa (tutees), akan lebih akrab dengan tutor dibandingkan dengan fasilitator dosen, sehingga lebih mudah dalam proses pembelajaran (sheldon; 1973 cit. burke et al., 2007). interaksi dengan rekan sebaya juga diketahui dapat meningkatkan rasa percaya diri dan komitmen untuk belajar, meningkatkan perhatian bersama antara peserta dan bermanfaat untuk peningkatan keterampilan (topping & ehly, 1998; buckley & zamora, 2007). secara teori, hal yang diyakini mendukung keberhasilan pal terletak pada adanya fakta bahwa tutor dan mahasiswa peserta (tutees) mempunyai pengetahuan dasar dan pengalaman yang sama, yang dikenal sebagai keselarasan kognitif (cognitive congruence). adanya kesesuaian kognitif ini memungkinkan asisten mahasiswa memahami secara lebih mendalam tingkat pengetahuan, kebutuhan belajar, masalah kognitif yang dihadapi serta capaian yang diharapkan terhadap mahasiswa pesertanya sehingga asisten mahasiswa ini mampu menjelaskan konsep-konsep secara sederhana dengan menggunakan bahasa yang pali ng mudah difahami sesuai dengan level mahasiswa pesertanya (ten cate & durning, 2007a). keterampilan komunikasi bisa dilatih melalui metode peer-assisted learning karena memberikan kesempatan kepada seluruh mahasiswa, baik tutor maupun tutee untuk mengemukakan ide, pendapat, pertanyaan, maupun jawaban dalam diskusi kelompok kecil. pada saat yang sama, metode pal juga bisa digunakan untuk melatih keterampilan berfikir. tutor menyampaikan informasi yang berkaitan dengan materi secara terstruktur dan mudah dipahami oleh temannya. tutee juga dituntut untuk mencerna, mengkritisi, dan bahkan menawarkan informasi baru yang berkaitan dengan materi yang disampaiakan oleh tutor. dalam metode pal, terdapat 4 prinsip yang saling berkaitan secara sistemik, yaitu respon aktif siswa, kesempatan bagi siswa untuk memberikan respon, umpan balik, serta penguatan (heron, villareal, & yao, 2006). model pembelajaran dengan pal ini mampu menutup kesenjangan nilai antar mahasiswa, meningkatkan suasana akademik yang kondusif, budaya kolaborasi daripada kompetisi, situasi yang mendukung proses pembelajaran serta alternatif inovasi bagi institusi dengan keterbatasan sumber daya manusianya (ross & cummings, 2009). teori dasar pengembangan model pembelaj aran peer-assisted learning (pal) adalah teori constructivism dari jean piaget, yang menyatakan bahwa tahap perkembangan kognitif melibatk an berbagai macam faktor, seperti: kematangan, pengalaman, dan faktor lingkungan sosial. piaget berpendapat bahwa ketika orang menghadapi informasi baru yang tidak sesuai dengan pengaturan pengetahuan dan pemikiran mental mereka saat ini, sebuah kontradiksi yang menyebabkan ketidak seimbangan. hal ini menyebabkan pelajar mengakomodasi informas i baru dan mengubah pemahaman sehingga mencapai keseimbangan. dengan cara ini, pelajar membangun pengetahuan mereka sendiri. (falchikov, 2001). sejalan dengan piaget, teori zone of proximal development oleh vygotsky (1978), menyatakan bahwa perkembangan kognitif membutuhkan interaksi sosial. vygotsky menetapkan bahwa interaksi sosial memainkan peran penting d al am pengembangan kognisi (vygotsky, 1986). dukungan belajar dari rekan-rekan di "komunitas praktek", sebagai akibatnya, memberikan kesempatan bagi praktisi pemula untuk merenungkan proposisi pengetahuan (fakta dan konsep), pengetahuan kerajinan profesional (belajar dari pengalaman, keterampilan), dan pengetahuan pribadi (donaghy, carey & beeman, 1998 dalam ibrahim, 2011). vygotsky berpendapat bahwa berbagai keterampilan dapat dikembangkan dengan bimbingan orang dewasa atau kolaborasi dengan teman melebihi yang dapat dicapai sendiri. pusat untuk teorinya indonesian journal of nursing practices 110 adalah ide dari zone of proximal development (zpd) yang berarti suatu zona perkembangan ketika anak tidak mampu melakukan suatu kegiatan belajar tanpa bantuan, namun dapat melakukannya secara baik dibawah bimbingan orang dewasa. tingkat perkembangan ditentukan melalui pemecahan masalah di bawah bimbingan orang dewasa atau kolaborasi dengan rekanrekan yang lebih mampu (toping, 1996; falchikov, 2001; ten cate & durning, 2007). berdasarkan uraian di atas, maka didapatkan rumusan permasalahan: apakah penerapan model pembelajaran peer-assisted learning (pa l) mampu meningkatkan capaian kompetensi kognitif mahasiswa. penelitian ini diharapkan memperkaya konsep atau teori yang mendukung perkembangan ilmu keperawatan tentang model pembelajaran dengan pendekatan student centered learning (scl) dan dapat menjadi evaluasi dan masukan bagi pengeelola pendidikan (bagian akademik) akper pemkab ponorogo dalam mengambil kebijakan untuk perbaikan program pembelajaran. metode populasi dalam penelitian ini adalah mahasiswa semester iv akper pemkab ponorogo sejumlah 124 orang. tehnik sampling yang digunakan adalah simple random sampling. jumlah sampel dalam penelitian adalah 60 orang yang terbagi menjadi 2 kelompok, yaitu kelompok perlakuan (n=30) dan kelompok kontrol (n=30). penelitian ini menggunakan pendekatan penelitian quasy experiment dengan desain pre-test and post test with control group design. kelompok eskperime n dalam penelitian ini diberikan perlakuan penerapan model pembelajaran peer-assisted learning (pal), sedangkan kelompok kontrol diberikan dengan metode pembelajaran konvensional ceramah dari dosen. variabel bebas dalam penelitian ini adalah metode pembelajaran kooperatif peer-assisted learning (pal), sedangkan variabel terikatnya adalah kompetensi kognitif. penelitian dilakukan dari bulan oktober 2016 sampai bulan februari 2017 di akper pemkab ponorogo melalui rangkaian prosedur, meliputi: 1) tahap pemilihan tutor dilakukan oleh tim pengajar dan bekerjasama dengan kemahasiswaan untuk seleksi tutor, 2) tahap briefing tutor yang dilakukan oleh koordinator mata kuliah dan tim pengajar. briefing tutor dilakukan sebanyak 4 kali tatap muka/session. 3) evaluasi kesiapan dan pemahaman tutor tentan g materi yang telah diberikan saat briefing, 4) tahap pre-test kemampuan kognitif tutees, 5) tahap cognitive phase, yaitu tahap interaksi antara tutor dan tutees dalam rangka intelektualisasi dan pemahaman materi ( zone proximal development) dilakukan minimal 4 kali/session, 6) tahap post-test kemampuan tuttes setelah dilakukan peer-tutor metode pengumpulan data yang digunakan adalah tes menggunakan multiple choice questions (mcq) sejumlah 25 soal dengan mo d e l soal vignete yang disusun oleh peneliti dengan tim pengajar. instrumen penelitian sebelumnya telah dilakukan review oleh tim pengajar dan dilanjutkan dengan uji validitas dan reliabilitas pada tanggal 12 januari 2017 di prodi diploma iii keperawatan fik universitas muhammadiyah ponorogo. hasil uji validitas instrumen dengan pearson product moment, instrumen dinyatak an valid dengan nilai corrected item-total correlation lebih besar dari koefisien korelasi minimal (>0.444) sehingga instrumen dapat digunakan. instrumen juga dinyatakan reliable setelah dilakukan uji cronbach alpha, nilai sebesar 0.746>0,6. hal ini menunjukkan bahwa instumen memiliki reliabilitas yang tinggi sehingga dapat digunakan untuk mengukur kompetensi kognitif mahasiswa. kompetensi kognitif mahasiswa diukur seban y ak 2 kali, yaitu pre-test (sebelum mendapatkan perlakuan). setelah mahasiswa mendapatkan intervensi berupa pemberian materi dengan menerapkan metode pembelajaran peer-assisted learning (pada kelompok eksperimen) dan metode pembelajaran konvensional ceramah (kelompok kontrol), selanjutnya dilakukan posttest untuk mengevaluasi kompetensi kognitif mahasiswa. setelah semua data terkumpul selanjutnya dilakukan uji normalitas dan homogenitas data. vol. 1 no. 3 desember 2017 111 uji normalitas dengan kolmogorov-smirnov, sedangkan uji homogenitas dengan levene’s tes t of equality variances. tehnik analisa data untuk menguji hipotesis penelitian dengan menggunakan statistik parametrik. hal ini dikarenakan hasil dari uji normalitas dan homogenitas data menunjukkan data berdistribusi normal dan tidak ada perbedaan signifikan dari kedua varians. analisis data yang digunakan untuk menjawab hipotesis adalah uji paired t-test untuk melihat perbedaan rata-rata kompetensi kognitif pre-test dan post-test. sedangkan untuk melihat perbedaan metode peer-assisted learning dengan metode konvensional ceramah dilakukan uji independen t t-test. hasil hasil perhitungan uji normalitas menunjukkan bahwa kedua kelompok berdisribusi normal. berdasarkan perhitungan analisis uji homogenitas menunjukkan varians kedua kelompok homogen. tabel 1.1 perubahan kompetensi kognitif sebelum dan setelah perlakuan pada kelompok perlakuan dan kontrol mahasiswa semester iv akper pemkab ponorogo (n=60) kel ompok waktu pengukuran mean sd p-val ue perl akuan pre-test 42,40 9,83 0,000 post-test 84,27 7,04 kontrol pre-test 40,67 8,01 0,000 post-test 69,60 8,04 sumber: data pri mer, 2017 berdasarkan tabel 1.1 dapat diketahui bahwa mahasiswa kelompok intervensi sebelum perlakuan nilai mean 42,40+9,83, termasuk dalam kategori tidak kompeten. kompetensi meningkat setelah perlakukan menjadi 84,27+7,04, termasuk kategori kompeten. sedangkan pada kelompok kontrol sebelum perlakuan nilai mean 40,67+8,01, termasuk dalam kategori tidak kompeten. setelah mendapatkan intervensi non-pal, nilai mean meningkat menjadi 69,60+8,04, tetap dalam kategori tidak kompeten. rata-rata nilai kompetensi kognitif pada kelompok eks pe rimen lebih tinggi dibandingkan dengan kelompok kontrol. hasil uji paired t-test didapatkan ρ = 0.000 (ρ<0,05). hal itu berarti ada perbedaan rata-rata kompetensi kognitif mahasiswa pre-test dan post-test. hasil uji statistik independet t-test didapatkan ρ = 0.000, artinya ρ-value < α (0.05). artinya h1 diterima, sehingga dapat disimpulkan ada pengaruh penerapan metode pembelajaran peerassisted learning terhadap kompetensi kognitif mahasiswa. pembahasan hasil penelitian menunjukkan bahwa terjadi peningkatan kompetensi kognitif pada kelomp ok perlakuan dan kelompok kontrol setelah mendapatkan perlakuan (intervensi). nilai m ea n kompetensi kognitif kelompok perlakuan pada saat pre-test termasuk kategori tidak kompeten dan mean pada saat post-test meningkat menjadi kategori kompeten. sedangkan nilai mean kompetensi domain kognitif mahasiswa kelompok kontrol pada saat pre-test termasuk kategori tidak kompeten kemudian mengalami peningkatan nilai mean tapi tidak berubah kategoriya adalah tidak kompeten pada saat posttest. stanberg (1985, cit. topping, 1996) menyebutkan bahwa ada beberapa komponen yang teridentifikasi dan mungkin mengalami peningkatan selama proses pal diantaranya: kemampuan meta-kognitif dalam merencanakan, memonitor, dan mengevaluasi diri dalam mengajar. selain itu, dimungkinkan juga adanya peningkatan dalam menilai, terkait dengan penggunaan pengetahuan deklaratif, pengetahuan prosedural dan kontekstual. maksudnya adalah seorang mahasiswa ketika menjadi tutor pal, dalam proses mengajarkan keterampilan, sebenarnya dengan sendirinya d i a akan belajar dan terus belajar cara mengajar yang baik. termasuk di dalamnya cara menyampaikan suatu materi keterampilan agar lebih mudah dicerna oleh peserta, pemilihan kata yang tepat indonesian journal of nursing practices 112 bahkan memberikan contoh yang mudah dipahami oleh mahasiswa pesertanya. proses kognitif yang terjadi meliputi: proses memah ami (perceiving), membedakan (differentiating), memilah (selecting), menyimpan (storing), menyimpulkan (inferring), menerapkan (applying), menggabungkan (combining), menil ai (justifying), dan merespon (responding). peningkatan kompetensi kognitif mahasiswa pada kelompok yang diterapkan metode pal sejalan dengan teori zone of proximal development oleh vygotsky (1978), yang menyatakan bahwa perkembangan kognitif membutuhkan interaksi sosial. vygotsky menetapkan bahwa interaksi sosial memainkan peran penting dalam pengembangan kognisi (vygotsky, 1986). proses interaksi antar mahasiswa merupakan proses belajar sebagai upaya memahami informasi yang baru (brooks and brooks, 1993; eggen and kauchak, 2012). didukung juga dengan teori perkembangan kognitif piaget, bahwa kerjasama diantara rekan sebaya (peer-tutor) mendorong pertukaran pemikiran dan diskusi secara nyata, dan kerjasama. kerjasama diantara rekan sebaya penting untuk mengembangkan sikap, berfikir kritis, objektivitas, dan refleksi diskursif (falchikov, 2001). perbedaan nilai ini dikarenakan tutor pal dapat berfungsi dengan efektif, tutor yang memiliki keselarasan kognitif dengan tutee dan menguasai materi dengan baik mampu memberikan pemahaman kepada tutee. dalam penerapan peer-assisted learning, diharapkan tutor menjadi sumber belajar utama dan pemicu belajar bagi tutee (gunarya, 2011). berdasarkan tujuan pembelajaran yang berorientasi pada student center learning (scl), pembelajaran peer-assisted learning mendo ro n g tutor menggunakan kemampuan untuk lebih aktif berbagi informasi dengan tutee untuk mencapai solusi dan pemahaman serta mengelola pembelajarannya secara mandiri (roscoe & chi, 2014). metode pembelajaran peer-assisted learning, memiliki dua komponen utama, yaitu menjelaskan dan mempertanyakan. keduanya mempunyai dua unsur membangun pengetahuan (kognitif) dan memberitahukan pengetahuan. seorang tutor dalam suatu kelompok, mendapatkan manfaat saat memberikan penjelasan pada tutee. sebab saat memberikan informasi seorang tutor melakukan pengintegrasian konsep dan prinsip serta memunculkan ide baru. selain itu, saat tutee bertanya dengan pertanyaan yang spesifik dan mendalam, maka akan mendukung tutee untuk merefleksikan pengembangan pengetahuan (kognitif), dimana seorang tutor berperan membantu proses ini sekaligus menguatkan pemahamannya (roscoe & chi, 2014; (depaz & moni, 2012). model pembelajaran peer-assisted learning membantu tutor membangun metakognisi, merefleksikan pengetahuan dan pengalaman, serta mengkonstruksi pengetah u an dengan cara menyimpulkan maupun menyatukan ide. hal tersebut yang menyebabkan adanya peningkatan kompetensi kognitif mahasiswa pada kelompok perlakuan. stanberg (1985, cit. topping, 1996) menyebutkan bahwa ada beberapa komponen yang teridentifikasi dan mungkin mengalami peningkatan selama proses pal diantaranya: kemampuan meta-kognitif dalam merencanakan, memonitor, dan mengevaluasi diri dalam mengajar. penelitian ini melibatkan responden remaja, dimana pada masa ini terdapat tugas-tugas sesuai fase perkembangan. salah satu tugas perkembangan fase remaja adalah interaksi intens dengan teman untuk mengembangkan kecakapan intelektual dan konsep-konsep tentang kehidupan sosial (monks, knoers, & haditono, 2012). sejalan dengan pendapat inhelder dan piaget bahwa perubahan otak p ad a masa remaja dibutuhkan untuk perkembangan kognitif, melalui bertukar ide dengan teman sebaya akan meningkatkan perkembangan berfikir secara operasional. keterbatasan dari penelitian diantaranya: peneliti tidak melakukan eksplorasi gaya belajar, motivasi tutor dan tutee, beban belajar mahasiswa, observasi proses pal hanya pada satu kompetensi. selain itu, responden yang dilibatkan dalam penelitian, baik kelompok perlaku an atau kontrol adalah mahasiswa dalam satu institusi, vol. 1 no. 3 desember 2017 113 sehingga kemungkinan kedua kelompok bertemu dan berdiskusi diluar proses pembelajaran tidak dapat dikendalikan oleh peneliti. implikasi dari penelitian ini diharapkan metode pal membantu mahasiswa dalam membangun kerangka konseptual (constructivism) pengetahuan dan keterampilan. melalui pembelajaran pal, mahasiswa akan berlatih untuk mengasah kemampuan kognitif, menyampaikan ide pada teman belajar, dan berlatih komunikasi dua arah antara tutor dan tutee. kesimpulan pembelajaran dengan metode peer-assisted learning (pal) dan metode konvesional (ceramah) berpengaruh terhadap pencapaian kompetensi mahasiswa semester iv di akper pemkab ponorogo. metode pembelajaran pal mempunyai pengaruh signifikan untuk meningkatkan kompetensi kognitif mahasiswa. hasil penelitian ini diharapkan menjadi lan d asan institusi untuk menjadikan pal sebagai salah satu alternatif strategi pembelajaran student centered learning (scl) pada materi. peneliti selanjutnya diharapkan dapat melanjutkan penelitian dengan desain eksperimen murni dengan mengendalikan faktor-faktor yang mempengaruhi kompetensi mahasiswa, misalnya gaya belajar, motivasi, lingkungan belajar dll, selain itu juga perlu mempertimbangkan untuk melibatkan responden yang berbeda lokasi penelitian untuk kelompok kontrol dan eksperimen sehingga masing-mas in g tidak saling mempengaruhi. referensi brooks, j.g., & brooks, m.g. (1993). in search of understanding: the case for constructiv is t classrooms. alexandria, va: association for supervisio and curriculum development. brown, g., & atkins, m. (2002). effective teaching in higher education. london: taylor and francis e-library. buckley, s. & zamora, j. (2007). effects of participation in a cross year peer tutoring program in clinical examination skills on volunteer tutor's skills and attitudes toward teachers and teaching. bmc med education. 7; 20. depaz, i., & moni, r. (2012). using peer-teaching to support co-operative learning in undergraduate pharmacology. biosciences education jaournal, 11; 98108. eggen, paul & kauchak, don. (2012). strategi dan model pembelajaran mengejar konten dan ketrampilan berfikir. jakarta: indeks. falchikov, n. (2001). learning together: peer tutoring in higher education. london: routledge falmer. gunarya, a. (2011, maret 31). model perilaku belajar. retrieved from http://repository.unhas.ac.id/handle/123 456789/27 henning, j. m., weidner, t. g., & mellisa, m. c. (2008). peer assisted learning in clinical education: literatur review. athletic training education journal, 84-90. heron, t., villareal, d., & yao, m. (2006). peer tutoring systems: application in classroom and specialized enviroments. reading & writtings quarterly, 27-45. monks, f., knoers, a., & haditono, s. (2012). psikologi perkembangan: pengantar dalam berbagai bagiannya. cetakan 14. yogyakarta: universitas gadjah mada. mulder, h. (2006). competency based trainning: what, why & how? dalam proceeding, teaching learning procces & assesment in competence based education. roscoe, r., & chi, m. (2014). understanding tutor learning: knowledge building and knowledge telling in peer tutors explanation and questions. review of education research, 77 (4); 534-574. ross, m., & cummings, a. (2009). peer assisted learning, a practical guide for medical teachers edisi 3. uk: elsevier. secomb, j. (2008). a systematic review of peer teaching and learning in clinical education . journal of clinical nursing. 17, pp. 703-16. stone, r., cooper, s., & cant, r. (2013). the value of peer learning in undergraduate nursing education: a systematic revi e w. international scholary research notice, 110. ten, c., & durning, s. (2007). peer teaching in medical education: twelve reason to mo v e from theory to practice. medical teacher, 591-599. indonesian journal of nursing practices 114 topping, k. (1996). the effectivenss of peer tutoring in further ad higher education: a typology and review of the literatu re . higher education, vol. 32, o. 3, 321-345. vygotsky, l.s. (1978). mind in society: the development of higher psychological processes. cambridge: ma: harvard university press. yu, t., wilson, n., singh, p., lemanu, d., hawke n , s., & hill, a. (2011). medical students-asteachers: a systematic review of peerassisted teaching during medical school. advance in medical education and practice vol. 2, 157-172. 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/ 37 open access volume 7, issue 1, june 2023, p. 37-49 prevalence of erectile dysfunction among men with type 2 diabetes mellitus in indonesia: an observational study yanuar primanda1* , taufik wiyoga nugroho2, vignesvararajah lokeesan3 1department of adult nursing, school of nursing, universitas muhammadiyah yogyakarta, indonesia 2clinical nurse practitioner, rajawali 1a/hcuinpatient unit class iii and unit stroke, rsup dr. kariadi semarang, indonesia 3department of supplementary health sciences, faculty of health-care sciences, eastern university sri lanka corresponding author: yanuar primanda email: yanuarprimanda@umy.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.v7i1.18111 : 08 march 2023 : 22 may 2023 : 24 may 2023 abstract background: diabetes mellitus (dm) is a chronic metabolic disorder that can lead to multiple long-term complications in the human body including erectile dysfunction (ed). ed is a condition that commonly affects men and may reduce their quality of life. however, ed amongst men with type 2 dm (t2dm) has rarely been assessed and addressed by nurses who have an essential role in providing holistic patient care. objective: this study aimed to describe ed among men with t2dm based on their demographic characteristics and health profiles. methods: this was a descriptive study with a cross-sectional approach of 32 male respondents who were selected through convenience sampling in the outpatient department of pku muhammadiyah hospital yogyakarta, indonesia. the data was collected by using the erectile function’s domain of indonesian version of international index of erectile function (iief). descriptive statistics were used to present this study’s findings. results: the results showed that 62.5% of the participants had uncontrolled blood glucose levels with an average random blood glucose of 207.75 ± 77.21 mg/dl. only four respondents (12.5%) had received sexual counselling. twenty-nine respondents (90,6%) had ed which were categorized into mild (17.2%), mild to moderate (6.9%), moderate (24.1%) and severe (51.7%). conclusion: ed levels varied across age, duration of t2dm, random blood glucose levels, previous history of smoking, current smoking status, sexual counselling experience, complications, and occupation levels. severe ed was common amongst men with t2dm in this study. nurses should assess patient’s sexual function regularly and identify the effects of ed in men with t2dm. early detection of ed could allow nurses to plan adequate intervention and health education to provide better outcomes for men with t2dm. keywords: erectile dysfunction; indonesia; type 2 diabetes mellitus introduction diabetes mellitus (dm) is one of the most devastating diseases in the world that leads to multiple complications in the human body. the international diabetes federation reported that approximately 537 million adults between 20-79 are living with diabetes and almost 81% of them are living in low and middle income countries including indonesia (international diabetes federation, 2021). in indonesia, approximately 19.5 million people, which represents 10.8% of indonesian adult population, were living with dm in 2021 (international diabetes federation, 2021). in yogyakarta, indonesia, one of the special provinces in java, dm affects one third of people older than 15 years (ministry of health of the republic of https://creativecommons.org/licenses/by/4.0/ mailto:yanuarprimanda@umy.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/18111 https://orcid.org/0000-0003-3856-7232 https://orcid.org/0000-0002-2672-8046 https://crossmark.crossref.org/dialog/?doi=10.18196/ijnp.v7i1.18111&domain=pdf indonesian journal of nursing practices 38 indonesia, 2018). the indonesian ministry of health ranked yogyakarta as one of the top three provinces with the highest numbers of people living with dm, after jakarta and kalimantan (ministry of health of the republic of indonesia, 2018). therefore, this study was conducted in yogyakarta. dm causes various microvascular and macrovascular complications including erectile dysfunction (ed) (jelinek et al., 2017; litwak et al., 2013; papatheodorou et al., 2018). a complex process that involves vascular, neurologic, psychological and hormonal factors contribute to the development of ed amongst men with dm (jumani & patil, 2020). hyperglycaemia causes endothelial dysfunction as a result of the failure of nitric oxide induced smooth muscle relaxation (jumani & patil, 2020). hormonal factors, including hypogonadism are commonly found in men with dm who experience ed (cannarella et al., 2021). the complex pathogenesis of insulin and leptindependent altered function of the gonadotropinreleasing hormone neuron further contribute to hypogonadism and ed in men with dm (cannarella et al., 2021). several factors are associated with ed in men with dm including: advanced age (bahar et al., 2020; jumani & patil, 2020; omar et al., 2022; zeleke et al., 2021), the length of the duration of dm (omar et al., 2022; zeleke et al., 2021), poor blood glucose control (omar et al., 2022; zeleke et al., 2021), high cholesterol level (omar et al., 2022), active smoking status (jumani & patil, 2020), sedentary lifestyle (defeudis et al., 2022; jumani & patil, 2020), obesity or being overweight (defeudis et al., 2022; jumani & patil, 2020), increased calorie intake (defeudis et al., 2022), and excessive alcohol consumption (jumani & patil, 2020; zeleke et al., 2021). ed is common amongst men who have dm. a review study reported that the prevalence of ed among men with dm is about 60-80% (jumani & patil, 2020). a meta-analysis of 145 studies in 2017, which involved more than 90,000 men with dm, found that the overall prevalence of ed amongst men with dm was 52.5% (kouidrat et al., 2017). ed was also found to be more common amongst men with type 2 dm (t2dm) than those with type 1 dm (66.3% vs 37.5%) (kouidrat et al., 2017). a recent study from indonesia reported that the prevalence of ed among male with t2dm (n=815) was 32.4% (cholil et al., 2019). ed can lead to serious problems especially related to mental or psychological well-being and quality of life. amongst the general population, a metaanalysis study found that ed is associated with the risk of depression (liu et al., 2018). a previous study reported that compared to people without dm history, people with dm who experienced ed also have worse sexual satisfaction, emotional life (penson et al., 2003) and quality of life (avasthi et al., 2011). another study has confirmed that ed is a strong predictor of poor generic and disease-specific quality of life (malavige et al., 2014). feelings of low self-esteem, loneliness, unattractiveness, and negative relationship with their spouses were often reported by men with dm who had ed (barnardkelly et al., 2019). furthermore, ed also caused negative relationship effects including mutual mistrust, fear of losing support from spouse, general unhappiness, and infidelity (cooper et al., 2018). considering the devastating impact of ed amongst men with t2dm, the indonesian endocrinologist association (perkeni) recommends regular assessment of sexual function amongst men with dm using the international index of erectile function (iief) (indonesian endocrinologists association, 2021). ed is considered as a common complication that is rarely disclosed by men with dm to their health care professionals (indonesian endocrinologists association, 2021). these communication problems are a common barrier in assessing ed among men with dm because health care professionals rarely ask about ed issues and men with dm also do not regularly inform their practitioner regarding their ed condition (barnardkelly et al., 2019). the failure of early identification of ed causes there to be a lack of appropriate interventions place and leading to further deterioration and aggravation of the psychological distress of the patient, their spouse and their quality of life (barnard-kelly et al., 2019). barnard-kelly et al. (2019) further report that almost half of men who have dm experienced ed did not seek help. while studies have identified a high prevalence of ed among men with dm especially in t2dm, and the vol. 7 no. 1 june 2023 39 regular screening of sexual problems among men with dm is recommended, ed is one of the often neglected complications of dm (cannarella et al., 2021; verschuren et al., 2010). in yogyakarta, several studies have been conducted to describe or provide interventions related to dm including diabetic foot care (arianti, 2015; pranata et al., 2016; primanda et al., 2017; rias, 2016; rias et al., 2016; windasari, 2015), mental health (susanti, 2014; wardaningsih & widyaningrum, 2019), dietary behaviours (primanda et al., 2011; putranto & primanda, 2019), insulin management (santosa & rosa, 2014), and knowledge (haris & kristianti, 2020). however, few studies have been conducted related to ed amongst men with dm in yogyakarta. a literature review that sort to describe ed among men with dm in indonesia from 2010-2016 was only cited in four other studies from bali, manado (warsono & permana, 2017). similarly, another study also reported that sexuality including ed only appeared in the title of only about 100 studies relating to dm in 2009 (verschuren et al., 2010). this indicates that less attention is paid to ed in comparison to other dm complications. considering the high number of people with t2dm who live in yogyakarta, it is important to investigate the prevalence of ed in men with t2dm in the region. there are several barriers relating to addressing ed problems amongst men in general as well as men with dm have been reported, including factors associated with patients and health care providers. patients frequently encounter difficulties in discussing sexual health problems with their care providers because patients of feelings of embarrassment in discussing the problem (jiann et al., 2009; rutte et al., 2016). patients has experienced with health care providers were incapable, embarrassed, and unwilling to discuss ed (rutte et al., 2016). misconception surrounding the effectiveness of ed treatments, the importance of discussing ed to find appropriate treatment, and effects of ed treatment were reported as the reasons in avoiding discussions about ed by men with t2dm (jiann et al., 2009). health care providers were seen as un aware of the distressful nature of sexual problems (rowland, 2011) and perceived as reluctant or bothered by discussions relating to sexual issues (rowland, 2011; rutte et al., 2016). further, studies revealed that the barriers for nurses in assessing ed included communication (barnard-kelly et al., 2019), embarrassment, lack of time, not considering sexual assessment as a priority, fear of causing offence, and lack of knowledge of sexual health (bilal-salim, 2019). furthermore, it was noted that nurses have limited formal education in sexual health that inadequately prepare nurses to address ed issues in their daily practices (bilal-salim, 2019). while nurses face several barriers in managing patient sexual health, nurses have essential roles in providing holistic care to all of patients including those with t2dm and ed without discrimination. addressing patient’s sexual health forms part of holistic care which sometimes requires nurses to put aside any personal attitudes and beliefs about sexual health, resulting in nurses who can address sexual health issues adequately (bilal-salim, 2019). it is important to create supportive and safe environments to encourage men with t2dm to report sexual health issues and reduce their embarrassment associated with asking for help regarding their sexual health issues including ed (thongtang et al., 2021). sexual health related issues are an essential part in assessing men with t2dm to provide routine care (thongtang et al., 2021). further, nurses also have important roles in providing education and raising awareness of ed amongst men with t2dm (bilal-salim, 2019). therefore, nurses are expected to help with early identification of the problem, facilitate appropriate interventions and treatments that could subsequently improve the patient and their spouse’s sexual health and quality of life. due to the high prevalence of ed among men with t2dm and the lack of existing studies in exploring ed among men with t2dm in the indonesian context, this study was developed to assess ed among men with t2dm in a hospital outpatient department in pku muhammadiyah hospital yogyakarta, indonesia. this study’s aim was to answer the following research questions: 1. what was the prevalence of ed among men with t2dm? 2. what is the frequency and percentage of ed based on the demographic characteristics of men with t2dm? method a cross-sectional study was conducted to answer the research questions. the participants were 32 males with t2dm who were enrolled through a convenience sampling technique. the sample calculation was based on the prediction of indonesian journal of nursing practices 40 population number (n = 35, based on the number of patient in august – september 2017), z score (1.96), prediction of proportion (50%), and d value (0.05) (nursalam, 2016). the inclusion criteria were: male, diagnosed with t2dm based on the patient’s medical record, attending outpatient department of pku muhammadiyah yogyakarta hospital, 17 years old or above, able to communicate in bahasa indonesia, and willing to give consent to participate in this study. the exclusion criteria were: below 17 years old, patients who refused to give consent to participate in this study and those who withdrew from the study during the data collection period. the data collection was conducted by the author (tws) through a self-administered questionnaire in the outpatient department of pku muhammadiyah yogyakarta, indonesia from february to march 2018. the demographic questionnaire was developed by the researchers and the international index of erectile function (iief) for erectile function domain (rosen et al., 2002) was used to collect data. the demographic questionnaire contained questions related to demographic characteristics (age, gender, occupation, experience in receiving consultation about ed) and health profiles (duration of dm, smoking history, family history of dm, recent blood glucose test, known comorbidities). the iief erectile function domain has six total items with a five-point likert scale (very low = 1 to very high = 5) for one question and six-point likert scale (no sexual activity = 0 to almost always or always = 5) for five questions. the possible total score of the questionnaire was 0 – 30. the ed levels were categorized into no ed (score 26 – 30), mild (score 22 – 25), mild to moderate (score 17 – 21), moderate (score 11 – 16) and severe (score 0 – 10). the iief is a validated and reliable scale to assess ed (cronbach’s alpha, range 0.73 – 0.99 and test-retest reliability r, range 0.64 – 0,84) (rosen et al., 2002). the iief was available in english language. therefore for this study, it was translated into bahasa indonesia through six steps of a back translation process (wild et al., 2005). the indonesian version of iief was further tested for its validity and reliability among 20 participants with dm using pearson product moment correlation and cronbach’s alpha test. the results found that the bahasa indonesian version of iief used in this study has the value of r = 0.836 – 0.957 and the cronbach’s alpha of 0.953. the validity and reliability test showed that the iief bahasa indonesia version of the scale was valid and reliable to use in the indonesian context (polit & beck, 2018). descriptive statistics was used to present the findings. the continuous data was reported using mean±sd for normally distributed data while median (inter quartile range/iqr) for not normally distributed data. the categorical data was reported as frequency (percentage). there was no gold standard in measuring normality of the data (kim, 2013). the normal distribution in this study followed the normal distribution criteria based on kirkwood and sterne (2003) including : (1) median close to ±10% of mean, (2) mean ±3 x sd approximate the minimum and maximum values, (3) skewness coefficient, (4) kurtosis coefficient between -2 and +2; and (5) approximately distribution looks bellshaped. data was considered normally distributed if all the five normal distribution criteria have been met (kim, 2013; kirkwood & sterne, 2003). this study was granted ethical clearance from faculty of medicine and health sciences, universitas muhammadiyah yogyakarta ethical committee (058/ep-fkik-umy/i/2018). result the normality test revealed that the data of age and duration of t2dm were not normally distributed based on the kirkwood and sterne (2003)’s criteria. the median age of participants was 57.5 (iqr = 52.5 – 64.75) years and the median duration of being diagnosed with dm was 10 (iqr = 3.25 – 16) years. the average random blood glucose was 207.75±77.21 mg/dl. the previous history of smoking question showed that more than two thirds of participants (68.8%) were smokers. seven participants were active smokers during the study research. all of the participants had no prior history of ed before being diagnosed with t2dm. seven (21.9%) participants had previously consumed over the counter medications to treat their ed without a prescription. the majority of participants had never received sexual counselling from their physician or sexologist. amongst the participants, hypertension was experienced by five (15.6%) and dyslipidaemia by four (12.5%) individuals. other complications such as stroke and cardiovascular disease were only vol. 7 no. 1 june 2023 41 experienced by one participant. participants’ work levels could inform on required power and energy to accomplish their work and were categorised based on indonesian endocrinologist association (perkeni) into mild, moderate, hard, and very hard levels. most of participants (81.3%) have mild level of work level such as civil servant, retired, and teacher. see table 1. table 1. demographic characteristics and health profiles of participants (n = 32) variable values age 20 – 39 years 40 – 59 years ≥ 60 years 1 (3.1%) 18 (56.2%) 13 (40.6%) median age 57.5 (52.5 – 64.75) duration of t2dm ≤ 5 years 6 – 10 years ≥ 11 years 11 (34.4%) 9 (28.1%) 12 (37.5%) median duration of dm 10 (3.25 – 16) random blood glucose ≤ 180 mg/dl > 180 mg/dl 12 (37.5%) 20 (62.5%) mean random blood glucose 207.75 ± 77.21 previous history of smoking no yes 10 (31.2%) 22 (68.8%) current smoking status no yes 25 (78.1%) 7 (21.9%) history of ed no yes 32 (100%) 0 (0.0) consume over the counter medication to treat ed no yes 25 (78.1%) 7 (21.9%) received sexual counselling no yes 28 (87.5%) 4 (12.5%) complications hypertension dyslipidaemia others 5 (15.6%) 4 (12.5%) 23 (71.9%) works’ level mild moderate hard very hard 26 (81.3%) 3 (9.4%) 2 (6.3%) 1 (3.1%) note: dm = diabetes mellitus, ed = erectile dysfunction. data are expressed as mean±sd, median (q1-q3), or frequency (percentage) ed had been experienced by 90.6% of participants at various levels from mild to severe based on the iief scale. almost half of the participants (46.0%) experienced severe ed (see table 2). table 3 describes the responses of the participants based on indonesian journal of nursing practices 42 each item of the iief scale. more than half of the participants reported difficulty in obtaining an erection during sexual activities, during penetration, maintaining an erection, and completing sexual intercourse. only a quarter of participants reported no issues with erection during sexual activities. table 2. erectile dysfunction among participants (n = 32) ed levels frequency (%) no ed 3 (9.4%) mild ed 5 (15.6%) mild to moderate ed 2 (6.3%) moderate ed 7 (21.9%) severe ed 15 (46.9%) note: ed = erectile dysfunction table 3. the responds of the participants based on each item of iief (n = 32) items 0 1 2 3 4 5 how often were you able to get an erection during sexual activity? 2 (6.3%) 14 (43.8%) 4 (12.5%) 5 (15.6%) 5 (15.6%) 2 (6.3%) when you had erections with sexual stimulation, how often were your erections hard enough for penetration? 0 17 (53.1%) 4 (12.5%) 3 (9.4%) 7 (21.9%) 1 (3.1%) when you attempted intercourse, how often were you able to penetrate (enter) your partner? 2 (6.3%) 15 (46.9%) 6 (18.8%) 1 (3.1%) 4 (12.5%) 4 (12.5%) during sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? 2 (6.3%) 15 (46.9%) 5 (15.6%) 3 (9.4%) 6 (18.8%) 1(3.1%) during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? 2 (6.3%) 3 (9.4%) 5 (15.6%) 7 (21.9%) 5 (15.6%) 10 (31.3%) how do you rate your confidence that you could get and keep an erection?* 2 (6.3%) 11 (34.4%) 10 (31.3%) 8 (25%) 1 (3.1%) note: data presented as percentage. 0 = no sexual activity/did not attempt intercourse, 1 = almost never or never, 2 = a few times, 3 = sometimes, 4 = most times, 5 almost always or always.* 1 = very low, 2 = low, 3 = moderate, 4 = high, 5 = very high the levels of ed based on the demographic characteristics and health profiles are shown in table 4. only one participant who was younger than 40 years old has no ed issues. one third of participants between 40-59 years old and more than two thirds of elderly participants (more than 60 years old) experienced severe ed. more than half of those who had been diagnosed with dm for more than 11 years experienced severe ed. interestingly, almost half of participants who had been diagnosed with dm for less than 5 years also experienced severe ed. the percentage of severe ed between the participants who have controlled (less than 180 mg/dl) or uncontrolled (more than 180 mg/dl) blood glucose levels was comparable and accounted for approximately 50% of the participants. more than a third of those who had a history of smoking reported to have severe ed. only one participant who still actively smoking reported severe ed. two out of seven participants who bought over the counter ed vol. 7 no. 1 june 2023 43 medication without medical prescription reported severe ed. half of the participants who either have experience in receiving sexual counselling or had not reported having severe ed. nearly half of the participants in all of the complications subgroups experienced severe ed. table 4. levels of ed based on demographic characteristics and health profiles of participants (n=32) characteristics (n) ed levels no mild mildmoderate moderate severe age 20 – 39 years (n=1) 40 – 59 years (n=18) ≥ 60 years (n=13) 1 (100%) 2 (11.1%) 0 0 5 (27.8%) 0 0 1 (5.6%) 1 (7.7%) 0 4 (22.2%) 3 (23.1%) 0 6 (33.3%) 9 (69.2%) duration of dm ≤ 5 years (n=11) 6 – 10 years (n=9) ≥ 11 years (n=12) 1 (9.1%) 1 (11.1%) 1 (8.3%) 3 (27.3%) 2 (22.2%) 0 1 (9.1%) 0 1 (8.3%) 1 (9.1%) 3 (33.3%) 3 (25.0%) 5 (45.5%) 3 (33.3%) 7 (58.3%) random blood glucose ≤ 180 mg/dl (n=12) > 180 mg/dl (n=20) 2 (16.7%) 1 (5.0%) 1 (8.3%) 4 (20.0%) 1 (8.3%) 1 (5.0%) 2 (16.7%) 5 (25.0%) 6 (50%) 9 (45%) previous history of smoking no (n=10) yes (n=22) 0 3 (13.6%) 1 (10.0%) 4 (18.2%) 0 2 (9.1%) 2 (20.0%) 5 (22.7%) 7 (70%) 8 (36.4%) current smoking status no (n=25) yes (n=7) 1 (4.0%) 2 (28.6%) 4 (16.0%) 1 (14.3%) 1 (4.0%) 1 (14.3%) 5 (20.0%) 2 (28.6%) 14 (56.0%) 1 (14.3%) consume store bought medication to treat ed no (n=25) yes (n=7) 2 (8.0%) 1 (14.3%) 3 (12.0%) 2 (28.6%) 0 2 (28.6%) 7 (28.0%) 0 13 (52.0%) 2 (28.6%) received sexual counselling no (n=28) yes (n=4) 2 (7.1%) 1 (25%) 5 (17.9%) 0 2 (7.1%) 0 6 (21.4%) 1 (25%) 13 (46.4%) 2 (50%) complications hypertension (n=5) dyslipidaemia (n=4) others (n=23) 0 2 (50.0%) 1 (4.3%) 1 (20.0%) 0 4 (17.4%) 0 0 2 (8.7%) 2 (40.0%) 0 5 (21.7%) 2 (40.0%) 2 (50.0%) 11 (47.8%) occupation levels mild (n=26) moderate (n=3) hard (n=2) very hard (n=1) 2 (7.7%) 1 (33.3%) 0 0 4 (15.4%) 0 0 1 (100%) 2 (7.7%) 0 0 0 7 (26.9%) 0 0 0 11 (42.3%) 2 (66.7%) 2 (100%) 0 note: data presented as percentage ed = erectile dysfunction. discussion this study revealed that majority (90.6%) of participants had experienced ed at various levels and that severe ed was common (46.9%) amongst the participants. this number is considered higher than those in previous studies conducted in indonesia and overseas. a study conducted at an outpatient department of provincial hospital bali among 34 people with type 2 dm have found that 61.8% of them had experienced ed, though the indonesian journal of nursing practices 44 levels of severity of ed were not reported (sugiharso & saraswati, 2016). another more recent study conducted in manado amongst 38 participants with t2dm at endocrine polyclinic of tertiary hospital found that 89.5% of participants experienced ed and only four (10.5%) participants had severe ed (panelewen et al., 2017). in north west ethiopia, a study which involved 362 participants with t2dm in a diabetic clinic found that ed was found in 59.7% of participants and severe ed was found in 13.3% of participants (mehiret et al., 2021). in southern ethiopia, the number was slightly higher where 72.2% of male with dm have experienced ed (zeleke et al., 2021). there are several factors that may explain the high number of ed amongst participants in this study. the first possible reason is the uncontrolled blood glucose level of participants. previous studies have demonstrated the correlation between poor blood glucose control with the prevalence of ed amongst men with dm. zeleke et al. (2021) found that the odds of developing ed among men with dm with fasting blood glucose (fbg) ≥ 126mg/dl was increased by 10.3 times as compared with fbg < 126 mg/dl. another study found higher odds of ed among those with uncontrolled blood glucose where the odds of having ed was 15.26 times more likely to occurs among those with uncontrolled blood glucose (mehiret et al., 2021). high blood glucose levels can cause vasculopathy including microangiopathy, macroangiopathy, and endothelial dysfunctions which subsequently cause ed among men with dm (cannarella et al., 2021; castela & costa, 2016; jumani & patil, 2020; maiorino et al., 2014). it is also believed that high blood glucose is responsible for the autonomic and peripheral neuropathy which can further contribute to dm induced ed because of the destruction of sensory impulses that occur during erection (cannarella et al., 2021; jumani & patil, 2020; maiorino et al., 2014). the second possible factor is the long duration of dm. the odds of developing ed among men with dm for more than 10 years was 6.2 times higher than those with dm for less than 10 years (mehiret et al., 2021). it has also been found that the odds of ed among those who have had dm for more than 10 years is 17.7 higher than those with dm for less than 5 years (zeleke et al., 2021). another study also estimated that each 1-year increment in duration of dm was associated with 10% higher risk of ed (shiri et al., 2005). it is argued that these increased odds amongst people with long standing dm could be explained by increasing microvascular and macrovascular complications and neurogenic and vasogenic problems that mainly occur amongst people with long standing dm (zeleke et al., 2021). in addition, sexual hormones imbalances such as low testosterone concentration which occurs in approximately a quarter of males with t2dm could also contribute to ed among men with long standing dm (maiorino et al., 2014). aging is considered as another possible factor that can cause high percentage of ed among men with dm. regardless of existing medical conditions, an epidemiological review study found that the prevalence of ed increased with age. the prevalence of ed was 1-10% for those below 40 years old, 2-15% for those between 40-49 years old, 20-40% for 6069 years old age group, and 50-100% for those older than 70 years old (lewis et al., 2010). compared to those with age less than 25 years old, the odds of having ed for men with dm with an age of more than 55 years old is 3.2 times higher (zeleke et al., 2021). a previous study estimated that every 1-year increment of patient age was associated with 12% of higher risk of ed (shiri et al., 2005). aging affects physical and morphological changes in the body which can lead to ed. vascular alterations (e.g. vascular endothelium damages due to various processes in aging such as inflammation, pressure changes in the cavernosal space which manage the balance between a penis’ erectile/flaccid states, and penile morphological changes (e.g. destruction of corpus covernosum tissue, decreasing collagen and elastic fibres) are pathological changes due to the normal aging process that decline ed (ferrini et al., 2017; tirado et al., 2016) as well as the testosterone deficiencies (tirado et al., 2016). unhealthy lifestyles such as smoking may also contribute to the development of ed amongst men with t2dm in this study. most of the participants in this study had a previous history of smoking and some of them still smoked. people who actively engage in smoking have higher risk of developing ed vol. 7 no. 1 june 2023 45 between 1.4 3.1 times higher compared to those who do not smoke and the cumulative dose of the cigarettes consumed daily can predict the odds of developing ed (kovac et al., 2015). furthermore, the study also suggested that smoking cessation may increase erectile function although the study was only limited to younger group with low smoking history and rare comorbid conditions (kovac et al., 2015). other unhealthy behaviours such as physical inactivity and alcohol consumption can also increase the odds of having ed about three fold more than those who actively exercise and avoid alcohol (mehiret et al., 2021). the adoption of more healthy lifestyles could potentially reduce the oxidative stress, endothelial dysfunction, and insulin resistance and improve the erectile function (maiorino et al., 2014). the last possible contributing factor is participants’ existing medical conditions or dm complications. the prevalence of ed is higher amongst those with an underlying medical condition such as cardiovascular disease (hypertension and heart diseases), microalbuminuria, or pulmonary disease, although there was no statistically significant association between ed and microalbuminuria and pulmonary conditions (shiri et al., 2005). mehiret et al. (2021) found that hypertension increased the odds of ed by 3.59 times percent among men with dm. another previous study found that men who have depression had a 10.7 times higher risk of developing ed compared to those without ed (shiri et al., 2005). furthermore, men with both depression and cardiovascular diseases have significant risk of ed with a 17.2 times higher chance of developing ed compared to men without depression and cardiovascular diseases (shiri et al., 2005). it has also been argued that ed can predict the silent coronary artery diseases in men with dm, suggesting further screening for other comprehensive complications may be necessary amongst men with dm who have ed (lewis et al., 2010; maiorino et al., 2014). as discussed earlier, nurses have an important role in providing holistic care for people with t2dm. the results of this study showed that majority of men with t2dm had never received sexual counselling despite having prevalent ed. these results should alert the nurses about the importance of assessing ed in men with dm. early identification of these sexual issues could be beneficial for nurses so they may plan adequate intervention and treatments that could bring about better outcomes for their patient and their spouse. utilising questionnaires such as iief, the sexual health inventory for man (shim), the brief male sexual function inventory, and the ed inventory for treatment satisfaction could overcome the embarrassment surrounding discussing ed (bilal-salim, 2019). previous studies reported a lack of information and understanding about the impact of dm on sexual health amongst men with dm (barnard-kelly et al., 2019; cooper et al., 2018). therefore, it is imperative to increase the patient’s knowledge and awareness about ed as a consequence of t2dm. nurses may provide individual and/or group education with appropriate educational materials based on the patient’s learning preferences and organise regular mass communication campaigns to promote awareness to the broader population (bilal-salim, 2019). it is worth to note that this study only involved small sample size therefore findings were presented using descriptive statistics. however, this study used a translation process based on previous studies and found valid and reliable results. thus, the bahasa indonesia version of the iief for ed domain in this study could be used for future studies in indonesia. conclusion this study found that ed and severe ed are common amongst men with t2dm. considering the high number of participants who experienced ed, it is important for nurses to assess ed and overall sexual function routinely amongst men with t2dm. early identification of ed could help the nurses to plan appropriate interventions and health education which could prevent psychological and emotional issues and increase quality of life amongst patients who experience ed. further research is needed to assess the barriers of ed among men with t2dm based on the healthcare providers and develop related interventions to improve the ed and sexual problem assessment practices. it is also necessary to assess potential sexual problems amongst women who have t2dm since sexual issues do not only affect males. future research should consider the rigour methodological approach to improve the validity of the research. acknowledgement the research teams thank to all participants and school of nursing, faculty of medicine and health indonesian journal of nursing practices 46 sciences, universitas muhammadiyah yogyakarta for partial funding of the research publication. references arianti, a. 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(2005). principles of good practice for the translation and cultural adaptation process for patient-reported outcomes (pro) measures: report of the ispor task force for translation and cultural adaptation. value in health, 8(2), 94-104. https://doi.org/10.1111/j.15244733.2005.04054.x windasari, n. n. (2015). pendidikan kesehatan dalam meningkatkan kepatuhan merawat kaki pada pasien diabetes mellitus tipe ii. ijnp (indonesian journal of nursing practices); vol 2, no 1 (2015): muhammadiyah journal of nursingdo 10.18196/ijnp.v2i1.670. https://journal.umy.ac.id/index.php/ijnp/arti cle/view/670 zeleke, m., hailu, d., & daka, d. (2021). erectile dysfunction and associated factors among diabetic patients at, hawassa, southern, ethiopia. bmc endocrine disorders, 21(1), 139. https://doi.org/10.1186/s12902-02100807-5 https://ojs.unud.ac.id/index.php/eum/article/download/21109/13885 https://ojs.unud.ac.id/index.php/eum/article/download/21109/13885 https://journal.umy.ac.id/index.php/ijnp/article/view/646 https://journal.umy.ac.id/index.php/ijnp/article/view/646 https://he02.tci-thaijo.org/index.php/prijnr/article/view/242420 https://he02.tci-thaijo.org/index.php/prijnr/article/view/242420 https://he02.tci-thaijo.org/index.php/prijnr/article/view/242420 https://doi.org/https:/doi.org/10.1016/j.sxmr.2015.10.011 https://doi.org/https:/doi.org/10.1016/j.sxmr.2015.10.011 https://doi.org/10.1080/00224491003658227 https://journal.umy.ac.id/index.php/ijnp/article/view/3481 https://journal.umy.ac.id/index.php/ijnp/article/view/3481 https://jurnal.unitri.ac.id/index.php/care/article/view/534 https://jurnal.unitri.ac.id/index.php/care/article/view/534 https://doi.org/10.1111/j.1524-4733.2005.04054.x https://doi.org/10.1111/j.1524-4733.2005.04054.x https://journal.umy.ac.id/index.php/ijnp/article/view/670 https://journal.umy.ac.id/index.php/ijnp/article/view/670 https://doi.org/10.1186/s12902-021-00807-5 https://doi.org/10.1186/s12902-021-00807-5 indonesian journal of nursing practices 68 indonesian journal of nursing practices endar kurianto1, arianti1 1 program studi ilmu keperaw atan, fkik universitas muhammadiyah yogyakarta, jl braw ijaya, bantul, indonesia korespondensi: arianti email: arianti@umy.ac.id status cairan pada pasien pasca pembedahan di rs pku muhammadiyah gamping info artikel online issn doi : : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.2281 abstrak latar belakang : ti ndakan pembedahan dapat meni mbul kan keti daks ei mbangan cai ran dan el ektrol i t yang akan menyebabkan gangguan fi s i ol ogi s yang berat apabi l a ti dak di atas i . pemantauan s tatus kebutuhan cai ran pada pas ien pas ca pembedahan di p er l u k a n untuk memenuhi dan mempertahankan kebutuhan cai ran dal am tubuh. tuj uan penel i ti an i ni untuk mengetahui s tatus cai ran pada pas i en pas ca pembedahan di rs pku muhammadi yah gampi ng. metode : penel i ti an i ni menggunakan des kri pti f anal i ti k dengan rancangan s urvei dan pendekatan cross-sectional, s ampel dal am penel i ti an i ni adalah 44 res ponden. pengambi l an data menggu n a k a n metode wawancara dan obs ervas i menggunakan l embar obs ervas i pemantauan s tatus cai ran berdas arkan kebutuhan cai ran dan balance cairan. anal i s a data menggunakan metode uni vari at untuk menghi tung di s tri bus i frekuens i vari abel yang tel ah di tetapkan. hasil : mayori tas res ponden memi l i ki kebutuhan cai ran cukup dengan pres entas e s ebanyak 31 orang (70,5 %) dan balance cai ran kurang dengan pres entas e s ebanyak 29 orang (65,9 %). kesimpulan : mayori tas res ponden pas ca pembedahan di rs pku muhammadi yah gampi ng memi l i ki kebutuhan cai ran cukup, namun s tatus balance cai ran kurang. di harapkan perawat dapat mel akukan pengukuran kebutuhan cai ran dan balance cai ran pas i en dengan tepat, s el ai n i tu penel i ti s el anj utnya dapat mel akukan penel i ti an l anj utan terkai t faktor-faktor yang mempengaruhi balance cai ran pada pas i en pas ca pembedahan. kata kunci : pembedahan, pas ca pembedahan, cai ran, kebutuhan cai ran, bal ance cai ran abstract background: surgery can cause fluid and electrolyte imbalances that will cause severe physiological disturbances if not treated. monitoring fluid status in postoperative patients is needed to meet and maintain fluid requirements in the body. the purpose of this study was to determine fluid status in postoperative patients in pku muhammadiyah gamping hospital. method : this study used descriptive analytic with survey design and cross-sectional approach, the sample in this study were 44 respondents. retrieval of data using interview method and observation using observation sheet monitoring fluid status based on fluid requirements and fluid balance. data analysis uses the univariate method to calculate the specified frequency distribution of variables. 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/4613 vol. 2 no. 2 desember 2018 69 result : the majority of respondents have enough fluid requirement with a percentage of 31 people (70.5%) and less fluid balance with a percentage of 29 people (65.9%). conclusion: the majority of respondents after surgery at pku muhammadiyah gamping hospital had sufficient fluid requirements, but the balance status of fluids was lacking. it is expected that nurses can properly measure the fluid needs and fluid balance of patients, besides that the next researcher can conduct further research related to the factors that affect fluid balance in postoperative patients. keywords: surgery, post operative, fluid, fluid requirement, fluid balance mukhripah i¹, dwi r pendahuluan pembedahan adalah tindakan pengobatan menggunakan teknik invasif dengan membuka atau menampilkan bagian tubuh yang akan ditangani (sjamsuhidajat & de jong, 2010). pembedahan dapat digunakan untuk tindakan pemeriksaan (biopsi, laparotomi eksplorasi), kuratif (pengangkatan massa tumor dan apendisitis), reparative (memperbaiki luka), rekonstruktif dan paliatif (ditya, zahari, & afriwardi, 2016). tindakan pembedahan di dunia tahun 2012 mencapai 312, 9 juta atau telah meningkat 33,6 % selama 8 tahun sejak tahun 2004. (weiser, haynes, molina, lipsitz, esquivel, uribe -leitz, ruifu, azad, chao, berry & gawande, 2015) . prevalensi pembedahan di asia tenggara s e n d iri sebanyak 25.794.258 jiwa ditahun 2010 (rose, weiser, hider, wilson, gruen, & bickler, 2015). sedangkan di indonesia pembedahan menempati urutan ke 11 dari 50 pola penanganan penyakit di indonesia tahun 2012 (departemen kesehatan ri, 2013). prosedur pembedahan dapat memicu gangguan keseimbangan cairan dan elektrolit yang diakibatkan karena proses perioperatif seperti puasa sebelum pembedahan, kehilangan ban y ak cairan melalui saluran cerna, perdarahan dan perpindahan cairan kerongga ketiga yang mempengaruhi keseimbangan cairan. gangguan keseimbangan cairan dan elektrolit dapat beru p a kelebihan cairan (overhidrasi) maupun kekurangan cairan (dehidrasi) (sjamsuhidajat & de jong, 2010). perubahan komposisi cairan tubuh akibat prosedur pembedahan dapat menyebabkan gangguan fisiologi yang berat. kekurangan volume cairan tubuh sendiri dapat ditandai dengan penurunan tekanan darah dan nadi, penurunan turgor kulit, penurunan pengisian vena, membran mukosa kering, haus, kulit kering, kelemahan, peningkatan konsentrasi urin yang apabila berkelanjutan dapat menyebabkan syok hipovolemik, gagal organ dan kematian (black & hawks, 2014; indriawati, 2013; leksana, 2015). kelebihan volume cairan pada pasien pasca pembedahan dapat menyebabkan edema interstitial, peradangan lokal dan menghambat penyembuhan luka dengan meningkatkan risiko infeksi luka pasca pembedahan, luka menjadi rentan dan terjadi kebocoran anastomi (voldby & brandstrup, 2016). pemantauan status cairan pada pasien pasca pembedahan meliputi kebutuhan cairan dan balance cairan perlu diperhatikan. pemberian kebutuhan cairan atau terapi cairan bertujuan untuk memenuhi dan mempertahankan kebutuhan cairan dan elektrolit dalam tubuh seseorang yang menjalani pembedahan untuk mengganti asupan cairan selama pasien dipuasakan, mengganti kehilangan darah, kehilangan cairan kerongga ketiga, dan kehilangan cairan di lambung. perhintungan kebutuhan cairan berdasarkan kebutuhan basal ditambah kebutuhan pengganti setiap pasien (sjamsuhidajat & de jong, 2010). balance cairan adalah keseimbangan antara pengeluaran dan pemasukan dari cairan di dalam tubuh yang memungkinkan fungsi metabolik tubuh bekerja dengan benar (welch, 2010). berdasarkan penelitian puspita, pudjiadi, pusponegoro, pardede, karyanti, & roeslani indonesian journal of nursing practices 70 (2016) terdapat 57,4 % subyek yang mendapatkan cairan sesuai dengan perhitungan kebutuhan rumatan holliday-segar, sedangkan 23 % subyek mendapatkan jumlah yang kurang dari perhitungan cairan rumatan holliday-segar dan sebanyak 8,2 % subyek mendapatkan cairan lebih dari perhitungan cairan rumatan holliday-segar. penelitian puspita et al. (2016) menyatakan 57,1% klien pasca pembedahan mengalami hiponatremia akibat tidak mendapatkan terapi cairan yang tepat. hasil studi pendahuluan selama 3 hari di rumah sakit ditemukan sebagian besar pasien rawat inap pasca pembedahan mendapatkan terapi cairan 20 tetes per menit apapun kasusnya dengan variasi berat badan yang berbeda-beda tanpa memperhatikan kebutuhan basal dan pengganti pasien. berdasarkan latar be lakang di atas, penelitian mengenai status cairan pasien pasca pembedahan di rumah sakit pku muhammadiyah gamping perlu dilakukan. metode penelitian ini menggunakan metode deskriptif analitik dengan rancangan survei dan pendekatan cross-sectional. populasi dalam penelitian ini adalah pasien pasca pembedahan dalam satu bulan terakhir di rs pku muhammadiyah gamping yaitu dari bulan november 2017 sampai desember 2017 sebanyak 315 orang. pengambilan sampel menggunakan teknik nonprobability sampling dengan teknik konsekutif sampling dengan jumlah responden 44 orang. penelitian ini dilakukan pada tanggal 10 fe b ru ari 2018 sampai 10 maret 2018. dalam penelitian ini peneliti memperhatikan prinsip etik selama penelitian berlangsung yang mana menjaga kerahasiaan dan tidak merugikan responden. instrumen penelitian menggunakan lembar observasi pemantauan status cairan yang didasarkan pada kebutuhan cairan dan balance cairan yang dilakukan 24 jam. uji validitas instrumen lembar observasi tidak dibutuhkan, namun alat ukur seperti botol air dan timbangan dilakukan kalibrasi di badan metrologi yogyakarta. uji reabilitas menggunakan interrter reability dengan nilai 0,41. pengambilan data dilakukan setelah responden selesai melakukan prosedur pembedahan. peneliti/ asisten peneliti/ perawat/ keluarga responden mengamati pemberian cairan den gan mengisi lembar observasi status cairan selama 24 jam pertama. kebutuhan cairan pasien diklasifikasikan kurang jika cairan < bb x 30 ml/ 24 jam, cukup jika intake cairan = bb x 30-40 ml/24 jam, lebih jika intake cairan > bb x 40 ml/24 jam. klasifikasi balance cairan pasien pasca pembedahan dikatakan kurang jika intake cairan < ouput cairan + iwl, cukup jika intake cairan = output cairan + iwl, lebih jika intake cairan > ouput cairan + iwl. analisa data dalam penelitian ini menggunakan analisa univariat. hasil karakteristik responden tabel 1 distribusi frekuensi data demografi responden pasca pembedahan di rs pku muhammadiyah gamping 2018 (n = 44) no vari abel frekuensi (n) pers entas e (%) 1. jeni s kel ami n laki – l aki 19 43,2 perempuan 25 56,8 2. jeni s anes tes i spi nal 20 45,4 general 23 52,3 bl ok 1 2,3 3. jeni s pembedahan eks i s i 24 54,5 el ekti f 9 20,5 ori f 8 18,3 amputas i 3 6,8 4. di agnos a medi s herni a 2 4,5 nefrol i ti as is 3 6,8 tors i o tes ti s 2 4,5 hemoroi d 4 9,1 apendi s i ti s 3 6,8 tumor & kanker 20 45,5 fraktur 8 18,2 infeks i 2 4,5 sumber : data primer, 2018 tabel 1 menunjukkan mayoritas responden berjenis kelamin perempuan (56,8 %), jenis anestesi mayoritas anestesi general (52,3 %), mayoritas jenis pembedahan eksisi (54,5 % ) , d an mayoritas diagnosis medis tumor & kanker sebanyak (45,5%). vol. 2 no. 2 desember 2018 71 tabel 2 distribusi frekuensi data demografi responden pasca pembedahan di rs pku muhammadiyah gamping 2018 no vari abel mi n maks mean 1 us i a (tahun) 20 89 47,43 2 duras i pembedahan (jam) 1 3 1,88 3 berat badan (kg) 35 90 56,34 sumber : data primer, 2018 tabel 2 menunjukkan karakteristik responden berdasarkan usia diperoleh ratarata 47,43 tahun. durasi pembedahan diperoleh rata-rata 1,88 jam. pada karakteristik berat badan diperoleh rata-rata pada 56,34 kg. kebutuhan cairan tabel 3 distribusi data kebutuhan cairan pasien pasca pembedahan di rs pku muhammadiyah gamping 2018 (n = 44) kebutuhan cai ran frekuens i (n) pers entas e (%) kurang 7 15,9 cukup 31 70,5 lebi h 6 13,6 sumber : data primer, 2018 tabel 3 menunjukkan kebutuhan cairan responden pasca pembedahan, mayoritas responden kebutuhan cairan cukup dengan presentase sebanyak 31 orang (70,5 %). balance cairan tabel 4 distribusi data balance cairan pasien pasca pembedahan di rs pku muhammadiyah gamping 2018 (n = 44) balance cai ran frekuens i (n) pers entas e (%) kurang 29 65,9 cukup 3 6,8 lebi h 12 27,3 sumber : data primer, 2018 tabel 4 menunjukkan balance cairan pada responden pasca pembedahan mayoritas balance cairan kurang dengan presentase sebanyak 29 orang (65,9 %). pembahasan karakteristik responden 1. jenis kelamin mayoritas responden adalah perempuan (56,8 %). perempuan lebih mudah untuk mengalami kehilangan cairan atau dehidrasi dibandingkan dengan laki-laki, karena jumlah cairan yang terdapat dalam tubuh perempuan lebih sedikit dibandingkan dengan laki –laki (sulistomo, sutarina & ilyas, 2014). laki –laki memiliki kandungan cairan tubuh yang lebih banyak dari perempuan karena lakilaki memiliki massa tubuh yang lebih tinggi (briawan et al., 2011 dalam ulvie, kusuma & agusty, 2017). hasil penelitian ini didukung oleh hasil peneliti an dari ferdian, supriyadi & puguh (2015) yang menyatakan bahwa mayoritas pasien pasca pembedahan atau 68,8 % adalah perempuan. 2. diagnosa medis diagnosa medis responden mayoritas penyakit tumor dan kanker (45,5 %). hal ini didukung o l e h hasil riset dari kemenkes (2013) yang menunjukan bahwa daerah istimewa yogyak arta menempati posisi teratas di indonesia untuk pravelensi penyakit tumor dan kanker yaitu sebesar 4.1 % atau sebanyak 14.596 penderita. tindakan untuk mengatasi kanker dan tumor, salah satunya adalah dengan pembedahan, terutama pembedahan eksisi. pembedahan eksisi dalam pakteknya akan meningkatkan kehilan gan cairan tubuh, hal ini disebabkan oleh jumlah perdarahan yang lebih banyak (partologi, 2008; lumbuun & wardhana, 2017). walapun biasanya hal tersebut sudah diantisipasi dengan pemberian cairan oleh tim medis saat intra pembedahan tetapi secara fisiologis keseimbangan cairan pad a pasien akan tetap terganggu (sjamsuhidajat & de jong, 2010). 3. jenis anestesi mayoritas responden mendapatkan jenis aneste si general (52,3 %). menurut keat., et all., (2013) anestesi general adalah keadaan dimana semua bagian tubuh tidak merasakan atau kehilangan sensasi dan kesadaran. (press, 2013). indonesian journal of nursing practices 72 anestesi general menyebabkan efek istirahat pada sistem tubuh, sehingga setelah pembedahan tubuh memerlukan waktu untuk kembali berfungsi. selama waktu tersebut berlangsung pasien biasanya dianjurkan berpuasa agar tidak menyebabkan mual dan muntah (yin, ye, zhao, li , & song, 2014). puasa pasca pembedahan, serta efek samping dari anestesi general seperti mual bahkan muntah menyebabkan tubuh kekurangan cairan dan mengalami syok (setiyanti, 2016). 4. jenis pembedahan mayortias jenis pembedahan adalah pembedahan eksisi (54,5 %). pembedahan eksisi adalah tindakan untuk membuang/ memotong jaringan terutama tumor, selain itu tindakan eksisi juga dapat digunakan untuk biopsy dan memperbaiki penampilan (partologi, 2008). menurut lumbuun & wardhana (2017) tindakan pembedahan eksisi dapat meningkatkan resiko untuk perdarahan saat tindakan dilakukan. perdarahan saat tindakan pembedahan akan menyebabkan tubuh kehilangan cairan dan mengganggu keseimbangan cairan dalam tubuh (sjamsuhidajat & de jong, 2010). 5. usia mayoritas responden berusia rata-rata 47,43 tahun. menurut abdullah & yuliana (2015) menyatakan bahwa usia diatas 20 tahun sampai 65 tahun adalah usia dewasa. pada orang dewasa presentase cairan tubuh pada berkisar antara 50 60%/kgbb pada laki-laki dewasa sedangkan p ad a perempuan dewasa hanya 50 %/kgbb (vaughans, 2013). penelitian di negara hongkong menunjukkan bahwa 50 % konsumsi cairan pada orang dewasakurang (ratih & dieny pada tahun, 2017). hasil penelitian dari the indonesian regional hydration study (thirst) juga menunjukkan bahwa 49,1 % orang dewasa di indonesia memiliki asupan cairan yang kurang (vandermark, 2016). dalam penelitian ini mayoritas responden asupan cairannya cukup tetapi 65,9 % balance cairan pada mayoritas responden dalam penelitian ini kurang. darsini & hamidi (2018) menjelaskan bahwa u s i a berkaitan dengan cairan tubuh karena secara fisiologis semakin bertambah usia seseorang maka kebutuhan cairan tubuh semakin meningkat. pertambahan usia seseorang akan menyebabkan penurunan dari fungsi organ tubuh terutama ginjal dan paru-paru yang berfungsi mengendalikan cairan didalam tubuh, sehingga organ tersebut kurang bisa bekerja secara maksimal untuk mengatur keseimbangan cairan (saputra, 2013). 6. durasi pembedahan mayoritas rata-rata durasi pembedahan adalah 1,88 jam atau hampir mendekati 2 jam. secara fisologis pembedahan akan menyebabkan tu b u h kehilangan cairan (van regenmortel, jorens, & malbrain, 2014). kehilangan cairan selama pembedahan biasanya diakibatkan oleh puasa sebelum pembedahan, perdarahan dan perpindahan cairan kerongga ketiga (sjamsuhidajat & de jong, 2010). durasi pembedahan yang semakin lama akan menyebabkan tubuh kehilangan cairan semakin besar. hal ini sesuai dengan pendapat dari miller, roche dan mythen (2015) bahwa kehilangan cairan tubuh selama pembedahan, terutama pembedahan besar berkisar antara 0,5 – 1 ml/kg setiap satu jamnya, selain itu kehilangan cairan selama pembedahan juga disebabkan oleh berpindahnya cairan kerongga ketiga. selain itu cairan ekstraseluler akan hilang hingga 28 % setelah 2 jam lamanya pembedahan (kayilioglu et al., 2015). 7. berat badan mayoritas responden memiliki berat badan 56, 34 kg dengan berat badan terendah 35 kg dan berat badan tertinggi 90 kg. kehilangan cairan berhubungan dengan berat badan karena menurut ratih & dieney (2017) saat tubuh merasa haus, maka telah terjadi kehilangan cairan 1-2 % dari berat badan tubuh. kehilangan cairan 5 % dari berat badan maka sudah dikategorikan dalam dehidrasi ringan (amin, 2015). menurut sjamsuhidajat & de jong (2010) berat badan digunakan sebagai parameter un tu k mengukur kebutuhan cairan pasien pasca pembedahan yaitu antar 30-40 ml/kg bb. vol. 2 no. 2 desember 2018 73 kebutuhan cairan mayoritas reponden memiliki kebutuhan cairan cukup (70,5%). kebutuhan cairan dapat dikatakan cukup apabila seseorang dapat mengkonsumsi cairan sesuai dengan kebutuhannya, dalam hal ini bisa menggunakan rumus kebutuhan cairan yaitu 30 40 dikali dengan berat badan begitu juga untuk menentukan apakah kebutuhan cairan lebih atau kurang bisa menggunakan rumus tersebut (sjamsuhidajat & de jong, 2010). kebutuhan cairan pada responden dalam penelitian ini akan dikatakan cukup apabila jumlah cairan yang diberikan berada dalam rentang hasil perkalian antara berat badan dikali 30-40 ml dalam waktu 24 jam. kebutuhan cairan pada responden dalam penelitian ini sebagian besar didapatkan melalui cairan intravena seperti infus dan melalui oral seperti air minum dan makanan. berdasarkan hasil observasi pada data status responden, didapatkan data bahwa pemenuhan kebutuan cairan melaui intravena pada mayoritas responden dalam penelitian ini menggunakan cairan rl (ringer laktat) dengan rumus 20 tpm (tetes per menit). menurut wongkar (2015) penggunaan rumus 20 tpm pada cairan infus ringer laktat adalah untuk memenuhi kebutu h an cairan dan elektrolit pada pasien pasca pembedahan. pemenuhan kebutuhan cairan pada pasien p as ca pembedahan selama 24 jam memerlukan cairan sekitar 1500 ml, sehingga rumus 20 tpm tepat apabila digunakan untuk rehidrasi pasien pasca pembedahan (saputra, 2013). sedangkan menurut leksana (2015) menjelaskan bahwa kebutuhan cairan harus disesuaikan berdasark an berat badan yaitu (10kg pertama x 100 ml) + (10 kg kedua x 50 ml ) + (sisanya x 200 ml) penjumlahan seluruhnya adalah kebutuhan cairan selama 24 jam. perhitungan kebutuhan cairan pada orang dewasa yang telah menjalani pembedahan sendiri berkisar antara 25ml -35ml/kgbb/hari (mac sweeney, mckendry, & bedi, 2013) . dasar pemenuhan kebutuhan cairan pasien pasca pembedahan adalah 25-30 ml/kg/bb dalam 24 jam (van regenmortel, jorens & malbrains 2014) . kebutuhan cairan pasca pembedahan adalah 3040 ml/kg berat badan dalam 24 jam (sjamsuhidajat & de jong, 2010). pemuhan kebutuhan cairan melal ui oral harus tetap ditingkatkan terutama saat pasien sudah bisa makan dan minum disamping pemberian cairan melalui intravena karena menurut leksana (2015) rehidrasi secara oral akan mengembalikan volume intavaskuler dan sebagai petunjuk adanya asidosis atau tidak. berdasarkan alogaritma terapi pemenuhan kebutuhan cairan pasca pembedahan, pemberian intake cairan oral dalam 24 jam pertama dapat diberikan apabila pasien dalam kondisi yang stabil (aguirreurreta & suarez, 2016). pemberian seluruh terapi cairan intravena harus segera dihentikan pada pasien pasca pembedahan yang telah dirawat lebih dari 3 h ari diruang perawatan dan pemberian cairan oral seperti makanan, minuman dan suplemen harus ditingkatkan (srinivasa et al., 2013). pemenuhan kebutuhan cairan melalui intravena sebaiknya hanya digunakan saat diperlukan saja, penggunaannya pun harus singkat dan pasien harus dipantau secara seksama karena penggunaan cairan intravena berpotensi menimbulkan bahaya bagi tubuh, bahkan kematian (mac sweeney et al., 2013). pemberian cairan intravena hanya diberikan jika pasien mengalami oliguria kurang dari 0,5/kg/ jam selama lebih dari 4 jam atau terdapat gangguan fisiologis seperti takikardi, denyut n ad i lebih dari 90 kali/menit dan tekanan darah sistolik dibawah angka 90 mmhg (srinivasa et al . , 2013). balance cairan mayoritas responden memiliki balance cairan kurang (65,9 %). balance cairan yang dikatakan cukup adalah apabila intake cairan sama hasiln y a dengan output cairan ditambah dengan iwl (insensible water loss) (mutmainah & purwanti, 2017; asfour, 2016; yuliana, syuibah & ambarwati, 2014). balance cairan yang kurang pada penelitian ini berkisar antara minus 10 ml hingga minus 575 ml, maka untuk kecukupuan balance cairan dalam penelitian ini adalah apabila intake cairan dikurangkan dengan output cairan plus iwl hasilnya 0 tanpa ada nilai kompensasi dari tubuh terhadap balance cairan. indonesian journal of nursing practices 74 balance cairan yang kurang bisa disebabkan o l e h cairan ekstraseluler yang akan hilang hingga 28 % setelah 2 jam lamanya pembedahan (kayilioglu dkk., 2015). hal ini sejalan dengan hasil penelitian bahwa terdapat 27 responden (61,4 %) menjalani pembedahan lebih dari 2 jam. hal ini juga sejal an dengan hasil penelitian ini, bahwa 65,9 % responden memiliki balance cairan kurang. operasi besar yang berlangsung lama dengan pemberian anestesi general yang disertai perdarahan, buang air kecil, kehilangan cairan di rongga ketiga dan kehilangan cairan yang tidak terduga menyebabkan efek jangka panjang y ai tu balance cairan yang terganggu selama periode perawatan pasca pembedahan (kayilioglu et al., 2015). penyebab balance cairan yang kurang pada pasien pasca pembedahan juga bisa diakibatkan oleh efek anestesi setelah pembedahan. penggunaan anestesi terutama anestesi general pada tindakan pembedahan dimaksudkan untuk mempermudah dalam melakukan tindakan karena anestesi general dapat menyebabkan keadaan fisiologis tubuh mengalami perubahan seperti hilang rasa nyeri (analgesia), kesadaran menurun dan otot mengalami relaksasi (morgan & mikhail, 2013). tetapi pada pasca pembedahan biasanya pasien disarankan untuk berpuasa sampai kondisi mekanisme tubuh kembali normal, hal ini biasanya ditandai dengan bunyi peristaltik usus dan adanya aktivitas buang angin. puasa pasca pembedahan sendiri bertujuan untuk mencegah komplikasi, mencegah mual dan muntah yang diakibatkan oleh efek anestesi (yi n , ye, zhao, li, & song, 2014). hal ini sesuai dengan kondisi para responden yang kebanyakan mengatakan memiliki rasa mual setelah pembedahan tetapi tidak ada yang muntah. ef e k samping dari anestesi general seperti mual dan muntah serta puasa pasca pembedahan akan menyebabkan tubuh kekurangan cairan dan mengalami syok (setiyanti, 2016). suhu yang dingin akan mempengaruhi balance cairan karena menurut penelitian dari kennefi ck, et al., menyebutkan bahwa dalam keadaan terhidrasi atau dehidrasi, 40 % persepsi haus seseorang tidak akan terasa dalam lingkungan yang dingin dibandingkan dilingkungan normal (ratih & dieny, 2017). hal ini sesuai dengan area ruang perawatan pasca pembedahan responden yang memiliki alat pendingin ruangan. kennefick , et al., juga berpendapat bahwa manusia tidak bisa secara alami melembabkan diri secara al ami dan akan sangat terdehidrasi dalam cuaca dingin karena stimulus fisiologi haus menurun (ratih & dieny, 2017). kesimpulan karakteristik responden pasca pembedahan di rumah sakit pku muhammadiyah gamping sebagian besar berjenis kelamin perempuan, jenis anastesi general, pembedahan eksisi dan diagnosa medis kanker dan tumor. usia rata –rata pada responden penelitian ini berkisar 47,43 tahun dengan durasi rata-rata pembedahan adalah 1,88 jam dan berat badan rata-rata 56,34 kg. status cairan mayoritas kebutuhan cairan responden pasca pembedahan cukup, akan tetapi balance cairan kurang. berdasarkan hasil penelitian, maka perawat dapat melakukan penghitungan kebutuhan cairan dan balance cairan pada pasien pasca pembedahan. 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(2016). fluid therapy in the perioperative setting—a clinical review. journal of intensive care, 4(1). diakses pada tanggal 16 mei 2017 dari, https://www.researchgate.net/publicatio n /301334357_fluid_therapy_in_the_periop erative_setting-a_clinical_review weiser, t. g., haynes, a. b., molina, g., lipsitz , s . r., esquivel, m. m., uribe-leitz, t., … berry , w. r. (2015). estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. the lancet, 385, s11. welch, k. (2010). fluid balance. learning disability practice ; 13 : 6, 33 -38. diakses pada tangal 21 oktober 2017 dari, https://journals.rcni.com/learningdisability-practice/fluid-balanceldp2010.07.13.6.33.c7890 wongkar, m. f. (2015). ketrampilan perawatan gawat darurat dan medikal bedah. yogyakarta: gosyen publishing. yin, x., ye, l., zhao, l., li, l., & song, j. (2014). early versus delayed postoperative oral hydration after general anesthesia: a prospective randomized trial. int j clin ex p med, 7, 3491–3496 yuliana, a.r., syuibah, u.,& ambarwati.(2014). pemenuhan kebutuhan cairan pada anak a. dengan gastroentritis di ruang bougenville 3 rumah sakit umum daerah kudus. jpk vol.1, no, 1, juli 2014:93-98. kudus : akademi keperawatan krida husada kudus. https://www.researchgate.net/publication/301334357_fluid_therapy_in_the_perioperative_setting-a_clinical_review https://www.researchgate.net/publication/301334357_fluid_therapy_in_the_perioperative_setting-a_clinical_review https://www.researchgate.net/publication/301334357_fluid_therapy_in_the_perioperative_setting-a_clinical_review 42 muhammadiyah journal of nursing abstract background: chronic renal failure is a disorder function of renal with increase of ureum level in the blood. the therapy of this disease today is by used dialisa ( hemodialisys and peritoneal dialisys) which needed expensive cost. thus, its very necessary to found new method for decrease the ureum level. as specialy lavement therapy. objectives: this study aimed to know about the eff ect of high enema to decrease the blood ureum level of chronic renal failure patients. method: this study used quasi experiment with pre test and post test with control group design. the cronic renal failure patient took with purposive sampling teknics consist of15 person for control and 15 person for treated group. t-test was applied to analyze the data. result: the average of blood ureum level before and after treated by 3 days high enema are 257,40 and 355,98 respectively. thus the average of blood ureum level before and after in control group are 353,86 and 398,97 respectively. base on the t-test the diff erence of blood ureum level before and after treated by 3 days high enema, found that t value was 0.309 (p = 0.003). thus the diff erence of blood ureum level before and after 3 days in control group, found that t value was -2.157 (p = 0.025). that’s mean the high enema has an eff ect to decrease the blood ureum level of chronic renal failure patients signifi canthy. conclusion: the high enema has an eff ect to decrease the blood ureum level of chronic renal failure patients keyword: high enema, bood ureum level, chronic renal failure. efektifi tas huknah tinggi dalam menurunkan kadar ureum darah pada pasien dengan gagal ginjal kronik di rsud. prof. dr. margono soekarjo purwokerto i. pendahuluan gagal ginjal kronik merupakan gangguan faal ginjal yang berjalan kronik yang ditandai dengan adanya kadar ureum yang sangat tinggi di dalam darah. pengobatan penyakit gagal ginjal kronik yang selama ini digunakan adalah dengan dialisa (hemodialisa dan peritoneal dialisa) yang memerlukan biaya yang sangat tinggi sehingga diperlukan metode baru untuk menurunkan kadar ureum tersebut yaitu terapi huknah tinggi . telah diketahui bahwa tidak adekuatnya suatu tindakan hemodialisis akan meningkatkan mortalitas. di amerika serikat penderita yang mengalami tindakan hemodialisa 22 24 %, di jepang dan di eropa 10 15 %. masalah tersebut menjadi sangat penting karena mortalitas penyakit gagal ginjal kronik yang hemodialisa reguler terus meningkat, seperti di amerika serikat pada tahun 1981 mortalitasnya 21,0 % dan tahun 1988 24,3%. akibat tidak adekuatnya hemodialisa menyebabkan kerugian materi yang sangat besar dan tidak produktifnya penderita hemodialisa reguler tersebut (peterson, 1995). gagal ginjal kronik dapat menyebabkan fungsi ginjal penderita tidak dapat disembuhkan total kembali seperti sediakala bahkan dapat berlanjut lebih parah. penderita gagal ginjal kronik ini hidupnya dapat dipertahankan dengan melakukan hemodialisa atau transplatasi ginjal, yang harus didukung dengan perawatan dirumah yang benar seperti pengaturan makanan yang harus dipatuhi, usaha ini agar dapat dilaksanakan dengan baik maka peranan keluarga tidak dapat diabaikan (venofer, 2006). pada ginjal dapat terganggu oleh berbagai penyakit/ keadaan patologik baik yang mengenai ginjal maupun made suandika1, elsye maria rosa2, yuni permatasari i 3 1) yakpermas banyumas 2, 3) magister keperawatan umy e-mail: suandika2010@hotmail.co.id 43 muhammadiyah journal of nursing yang primernya bukan pada ginjal. gangguan tersebut juga dapat berupa terganggunya faal tertentu ginjal atau beberapa faal ginjal sekaligus. walaupun terganggunya faal ginjal pada tingkat yang lanjut mudah diketahui secara klinik tetapi pemeriksaan biokimia masih diperlukan untuk memastikan, baik untuk diagnosa maupun untuk menentukan cara pengobatannya serta prognosanya. gangguan yang ringan hanya dapat diketahui dengan pemeriksaan biokimiawi (prodjosudjadi, 2004). ii. tujuan untuk mengetahui efektifi tas huknah tinggi terhadap penurunan kadar ureum darah pada pasien dengan gagal ginjal kronik di rsud. prof. dr. margono soekardjo purwokerto. a. untuk mengetahui kadar ureum darah sebelum dilakukan huknah tinggi pada pasien gagal ginjal kronik di rsud. prof. dr. margono soekarjo purwokerto. b. untuk mengetahui kadar ureum darah setelah dilakukan tindakan huknah tinggi pada pasien gagal ginjal kronik di rsud. prof. dr. margono soekarjo purwokerto. c. untuk mengetahui perbedaan kadar ureum darah pada kelompok kontrol dan kelompok intervensi. penelitian ini besifat eksperimental dengan pre post test with control group design. metode pengambilan sampel adalah metode purposive sampling yang berjumlah 30 orang yang terdiri dari 15 orang kelompok kontrol dan 15 orang kelompok perlakuan. analisa yang digunakan pada penelitian ini adalah analisa statistik t-test. penelitian ini dimulai dari pengadaan permohonan ijin penelitian ke pihak rsud margono purwokerto. kemudian mencari pasien yang setuju untuk dilakukan penelitian. penelitian akan dimulai dengan melakukan pendataan pasien yang memenuhi kriteria. lalu pasien dilakukan pemeriksaan kadar ureum darah sebelum dilakukan tindakan huknah tinggi, setelah itu pasien dilakukan tindakan huknah tinggi sebanyak 1 kali dalam sehari iii. hasil & pembahasan rerata kadar ureum darah sebelum dan sesuadah terapi setelah 3 hari adalah masingmasing 257,40 dan 355,98. dengan demikian rata-rata kadar ureum sebelum dan sesudah pada kelompok kontrol masing-masing adalah 353,86 dan 398,97. berdasarkan t-uji perbedaan kadar ureum sebelum dan sesudah huknah tinggi selama 3 hari, ditemukan bahwa nilai t adalah 0,309 (p = 0,003). dengan demikian perbedaan kadar ureum sebelum dan setelah 3 hari pada kelompok kontrol, menemukan bahwa nilai t adalah -2,157 (p = 0,025). itu berarti huknah tinggi efektif dalam menurunkan kadar ureum kronis pasien gagal ginjal. perbandingan kadar ureum darah post 3 hari pada kelompok perlakuan dengan kadar ureum darah post 3 hari pada kelompok kontrol pada pasien dengan gagal ginjal kronik di ruang mawar rsud. prof. dr. margono soekardjo purwokerto setelah dilakukan uji statistik t-test independent didapatkan nilai t = -2.859 (p = 0.008). hal ini menunjukkan bahwa terdapat perbedaan kadar ureum darah post 3 hari pada kelompok perlakuan dengan kadar ureum darah post 3 hari pada kelompok kontrol secara bermakna karena nilai p < 0.05 iv. kesimpulan huknah tinggi efektif dalam menurunkan kadar ureum darah pada pasien dengan gagal ginjal kronik di rsud. prof. dr. margono soekardjo purwokerto. v. daftar pustaka budiman, c. 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(2006). iron sucrose injection, usp. kidney fuction. america regent whorton j (2000) nutrision of kidney deases usa. vol. 1 no. 3 desember 2017 91 indonesian journal of nursing practices nila yuliani1, titih huriah2, yanuar primanda2 1 akper samaw a sumbaw a 2 universitas muhammadiyah yogyakarta em ail: nilayuliana066@gmail.com pengaruh siklus belajar 5e kombinasi problem based learning (pbl) terhadap peningkatan kognitif, afektif, psikomotor pada mahasiswa diploma keperawatan info artikel masuk revisi diterima doi number : : 25 agustus 2017 : 20 november 2017 : 30 november 2017 : 10.18196/ijnp.1366 abstrak mutu pendi di kan yang rendah merupakan mas al ah utama dal am dunia pendi di kan. has i l uj i kompetens i nas i onal untuk ti ngkat di pl oma keperawatan mas i h s angat rendah bi l a di bandi ngkan tenaga kes ehatan l ai n. ni l ai batas l ulus untuk d3 keperawatan mas i h di bawah 50 yaitu 42,16 dengan pros entas e kel ul us an hanya 47,81%. pros es bel aj ar mengaj ar merupakan s al ahsatu faktor yang berkontri bus i terhadap kual itas pendi di kan. tuj uan pada penel i ti an i ni adal ah untuk mengetahui pengaruh model s i kl us bel aj ar 5e kombi nas i pbl dal am meni ngkatkan kemampuan kogni ti f, afekti f, dan ps i komotor mahas i s wa di pl oma keperawatan. des ai n penel i ti an menggunakan kuas i eks peri men dengan rancangan pretes t-pos ttes t control group des i gn. lokas i penel i tian di l akukan di akper samawa sumbawa. 58 mahas i s wa di dapatkan mel alui total sampl i ng. data anal is is menggunakan anal isis des kripti f, chi square dan t-tes t. has i l penel i ti an menunj ukkan ni l ai rerata kogni ti f s ebel um i ntervens i adal ah 39,28 dan s etel ah i ntervens i meni ngkat menj adi 47,85, ni l ai rerata afekti f s ebel um i ntervens i adal ah 45,17 dan s etel ah i ntervensi meni ngkat menj adi 52,89, ni l ai rerata ps i komotor s ebel um i ntervensi adal ah 44,39 dan s etel ah i ntervens i meni ngkat menj adi 53,03. setel ah di terapkan i ntervens i model s i kl us bel aj ar 5e dengan kombi nas i pbl, terdapat peni ngkatan kogni ti f, afekti f, dan ps i komotor yang s i gni fikan dengan ni l ai p-val ue 0,041; 0,012 dan 0.000. kata kunci: model s i kl us bel aj ar 5e, pbl, kogni ti f, afekti f, ps i komotor, mahas i s wa di ploma keperawatan abstract low quality education is a major problem in education. the result of national competency test for nursing diploma student is still very low when compared with the other profession. the passing grade for nursing diploma student is still below 50, that is 42.16 with passing percentag e only 47.81%. teaching learning process is one of the factors that contribute to quality of education. the purpose of this research is to know the effect of pbl innovation with 5e learning cycle model in increase cognitive, affective, and psychomotor ability of diploma nursing student. the research design used quasi experiments with pretest-posttest control group design. the research location conducted in akper samawa sumbawa. 58 students obtained through total sampling technique. data analysis used descriptive, chi square and t test analysis. the result showed that the cognitive mean score before intervention was 39.28 and after intervention the score increase to 47.85, affective mean value before intervention is 45.17 and after intervention the score increase to 52.89, the mailto:nilayuliana066@gmail.com indonesian journal of nursing practices 92 psychomotor average score before intervention was 44.39 and after intervention the score increase to 53.03. after the intervention of the 5e learning cycle model combined with pbl, there were significant cognitive, affective, and psychomotor improvements with p -value values of 0.041, 0.012 and 0.000 respectively. keywords: 5e learning cycle model, pbl, cognitive, affective, psychomotor, diploma nursing students pendahuluan mutu pendidikan yang rendah merupakan masalah utama dalam dunia pendidikan keperawatan di indonesia. pendidikan era globalisasi menuntut manusia untuk mampu bersaing dan mampu memunculkan kreasi -kreasi baru. pendidikan menjadi wahana untuk meningkatkan dan mengembangkan kualitas sumber daya manusia. sumber daya manusia yang berkualitas memerlukan sebuah sistem, tujuan dan pendidikan yang bermutu. beberapa faktor yang menyebabkan mutu pendidikan rendah, salah satunya adalah faktor proses belajar mengajar (teaching learning). pembelajaran atau proses belajar mengajar merupakan proses timbal bali k antara dosen dan mahasiswa beserta unsur-unsur yang ada didalamnya misalnya: tujuan dan sasaran pembelajaran, pemilihan materi, situasi yang kondusif sampai dengan metode evaluasi yang sesuai dengan kurikulum yang digunakan. pembelajaran yang monoton tanpa inovasi yang hanya berpusat pada pendidik tanpa melihat dari sudut pandang yang lain akan membuat mahasiswa menjadi bosan dan kurang termotivasi dalam belajar. kurangnya motivasi akan berdampak pada keaktifan siswa dalam belajar. tuntutan global akan mutu lulusan pendidikan dan sistem pendidikan tinggi (pt) saat ini membawa konsekuensi untuk memperkuat penguasaan ilmu pengetahuan dan teknologi. tuntutan kompetensi tersebut dapat diwujudkan apabila peserta didik dapat mengikuti serangkaian proses pembelajaran yang efektif, inovatif dan berorientasi pada peserta didik (murphy, et al, 2011). tantangan dan kebijakan tersebut, tidak hanya menjadi tantangan bagi peserta didik untuk lebih aktif dan mandiri dalam belajar, tapi juga menjadi tantangan institusi pe ndidikan untuk terus meningkatkan perannya dalam menyediakan lingkungan belajar yang nyaman dan metode pembelajaran yang tepat sehingga dapat menfasilitasi dan memotivasi peserta didik dalam proses pembelajaran dalam mencapai kompetensi yang ditentukan. strategi pembelajaran yang inovatif dapat diperoleh dengan merubah strategi pembelajaran konvensional (teacher center learning) (tiwari et al, 2006; khatiban dan sangestani, 2014). beberapa strategi atau metode yang dapat membantu mahasiswa dalam meningkatkan hasil belajarannya, salah satunya adalah model siklus pembelajaran 5e yang dianggap sebagai model yang bisa mencapai integrasi ini (balci et al, 2006; hee jun won, 2013) yang dikombinasikan dengan metode pbl (problem based learning) (rideout, 2002; khatiban dan sangestani, 2014). model siklus belajar engagement, exploration, explanation, elaboration, dan evaluation (5e) merupakan metode yang mampu mencapai integrasi pada prosedur simulasi di laboratorium antara teori dan praktek (balci, 2006; afifah et al, 2013). penerapan model siklus 5e pada setiap tahapnya berkontribusi untuk perubahan konseptual mahasiswa dari pengetahuan sebelumnya yang memunculkan pengetahuan baru, pemahaman tentang pengetahuan ilmiah dan keterampilan melalui praktikum kl inis (khatiban dan sangestani, 2014). mahasiswa diploma keperawatan pada tatanan klinis akan menghadapi berbagai macam masalah kesehatan pasien sehingga memerlukan adanya metode pembelajaran yang menggunakan skenario klinis dan didapat dalam metode problem based learning (pbl). dalam metode pbl, mahasiswa mengeksplorasi kompleksitas situasi kehidupan nyata, mencari hubungan di seluruh disiplin ilmu, dan menggunakan pengetahuan vol. 1 no. 3 desember 2017 93 yang ada dan baru yang diperoleh dalam proses keperawatan, situasi yang sama dengan tahap exploration pada model siklus belajar 5e (afifah, 2013). metode pbl tidak memiliki tahap elaboration yang dapat membantu mahasiswa dalam menerapkan konsep belajar pada skenario klinis yang menimbulkan masalah keperawatan (afifah et al, 2013). sehingga, metode pbl dapat digabungkan dengan model siklus belajar 5e pada proses pembelajaran mahasiswa dalam prosedur simulasi di laboratorium, khususnya pada mata kuliah dengan teori dan praktek seperti keperawatan medikal bedah (kmb). hasil kuesioner pada 85 mahasiswa terhadap evaluasi kinerja dosen di akper samawa sumbawa didapatkan data 75% mahasiswa merasa bosan, mengantuk, dan kurang menarik dengan metode ceramah yang digunakan dosen pada pendekatan tcl. mahasiswa menginginkan lebih banyak diskusi dalam proses pembelajaran. dari semua mata kuliah keperawatan di akper samawa sumbawa tahun akademik 2014/2015, kmb memiliki nilai paling rendah dari mata kuliah lainnya. pembelajaran pada materi kmb memiliki suatu peran yang penting dalam pendidikan keperawatan karena mahasiswa akan mampu memberikan dan melaksanakan asuhan keperawatan yang komprehensif sehingga permasalahan yang muncul dapat diatasi dalam tatanan nyata. penelitian ini bertujuan untuk mengetahui pengaruh model siklus belajar 5e dengan kombinasi pbl terhadap peningkatan kognitif, afektif, dan psikomotor mahasiswa diploma keperawatan pada mata kuliah kmb. metode desain penelitian yang digunakan adalah kuasi eksperimen dengan pendekatan pre-test post-test with control group. populasi penelitian adalah semua mahasiswa semester iv (tingkat ii) yang mendapat mata kuliah kmb ii di dua kabupaten di nusa tenggara barat (ntb) yaitu mahasiswa di akper samawa sumbawa sebagai kelompok intervensi dan di poltekkes mataram prodi keperawatan bima sebagai kelompok kontrol. sampel adalah semua mahasiswa semester iv (tingkat ii) yang mendapat mata kuliah kmb ii yang berjumlah 58 orang dengan pembagian 28 mahasiswa di akper samawa sumbawa dan 30 mahasiswa di poltekkes mataram prodi keperawatan bima. kriteria inklusi yang diterapkan yaitu populasi mahasiswa yang berada di semester 4 (tingkat ii), telah melewati pembelajaran pada mata kuliah anatomi fisiologi, patofisiologi, konsep dasar keperawatan, keperawatan dasar, dan farmakologi keperawatan, mahasiswa tidak sedang mengalami suatu penyakit yang menimbulkan resiko cedera pada dirinya seperti penyakit epilepsy, dan lainlain berdasarkan informasi yang didapatkan dari dosen. kriteria eksklusi pada penelitian ini adalah mahasiswa membatalkan kesediaannya untuk ikut dalam penelitian dan mahasiswa yang berhalangan hadir saat penelitian dilakukan. intervensi yang diberikan adalah penerapan metode pembelajaran model siklus belajar 5e dengan pbl sedangkan pada kelompok kontrol dengan penerapan metode konvensional (ceramah, demonstrasi). analisis data yang digunakan adalah uji deskriptif, chi square, paired t-test dan independen t-test. tahap intervensi penerapan model siklus belajar 5e dengan pbl terdiri dari 5 tahap yaitu engagement, exploration, explanation, elaboration, evaluation yang dikombinasikan dengan pbl menggunakan satu skenario klinis dalam proses pembelajaran selama 2 minggu dengan lima kali pertemuan. pertemuan pertama tahap engagement dengan memunculkan learning outcome, pertemuan kedua tahap exploration dengan menjawab learning outcome, pertemuan ketiga tahap explanation persiapan skill (mahasiswa melakukan role play dalam kelompoknya) di laboratorium, pertemuan keempat tahap elaboration mahasiswa melakukan simulasi dengan pasien standar di laboratorium untuk menilai kemampuan psikomotor, pertemuan kelima tahap evaluation mahasiswa menunjukkan sikap dan pengetahuan yang telah dipelajari pada tahap sebelumnya. penilaian kognitif mahasiswa yaitu dengan memberikan tes tertulis multiple choice questions (mcq) pada materi pembelajaran kmb ii sistem muskuloskeletal (fraktur). penilaian afektif mahasiswa dengan membagikan kuesioner skala indonesian journal of nursing practices 94 sikap (self asessment). penilaian psikomotor mahasiswa dengan mengisi lembar checklist rentang gerak pasif (rom) dari hasil observasi dosen terhadap tindakan keterampilan mahasiswa. hasil karakteristik mahasiswa mahasiswa yang mengikuti penelitian adalah 58 orang. kelompok intervensi berjumlah 28 orang dan kelompok kontrol berjumlah 30 orang. karakteristik mahasiswa dapat dilihat pada tabel 1 berdasarkan tabel 1, distribusi karakteristik mahasiswa berdasarkan usia pada kelompok intervensi dengan rerata usia 20.18, usia termuda adalah 18 tahun dan tertua 23 tahun. pada kelompok kontrol rerata usia 20.16 dengan usia termuda 18 tahun dan tertua 26 tahun. karakteristik responden berdasarkan jenis kelamin terlihat baik pada kelompok intervensi dan kelompok kontrol, sebagian besar responden adalah perempuan. hasil uji homogenitas terlihat bahwa tidak terdapat beda antara kelompok intervensi dan kelompok kontrol berdasarkan usia dan jenis kelamin. tabel 1. distribusi frekuensi responden berdasarkan usia dan jenis kelamin pada mahasiswa diploma keperawatan (n=58) karakteristik responden kelompok intervensi (f,%) kelompok kontrol (f,%) p jeni s kel ami n laki -l aki perempuan us i a mi n-maks mean±sd 10 (35,7) 18 (64,3) 18-23 20,17±1,15 7 (23,3) 23 (76,7) 18-26 20,16±1,82 0,301 0,977 pengaruh model siklus belajar 5e dengan kombinasi pbl terhadap peningkatan kognitif, afektif dan psikomotor pada kelompok intervensi, model siklus belajar 5e dengan kombinasi pbl pada mahasiswa dapat meningkatkan kognitif, afektif dan psikomotor mahasiswa dengan nilai p=0,015, p=0,000 dan p=0,044. perubahan nilai kognitif, afektif dan psikomotor sebelum dan sesudah perlakuan pada kelompok intervensi dapat dilihat pada tabel 2. tabel 2. pengaruh model siklus belajar 5e dengan kombinasi pbl terhadap peningkatan nilai kognitif, afektif dan psikomotor pada kelompok intervensi variabel penelitian pra intervensi post intervensi mean difference p* min-maks mean±sd min-maks mean±sd as pek kogni ti f 10-60 39,28±12,45 10-80 47,85±19,69 8,57 0,015 as pek afekti f 35-54 45,17±5,56 42-59 52,89±4,17 7,71 0,000 as pek ps i komotor 18-78 44,39±14,05 28-89 53,03±14,60 8,64 0,044 *p< 0,05 based on paired t-test pada kelompok kontrol dengan pemberian intervensi standar yaitu pemberian perkuliahan secara klasikal dan pembelajaran skill laboratory memperlihatkan peningkatan pada aspek kognitif, afektif dan psikomotor mahasiswa dengan nilai p=0,048, p=0,038 dan p=0,000. perubahan nilai kognitif, afektif dan psikomotor sebelum dan sesudah perlakuan pada kelompok kontrol dapat dilihat pada tabel 3. vol. 1 no. 3 desember 2017 95 tabel 3. peningkatan nilai kognitif, afektif dan psikomotor sebelum dan setelah intervensi pada kelompok kontrol variabel penelitian pre-test post-test mean difference p* min-maks mean±sd min-maks mean±sd as pek kogni ti f 10-60 31,00±11,55 10-60 38,33±14,87 7,33 0,048 as pek afekti f 44-59 52,10±4,10 41-59 49,60±5,31 -2,50 0,038 as pek ps i komotor 18-52 32.50±8,89 46-91 73,40±11,48 40,90 0,000 *p< 0,05 based on paired t-test hasil penelitian menunjukkan bahwa penerapan model siklus belajar 5e dengan kombinasi pbl dapat meningkatkan ketiga aspek pembelajaran yaitu kognitif, afektif dan psikomotor dengan nilai p value < 0,005 pada semua aspek. hasil analisis dengan membandingkan antara kelompok intervensi dan kelompok kontrol dapat dilihat pada tabel 4. tabel 4. perubahan nilai kognitif, afektif, dan psikomotor pada kelompok intervensi dan kelompok kontrol variabel penelitian post-test kelp. intervensi post-test kelp. kontrol mean difference p* min-maks mean±sd min-maks mean±sd as pek kogni ti f 10-80 47,85±11,55 10-60 38,33±14,87 9,52 0,041 as pek afekti f 42-59 52,89±4,17 41-59 49,60±5,31 3,29 0,012 as pek ps i komotor 28-89 53,03±14,60 46-91 73,40±11,48 -20,36 0,000 *p< 0,05 based on independent t-test pembahasan pengaruh model siklus belajar 5e dengan kombinasi pbl terhadap peningkatan kognitif hasil analisis menunjukkan bahwa meskipun dua metode yang digunakan dalam penelitian ini yaitu model siklus belajar 5e dengan kombinasi pbl yang diterapkan pada kelompok intervensi dan metode konvensional yang diterapkan pada kelompok kontrol, keduanya berpengaruh dalam meningkatkan nilai kognitif, namun tingkat peningkatan lebih tinggi dengan menggunakan model siklus belajar 5e dengan kombinasi pbl. dengan kata lain metode model siklus belajar 5e dengan kombinasi pbl lebih efektif dalam meningkatkan nilai kognitif mahasiswa. terjadinya peningkatan nilai kognitif pada kelompok intervensi yang menggunakan metode model siklus belajar 5e dengan kombinasi pbl karena pada tahap metode ini membuat mahasiswa aktif dalam proses pembelajaran. adanya stimulus berupa masalah atau kasus yang diberikan fasilitator untuk ditanggapi oleh mahasiswa sehingga membuat mahasiswa mencoba menjawab atau mengemukakan pendapatnya masing-masing berdasarkan pengetahuan atau pengalamannya sendiri. dari kompleksnya kasus atau masalah yang diberikan membuat mahasiswa memiliki rasa ingin tahu untuk menyelesaikan masalah terse but. pada siklus belajar 5e, mahasiswa dapat mempelajari materi secara bermakna dengan bekerja dan berfikir, pengetahuan dikonstruksi dari pengalaman mahasiswa melalui penyelidikan dan penemuan untuk memecahkan masalah. mahasiswa dapat mengungkapkan konsep yang sesuai dengan pengalamannya dan menggunakan pemahaman yang telah diperoleh untuk memecahkan permasalahan lain yang berhubungan dengan kehidupan sehari-hari (utami et al, 2013). dalam tahapan model siklus belajar 5e mahasiswa dapat menjelaskan suatu konsep dengan pemikiran sendiri berdasarkan pencarian atau penyelidikannya (afifah et al, 2013). beberapa penelitian menunjukkan bahwa dengan menggunakan metode model siklus belajar 5e dapat berpengaruh terhadap peningkatan kognitif siswa (jun w et al, 2013; sari et al, 2014; sari es et al, 2014). terjadinya peningkatan kognitif pada kelompok kontrol didukung dengan adanya dosen dengan pendidikan s2 keperawatan sehingga akan indonesian journal of nursing practices 96 mempengaruhi kemampuan dosen dalam menyampaikan materi dengan baik. dosen memberikan materi di kelas mahasiswa mendengarkan dengan baik dan adanya diskusi antara dosen dengan mahasiswa. mahasiswa terlihat bertanya saat dosen menjelaskan materi yang diberikan. dosen menyampaikan materi dengan semangat dan cara penyajian atau mempresentasikan materi disertai dengan gambar-gambar yang membuat mahasiswa cukup tertarik untuk memperhatikan. kualitas mengajar yang baik artinya dosen memanfaatkan dan mengembangkan fasilitas yang ada secara adekuat. metode mengajar yang baik merupakan hal yang utama dan mendasar dalam meningkatkan kemampuan mahasiswa (hameed and ulah, 2016). sebagian besar pendidikan keperawatan masih menggunakan metode tradisional yaitu dosen menerangan di depan dan mahasiswa mendengarkan secara pasif. namun kelebihan dari metode ceramah adalah dosen dapat mengarahkan dan mencapai tujuan pembelajaran dengan mudah (bhalli et al, 2016). hasil penelitian dengan membandingkan nilai kognitif antara kelompok intervensi yang menggunakan metode model siklus belajar 5e dengan kombinasi pbl dan kelompok kontrol yang menggunakan metode konvensional seperti ceramah, didapatkan bahwa peningkatan nilai kognitif pada kelompok intervensi maupun kelompok kontrol hampir sama namun peningkatan lebih tinggi diperoleh kelompok intervensi. hal ini berarti bahwa kelompok intervensi yang menggunakan metode model siklus belajar 5e dengan kombinasi pbl lebih efektif dalam meningkatkan kognitif mahasiswa dari pada kelompok kontrol yang menggunakan metode konvensional. model siklus belajar 5e adalah metode pembelajaran dengan pendekatan student centered learning (scl) artinya mahasiswa menjadi pusat dalam pembelajaran. scl merupakan strategi pembelajaran orang dewasa atau yang biasa dikenal dengan adult learning. pertumbuhan dan kematangan seseorang, dimana konsep diri anak-anak masih bergantung pada orang lain sedangkan orang dewasa konsep dirinya sudah matang dan mandiri (nursalam dan efendi, 2012). orang dewasa memiliki perasaan bahwa dalam suasana atau situasi belajar yang bagaimanapun, mereka boleh berbeda pendapat dan berbuat salah tanpa rasa terancam akan suatu sanksi yang ditujukan pada dirinya (nursalam dan efendi, 2012). berbeda dengan metode konvensional yang digunakan pada kelompok kontrol dimana pendekatan yang digunakan berpusat pada guru atau dosen yang dikenal dengan istilah teacher centered learning (tcl). pada pendekatan tcl, dalam proses belajar mengajar mahasiswa menjadi pendengar aktif menerima segala yang disampaikan dosen saat memberikan materi. hal ini membuat mahasiswa menjadi tergantung pada dosen sehingga menyebabkan kurangnya keinginan untuk mencari tahu untuk mendapatkan pemahaman yang mendalam secara mandiri dari materi tersebut. beberapa penelitian menujukkan hasil bahwa dengan menggunakan pendekatan scl dalam proses pembelajaran seperti salah satunya metode model siklus belajar 5e dengan kombinasi pbl berpengaruh terhadap peningkatan kognitif mahasiswa dibandingkan dengan mahasiswa yang menggunakan metode konvensional seperti ceramah (jun w et al, 2013). pengaruh model siklus belajar 5e kombinasi pbl dengan terhadap peningkatan afektif hasil penelitian menunjukkan bahwa model siklus belajar 5e dengan kombinasi pbl dapat meningkatkan afektif mahasiswa secara signifikan dengan nilai p=0,012. perubahan nilai afektif sebelum dan sesudah intervensi dapat dilihat pada tabel 4. berdasarkan pada tabel 4 terdapat perbedaan peningkatan afektif yang signifikan antara kelompok intervensi dengan kelompok kontrol. pada kelompok intervensi terjadi peningkatan nilai afektif 7,7 dengan rerata sebelum intervensi adalah 45,17 dan setelah intervensi meningkat menjadi 52.89 sedangkan pada kelompok kontrol terjadi penurunan nilai afektif 2,5 dengan rerata sebelum intervensi 52,10 dan setelah intervensi vol. 1 no. 3 desember 2017 97 menurun menjadi 49,60. hasil analisis menunjukkan bahwa meskipun dua metode yang digunakan dalam penelitian ini yaitu metode model siklus belajar 5e dengan kombinasi pbl yang diterapkan pada kelompok intervensi dan metode konvensional yang diterapkan pada kelompok kontrol semuanya berpengaruh terhadap nilai afektif, namun peningkatan hanya terjadi pada kelompok intervensi yang menggunakan model siklus belajar 5e dengan kombinasi pbl dari pada kelompok kontrol yang menggunakan metode konvensional. peningkatan nilai afektif pada kelompok intervensi yang menggunakan model siklus belajar 5e dengan kombinasi pbl terlihat dari mahasiswa antusias dalam berpartisipasi mengikuti proses pembelajaran pada tiap tahapnya. mahasiswa merespon dengan positif terhadap jalannya diskusi dalam kelompok. mahasiswa saling memberi support pada teman kelompoknya untuk mau mengemukakan pendapatnya dalam diskusi. pada tahap siklus belajar 5e di mana tujuannya menangkap perhatian mahasiswa untuk terlibat dalam sebuah konsep baru sehingga membangkitkan antusiasme mahasiswa (hatice dan morgil, 2007). dalam siklus belajar 5e ditekankan proses diskusi secara aktif dalam kelompok, dimana dengan adanya diskusi mampu melatih dan membiasakan mahasiswa mengembangkan sikap menghargai pendapat orang lain. selain itu juga dengan adanya diskusi dalam kelompok dapat melatih mahasiswa untuk dapat bekerja sama dengan baik di dalam kelompoknya sehingga mampu mewujudkan integrasi sosial di antara para siswa yang terlibat (silberman, 1996). hasil penelitian juga menunjukkan bahwa dengan penerapan model siklus belajar 5e lebih efektif dalam meningkatkan kemampuan afektif mahasiswa dibandingkan dengan metode konvensional ( rahayuningsih, masykuri, utami, 2012). penurunan nilai afektif pada kelompok kontrol yang menggunakan metode konvensional terjadi yaitu di awal perkuliahan mahasiswa cukup antusias dengan memperhatikan penjelasan dari dosen. namun, setelah kurang lebih satu jam penjelasan dari dosen mahasiswa terlihat bosan dengan tidak memperhatikan penjelasan dari dosen sampai selesai dan terlihat mengobrol dengan temannya. metode ceramah bila digunakan dalam waktu lama akan membosankan sehingga menyebabkan mahasiswa menjadi pasif dalam pembelajaran (djamarah, zain, 2013). konsentrasi mahasiswa akan menurun dengan cepat setelah mendengarkan ceramah lebih dari 20 menit secara terus-menerus (budiardjo, 1997). kelemahan dari metode ceramah adalah mahasiswa tidak mendapat kesempatan untuk berpikir dan berperilaku kreatif karena pengajaran yang berpusat pada dosen. akibatnya mahasiswa menjadi pasif dan cepat menjadi bosan. hasil penelitian menunjukkan bahwa metode ceramah tidak mampu meningkatkan sikap atau afektif mahasiswa (khatiban, sangestan, 2014). pengaruh model siklus belajar 5e kombinasi pbl dengan terhadap peningkatan psikomotor penelitian ini mendapatkan hasil bahwa pada kelompok intervensi maupun kelompok kontrol terjadi peningkatan nilai psikomotor yang signifikan. hal ini ditunjukkan dengan meningkatnya nilai pada post-tes setelah pemberian intervensi metode model siklus belajar 5e dengan kombinasi pbl pada kelompok intervensi dan metode konvensional pada kelompok kontrol. terjadi peningkatan nilai psikomotor pada kelompok intervensi yang menggunakan model siklus belajar 5e dengan kombinasi pbl karena pada tahap metode ini mahasiswa diberi kesempatan untuk mencoba tindakan keperawatan secara komprehensif. mahasiswa mampu menunjukkan kemampuannya dalam mengelola masalah pasien secara mandiri. pada model siklus belajar 5e tahap ketiga dalam siklus belajar 5e yaitu explanation, di mana tujuan kegiatan pada tahap ini meminta mahasiswa melakukan tindakan atau keterampilan yang direncanakan berdasarkan tahap sebelumnya (jun w et al, 2013). tahap explanation dalam siklus belajar 5e memfokuskan mahasiswa dari indonesian journal of nursing practices 98 keterlibatan dan eksplorasi pengalaman mereka dan memberikan kesempatan bagi mahasiswa untuk menunjukkan pemahaman mereka dalam proses keterampilan (piyayodilokchai et al, 2013). pada tahap keempat dalam siklus belajar 5e yaitu elaboration dimana mahasiswa berpartisipasi dalam situasi klinis simulasi dengan pasien standar (sps). metode sp adalah simulasi real -pasien yang menyediakan tenaga profesional kesehatan dimana untuk melatih keterampilan keperawatan mahasiswa yang dapat meningkatkan kemampuan psikomotor (jun w et al, 2013). peningkatan pada kelompok kontrol yang menggunakan metode konvensional, terjadi karena mahasiswa mendapatkan pengalaman praktikum laboratorium dari dosen yang memberikan demonstrasi terkait prosedur tindakan keperawatan yang diberikan. mahasiswa memperhatikan dengan seksama demonstrasi dari dosen yang menunjukkan prosedur tersebut. adanya faktor pendukung seperti ketersediaan laboratorium dengan alat-alat yang lengkap yang menunjang mahasiswa untuk lebih terampil dalam kemampuan skillnya. demonstrasi akan membuat proses pembelajaran lebih menarik dengan cara mengamati secara langsung, mahasiswa akan memiliki kesempatan untuk membandingkan antara teori dan kenyataan (ngalimun, 2016). demonstrasi dapat membuat pengajaran lebih jelas dan lebih konkrit, mahasiswa dirangsang untuk aktif mengamati, menyesuaikan antara teori dan kenyataan dan mencoba melakukannya sendiri (djamarah, dan zain, 2013). hasil penelitian menunjukkan bahwa demonstrasi dapat meningkatkan keterampilan atau psikomotor mahasiswa (kaur et al, 2015). penilaian psikomotor lebih tinggi didapatkan pada kelompok kontrol. peningkatan yang lebih tinggi pada kelompok kontrol yang menggunakan metode konvensional yaitu demonstrasi oleh dosen dibandingkan dengan metode model siklus belajar 5e yang menggunakan role play dari mahasiswa. dalam pendekatan scl yaitu pada metode model siklus belajar 5e, mahasiswa dituntut untuk sepenuhnya aktif dalam mengikuti proses pembelajaran. mahasiswa harus berupaya secara mandiri dalam mencari atau menemukan segala sesuatu yang diperlukan dalam pemahaman materi. pada tahap explanation, mahasiswa melakukan role play dengan teman sekelompok untuk menunjukkan keterampilan terhadap rencana tindakan yang telah ditetapkan bersama kelompok. dari 15 orang dalam kelompok yang mendapat peran dalam role play hanya sebagian orang saja sedangkan yang lain hanya melihat jalannya role play tersebut sehingga memungkinkan akan berpengaruh terhadap pemahaman mahasiswa yang lain dalam kemampuan psikomotor tanpa adanya keinginan untuk mencoba. pada kelompok kontrol yang menggunakan metode konvensional seperti demonstrasi, ratarata mahasiswa lebih mampu dalam kemampuan psikomotorik. hal ini, dimungkinkan karena mahasiswa sudah terbiasa mempelajari prosedur simulasi keterampilan psikomotor bersama dosen sehingga kemampuan psikomotor lebih tinggi diperoleh kelompok kontrol yang menggunakan metode konvensional dengan demonstrasi. role play yang dilakukan pada kelompok intervensi membuat mahasiswa melatih dirinya, memahami, dan mengingat isi bahan yang diperankan (djamarah dan zain, 2013). mahasiswa akan terlatih untuk berinisiatif dan kreatif, pada saat melakukan role play mahasiswa dituntut untuk mengemukakan pendapatnya namun kelemahan dari role play sebagian besar anak yang tidak ikut bermain peran mereka menjadi kurang kreatif. hal ini terjadi karena kurangnya motivasi dari mahasiswa, dimana motivasi adalah keadaan seseorang yang mendorongnya untuk melakukan sesuatu (islamuddin, 2012). berdasarkan hasil penelitian dengan membandingkan hasil belajar yang menggunakan demonstrasi dan role play dalam meningkatkan keterampilan atau kemampuan psikomotor menunjukkan bahwa role play lebih efektif di bandingkan dengan demonstrasi (mansyur, budu, nontii, 2014). namun, vol. 1 no. 3 desember 2017 99 keberhasilan proses belajar mengajar dipengaruhi tiga faktor utama yaitu kemampuan kognitif, motivasi prestasi dan kualitas pembelajaran. hasil penelitian menunjukkan bahwa motivasi memiliki pengaruh besar terhadap hasil belajar (setyowati, 2007). kesimpulan metode pembelajaran model siklus belajar 5e dengan kombinasi pbl dapat meningkatkan rerata nilai kognitif, afektif, dan psikomotorik mahasiswa pada mata kuliah kmb ii sistem muskuloskeletal di akper samawa sumbawa. hasil di atas menunjukkan bahwa metode pembelajaran model siklus belajar 5e dengan kombinasi pbl dapat menjadi masukan yang positif dalam menggunakan atau memilih metode pembelajaran. terdapat saran yang penulis ajukan kepada institusi akper samawa sumbawa yaitu melakukan pelatihan bagi dosen sebagai fasilitator dalam pembelajaran scl yang dilatih oleh trainer terstandar. untuk penelitian selanjutnya, penulis menyarankan agar menggunakan populasi yang lebih besar sehingga faktor-faktor yang menjadi keterbatasan penelitian dapat dikendalikan oleh peneliti yang berpengaruh terhadap hasil penelitian. referensi afifah, n.l., asim & muhardjito. 2013, pengaruh model pembelajaran 5-e learning cycle terhadap kerja ilmiah dan prestasi belajar fisika bagi siswa kelas x mia sma laboratorium um. unpublished balci s, cakiroglu j, tekkaya c, 2006. engagement, exploration, explanation, extension, and evaluation (5e) learning cycle and conceptual change text as learning tools. biochemistry and molecular biology education, may; 34 (3): 199-203 basic sciences years. professional medicine journal, 16;23(5): 614-619 bhalli ma, sattar a, asif m, 2016. teaching strategies: perception of medical students, used in budiardjo, l. 1997, metode instruksional, program applied approach bagian 3, jakarta: universitas terbuka djamarah, s.b., zain, a, 2013. statistik untuk kedokteran dan kesehatan ed. 3. salemba medika. jakarta. hameed imran, jan 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(2007). pengaruh motivasi belajar terhadap hasil belajar siswa kelas vii smpn 13 semarang. diakses tanggal 16 agustus 2017 dari http://lib.unnes.ac.id/1088/1/2668.pdf silberman, m., 1996. active learning: 101 strategies to teach any subject. boston: allyn & bacon tiwari, a., lai, p., so, m., & yuen, k. (2006). a comparison of the effects of problem‐based learning and lecturing on the development of students' critical thinking. medical education, 40(6), 547-554. utami, hastuti, yamtinah, padmini, dan arroyan, 2013. penerapan siklus belajar 5e disertai lks untuk peningkatan kualitas proses dan hasil belajar kimia. diakses tanggal 16 agustus 2017 http://pasca.unhas.ac.id/jurnal/files/450cf604c843c5656aff214771170996.pdf http://pasca.unhas.ac.id/jurnal/files/450cf604c843c5656aff214771170996.pdf http://lib.unnes.ac.id/1088/1/2668.pdf vol. 3 no. 1 juni 2019 35 ijnp (indonesian journal of nursing practices) vol 3 no 1 juni 2019 : 35-41 niken setyaningrum1, suib suib1 1 program studi ilmu keperaw atan stikes surya global korespondensi: niken setyaningrum email: nik3nimo3t@gmail.com efektifitas slow deep breathing dengan zikir terhadap penurunan tekanan darah pada penderita hipertensi info artikel online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.3191 abstrak latar belakang: hi pertens i adal ah s al ah s atu penyaki t pal i ng memati kan di duni a dan s aat i ni terdaftar s ebagai penyaki t pembunuh keti ga s etel ah penyaki t j antung dan kanker. perawatan hi pertens i membutuhkan waktu l ama dan meni mbul kan banyak kompl i kas i . ol eh karena i tu perl u i ntervens i non-farmakol ogi s yang al ami untuk mengendal i kan tekanan darah ti nggi . hi pertens i dap a t di kontrol dengan terapi non-farmakol ogi s menggunakan tekni k rel aks as i pernapasan dal am yang di kombi nas ikan dengan zi ki r. tujuan: tuj uan dari penel i ti an i ni adal ah untuk mengetahui efekti vi tas pernapas an dal am l ambat dengan zi ki r penurunan tekanan darah. metode: metode penel i ti an i ni menggunakan quas i eks peri mental dengan kel ompok kontrol . tekni k pengambi l an s ampel menggunakan purpos i ve s ampl i ng. ukuran s ampel terdi ri dari 30 pes erta yang di bagi menj adi 2 kel ompok dengan mas i ng-mas i ng 15 pes erta. kel ompok i ntervens i mendapat pengobatan pernapas an dal am l ambat dengan zi ki r s edangkan kel ompok kontrol hanya mendapat pengobatan pernapas an dal am l ambat. intervens i s el ama 14 hari . pengukuran yang di l akukan adal ah pengukuran tekanan darah menggunakan s phygmomanometer d an s tetos kop. anal i s i s yang di gunakan adal ah mann whi tney untuk tekanan darah. hasil: has i l penel i ti an setel ah i ntervens i di beri kan ada penurunan tekanan darah dengan ni l ai p 0,000 (s ys tol e) dan 0,045 (di as tol e). kesimpulan: intervens i non-farmakol ogi s pada pernapas an dal am yang l ambat dengan zi ki r l ebi h efekti f untuk menurunkan tekanan darah pada pas i en dengan hi pertens i . has i l penel i ti an i ni dapat di terapkan s ebagai terapi non-farmakol ogi s pada pas i en dengan hi pertens i dan bahan aj ar perawatan tambahan untuk hi pertens i kata kunci: slow deep breathing, zi ki r, tekanan darah abstract background: hypertension is one of the most deadly diseases in the world and is currently listed as the third killer disease after heart disease and cancer. treatment of hypertension takes a long time and causes many complications. therefore natural non pharmacological interventions are needed to control high blood pressure. hypertension can be controlled by non -pharmacological therapy using deep breathing relaxation techniques combined with zikir. objective: the purpose of this study was to determine the effectiveness of slow breathing with a decrease in blood pressure zikir. this research method use quasi experimental with a control group. the sampling technique use purposive sampling. the sample size consisted of 30 participants divided into 2 groups with 15 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/5428 indonesian journal of nursing practices 36 participants each. the intervention group received treatment for slow breathing with remembrance while the control group only received slow breathing treatment. intervention for 14 days. measurements taken are blood pressure measurements using a sphygmomanometer and stethoscope. the analysis used was mann whitney for blood pressure. results: after the intervention were given there was a decrease in blood pressure with a value of p 0.000 (systole) and 0.045 (diastole). conclusion: non-pharmacological interventions in slow deep breathing with remembrance are more effective for reducing blood pressure in patients with hypertension. the results of this study can be applied as non-pharmacological therapy in patients with hypertension and additional treatment teaching materials for hypertension keywords: slow deep breathing, zikir, blood pressure pendahuluan hipertensi adalah penyakit yang bisa menyerang siapa saja, baik muda maupun tua, orang kaya maupun orang miskin. hipertensi merupakan salah satu penyakit mematikan di dunia dan saat ini terdaftar sebagai penyakit pembunuh ketiga setelah penyakit jantung dan kanker (adib, 2009) . berdasarkan survei kesehatan rumah tangga (skrt) tahun 2001, diketahui bahwa umur, jenis kelamin, daerah tempat tinggal, obesitas, merokok, konsumsi alkohol dan aktifitas fisik terbukti memiliki hubungan secara signifikan terhadap kejadian hipertensi (siburian, 2001). jumlah perokok pria di indonesia menduduki peringkat k e dua tertinggi di dunia sebesar 57 persen dan perokok wanita menduduki peringkat ke enam sebanyak 3,6 persen (ng m, et al., 2014). menurut data riskesdas 2013 penduduk indones ia usia 15 tahun ke atas, sebesar 36,3% merokok, 93,5% kurang konsumsi buah dan sayur, 52,7% konsumsi garam lebih dari 2 ribu mg/hari, 15,4% obesitas, dan 26,1% kurang aktifitas fisik. hipertensi merupakan penyebab paling umum terjadinya kardiovaskular dan merupakan mas al ah utama di negara maju maupun berkembang. kardiovaskular juga menjadi penyebab nomor satu kematian di dunia setiap tahunnya. data who (2015) menunjukkan sekitar 1,13 miliar orang di dunia menderita hipertensi, 1 dari 3 orang di dun i a terdiagnosis menderita hipertensi, hanya 36, 8% d i antaranya yang minum obat. jumlah penderita hipertensi di dunia terus meningkat setiap tahunnya, diperkirakan pada 2025 akan ada 1,5 miliar orang yang terkena hipertensi. diperkirak an juga setiap tahun ada 9,4 juta orang meninggal akibat hipertensi dan komplikasi. di indonesia, berdasarkan data riskesdas 2013, prevalensi hipertensi di indonesia sebesar 25,8%, prevalensi tertinggi terjadi di bangka belitung (30,%) dan yan g terendah di papua (16,8%). sementara itu, data survei indikator kesehatan nasional (sirkesnas) tahun 2016 menunjukkan peningkatan prevalensi hipertensi pada penduduk usia 18 tahun ke atas sebesar 32,4%. selain itu, menurut data bpjs kesehatan, biaya pelayanan hiperte nsi mengal ami peningkatan setiap tahunnya, yakni rp. 2,8 triliun pada 2014, rp. 3,8 triliun pada 2015, dan rp. 4,2 triliun pada 2016 (depkes, 2018). faktor-faktor yang dapat mempengaruhi tekanan darah antara lain faktor umur, jenis kelamin, genetik, nutrisi, obesitas, olah raga, stres, merokok dan kualitas tidur (susilo & wulandari, 2011). dari beberapa faktor yang mempengaruhi tekanan darah, tidur merupakan suatu fenomena dasar yang penting bagi kehidupan, kurang lebih sepertiga dari kehidupan manusia dijalankan dengan tidur (havisa, 2014). respon terhadap stress merangsang kelenjar adrenal untuk memproduksi hormon kortisol dan epineprin (adrenalin) yang berpengaruh terhadap sistem endokrin, saraf dan imunitas (lorentz, 2006) endorpin berfungsi menghambat produksi korti s ol dan epinephin. meningkatkan produksi endo rp h in bisa dilakukan dengan excersice, meditasi, sholat vol. 3 no. 1 juni 2019 37 atau zikir untuk mendapatkan ketenangan (saleh, 2010). slow deep breathing yang dilakukan sebanyak enam kali permenit selama 15 menit memberi pengaruh terhadap tekanan darah melalui peningkatkan sensitivitas baroreseptor dan menurunkan aktivitas sistem saraf simpatis serta meningkatkan aktivitas sistem saraf parasimpatis pada penderita hipertensi primer (chacko n, et al., 2005). hasil studi pendahuluan yang dilakukan pada penderita hipertensi yang berobat di puskesmas godean 1, didapatkan hasil bahwa 10 pasien mengatakan jika terasa pusing dan kaku pada leher langsung berobat ke puskesmas dan hanya menggunakan terapi obat saja. pasien mengatakan hanya mengandalkan obat untuk menurunkan tekanan darah dan belum pernah mencoba alternatif non farmakologi untuk menurunkan tekanan darah. berdasarkan beberapa penelitian diatas dan kecenderungan penambahan angka kejadian hipertensi setiap tahunnya, sifat penyembuhan penyakit yang cukup lama serta komplikasi yang ditimbulkan dapat menyebabkan pembangunan sumber daya manusia menjadi kurang produktif secara sosial dan ekonomis. beban biaya yang ditanggung baik oleh penderita, masyarakat serta pemerintah akan semakin besar sementara efektifitas dan efisiensi kerja menurun sehingga diperlukan suatu pengelolaan penyakit h i p e rten si ini dengan baik untuk mencapai tujuan pembangunan kesehatan yang lebih berhasil (potter & perry, 2006). penelitian ini bertujuan untuk mengetahui perbedaan efektifitas gabungan intervensi non farmakologi slow deep breathing dengan zikir dan intervensi slow deep breathing secara terpisah terhadap penurunan tekanan darah dan peningkatan kualitas tidur pada penderita hipertensi. manfaat penelitian ini adalah memperkuat dukungan teoritis penggunaan terapi nonfarmakologi slow deep breathing dengan zikir dalam menurunkan tekanan darah pada pende ri ta hipertensi. memasyarakatkan latihan slow deep breathing dengan zikir dalam menurunkan tekanan darah pada penderita hipertensi, sehingga beban biaya yang ditanggung baik oleh penderita hipertensi, masyarakat serta pemerintah akan menurun sehingga efektifitas dan efisiensi kerja akan meningkat. metode desain yang digunakan dalam penelitian ini adal ah ”quasi experimental with control group design ”. pada penelitian ini membandingkan perbedaan tekanan darah pada penderita hipertensi yaitu pada kelompok intervensi slow deep breathing dengan zikir, sedangkan kelompok kontrol diberikan intervensi slow deep breathing secara terpisah. populasi pada penelitian ini adalah semua penderita hipertensi primer derajat yang rutin kontrol di puskesmas godean 1 yogyakarta, data yang diambil berjumlah 86 orang. pengambilan sampel dalam penelitian ini purposive sampling dengan jumlah sampel 30 responden terbahi menjadi 15 kelompok intervensi dan 15 kelompok kontrol. variabel bebas dalam penelitian ini adalah slow deep breathing dan zikir, sedangkan variabel terikatnya adalah tekanan darah pada penderita hipertensi. penelitian dilakukan wilayah kerja puskesmas godean 1 yang terdiri dari 4 desa. penelitian ini dilaksanakan pada bulan april juli 2018. instrumen yang dipakai dalam penelitian ini adalah spigmomanometer adalah suatu alat yang digunakan untuk mengukur tekanan darah sehingga alat ukur spigmomanometer sudah sesuai dengan fungsinya (valid). analisa yang digunakan mann whitney untuk tekanan darah. indonesian journal of nursing practices 38 hasil data karakteristik responden tabel 1 : data responden berdasarkan umur, jenis kelamin, pendidikan, pekerjaan, riwayat keluarga, riwayat merokok, riwayat alkohol dan lamanya hipertensi vari abel intervens i (n = 20) kontrol (n = 20) f % f % jeni s kel ami n laki -l aki 6 40 10 66,7 perempuan 9 60 5 33,3 total 15 100 15 100 umur 40 – 50 tahun 4 26,7 5 33,3 51 – 80 tahun 11 73,3 10 66,7 total 15 100 15 100 pendi di kan ti dak s ekol ah 0 0 0 0 sd 2 13,3 3 20 smp 6 40 9 60 sma 6 40 2 13,3 perguruan ti nggi 1 6,7 1 6,7 total 15 100 15 100 pekerj aan ti dak bekerj a 3 20 4 26,7 pns/tni/polri 0 0 1 6,7 karyawan swas ta 8 53,3 7 46,7 wi ras wasta 3 20 3 20 petani 1 6,7 0 0 total 15 100 15 100 ri wayat kel uarga ada 11 73,3 10 66,7 ti dak 4 26,7 5 33,3 total 15 100 15 100 ri wayat merokok ya 3 20 4 26,7 ti dak 12 80 11 73,3 total 15 100 15 100 ri wayat al kohol ya 0 0 0 0 ti dak 15 100 15 100 total 15 100 15 100 terdi agnos a hi pertens i < 1 tahun 1 6,7 4 26,7 1 – 3 tahun 7 46,7 6 40 >3 tahun 7 46,7 5 33,3 total 15 100 15 100 sumber : data responden hipertensi di wilayah kerja puskesmas godean 1 yogyakarta april -juli 2018 vol. 3 no. 1 juni 2019 39 berdasarkan tabel 1 didapatkan hasil responden jenis kelamin laki-laki mayoritas di kelompok kontrol yaitu sebanyak 10 responden (66,7%), sedangkan untuk kelompok intervensi mayoritas jenis kelamin perempuan sebanyak 9 responden (60%). umur responden untuk kelompok intervensi maupun kelompok kontrol mayoritas sama di rentang umur 51 – 80 tahun. pendidikan responden untuk kelompok intervensi setingkat smp dan s ma sama bayaknya yaitu masing-masing 6 responden (40%), sedangkan untuk kelompok kontrol mayoritas pendidikannya lulusan smp yaitu sebanyak 9 responden (60%). pekerjaan responden di kelompok intervensi dan kelompok kontrol mayoritas sama yaitu sebagai karyawan swasta. riwayat hipertensi kedua kelompok mayoritas mempunyai keluarga dengan riwayat hipertensi. mayoritas kedua kelompok tidak mempunyai riwayat merokok dan (100%) semua responden tidak ada yang memiliki riwayat mengkonsumsi alkohol. responden terdiagnosa hipertensi mayoritas rentang 13 tahun dengan jumlah responden sebanyak 7 responden (46,7%) untuk kelompok intervensi dan 6 responden (40%) u n tu k kelompok kontrol. tabel 2 : data distribusi tekanan darah sistol dan diastol kelompok intervensi dan kelompok kontrol vari abel tekanan darah intervens i (n = 15) kontrol (n = 15) pre pos t pre pos t f % f % f % f % tekanan darah si s tol 120 0 0 3 20 0 0 0 0 130 0 0 5 33,3 0 0 0 0 140 4 26,7 4 26,7 2 13,3 5 33,3 150 5 33,3 3 20 3 20 4 26,7 160 4 26,7 0 0 4 26,7 5 33,3 170 2 13,3 0 0 5 33,3 1 6,7 180 0 0 0 0 1 6,7 0 0 total 15 100 15 100 15 100 15 100 tekanan darah di as tol 80 1 6,7 5 33,3 0 0 1 6,7 90 6 40 6 40 4 26,7 4 26,7 100 1 6,7 1 6,7 3 20 5 33,3 110 2 13,3 3 20 4 26,7 4 26,7 120 5 33,3 0 0 4 26,7 1 6,7 total 15 100 15 100 15 100 15 100 sumber : data responden hipertensi di wilayah kerja puskesmas godean 1 yogyakarta april -juli 2018 tabel 3 : uji normalitas variabel tekanan darah pada kelompok intervensi dan kelompok control vari abel n p value tekanan darah si s tol sebel um 60 0,011 ses udah 0,099 tekanan darah di as tol sebel um 60 0,000 ses udah 0,006 hasil analisis uji normalitas tabel 3 terdapat variabel dengan nilai p < 0,05 yaitu variabel tekanan darah sistol dan diastol hal tersebut berarti bahwa variabel tersebut distribusi tidak normal. indonesian journal of nursing practices 40 tabel 4 : perbedaan tekanan darah pada kelompok intervensi dan kelompok control vari abel mean n p value tekanan darah si s tol sdb dengan zi ki r (intervens i ) 134 15 0,000 sdb (kontrol ) 151 15 tekanan darah di as tol sdb dengan zi ki r (intervens i ) 91 15 0,045 sdb (kontrol ) 100 15 berdasarkan analisa data tabel 4 bahwa semua nilai p < 0,05 hal tersebut berarti terdapat perbedaan yang signifikan antara kelompok intervensi dan kelompok kontrol setelah mendapatkan perlak uan baik itu tekanan darah sistol maupun diastol. pembahasan perbedaan tekanan darah dari setiap responden terjadi karena ada beberapa faktor yang mempengaruhi besarnya tekanan darah setiap orang. hal ini sesuai dengan teori yang menyatakan bahwa terdapat faktor-faktor yang mempengaru h i besarnya tekanan darah setiap orang yaitu faktor usia, jenis kelamin, dan medikasi atau obat-obatan yang dikonsumsi (potter & perry, 2006). hasil analisa data dengan menggunakan analisa data mann whitney test bahwa terdapat perbedaan yang signifikan antara kelompok intervensi dan kelompok konytrol setelah masing-masing dilakukan intervensi yaitu slow deep breathing dengan zikir maupun hanya dilakukan slow deep breathing saja. berdasarkan hasil keduanya dapat menurunkan tekan darah sistol dan diastol, namu n dengan hasil yang signifikan maka slow deep breathing dengan zikir lebih baik untuk menurunkan tekanan darah. karena selain melakukan nafas dalam, responden juga melakukan relaksasi berupa zikir yaitu menyebut melafashkan kalimat alloh, sehingga membuat hati lebih tenang dan memasrahkan diri kepada alloh. didukung penelitian yang dilakukan oleh (hartanti, wardana, & fajar, 2016) bahwa nafas dalam yang dilakukan dapat menurunkan tekanan darah sistol dan diastol. slow deep breathing yang dikombinasikan dengan zikir akan membuat penderita hipertensi lebih tenang sehingga akan memicu keluarnya hormon endorfin. dengan mengendalikan perasaan lewat zikir maka dapat memusatkan pikiran dan lebih pasrah dalam hid u p sehingga dapat mengendalikan pikiran yang d ap at memicu stres. zikir di sini lebih berfungsi sebagai metode psikoterapi, karena dengan banyak melakukan zikir akan menjadikan hati tentram, tenang dan damai, serta tidak mudah diombangambingkan oleh pengaruh lingkungan dan budaya global (anggraieni, 2014). setiap individu terd ap at kebutuhan dasar spiritual (basic spiritual needs) yang harus dipenuhinya. seperti yang tercantum dalam surat az-zumar ayat 23 berikut: “gemetar karenanya kulit orang-orang yang takut kepada tuhannya. kemudian menjadi tenang kulit dan hati mereka diwaktu mengingat allah.” zikir bermanfaat untuk meningkatkan mood, menurunkan kecemasan dan meningkatkan tidur (hanlon, blackman, & glick, 2009). sesuai dengan firman allah swt: “yaitu orang-orang yang beriman dan hati mereka menjadi tentram dengan mengingat allah. ingatlah, hanya dengan mengingat allah-lah hati menjadi tentram.”(qs. arra’d : 28). hubungan antara pikiran dan materi, antara jiwa dan tubuh merupakan hubungan yang tidak dapat dipisahkan, keduanya saling mempengaruhi, jadi ketika jiwa menjadi tenang maka tubuh pun akan merespon dengan menjadi tenang (tortora & derrickson, 2009) hal ini sejalan dengan penelitian (al -halaj, 2014) mampu memacu sistem saraf parasimpatis yang mempunyai efek berlawanan dengan sistem saraf simpatis sehingga menyebabkan terjadinya keseimbangan pada kedua saraf autonom tersebut.hal inilah yang menjadi prinsip dasar d ari timbulnya respon relaksasi, yakni terjadinya keseimbangan antara sistem saraf simpatis dan sistem saraf parasimpatis. kesimpulan terdapat perbedaan yang signifikan tekanan darah pada penderita hipertensi pada kelompok intervensi dan kelompok kontrol. intervensi non farmakologi slow deep breathing dengan zikir lebih efektif untuk menurunkan tekanan darah pada penderita hipertensi. vol. 3 no. 1 juni 2019 41 ucapan terimakasih dalam pembuatan paper itu penulis mengucap kan terimakasih kepada hibah pdp kemenristekdikti 2017, yang telah memberikan dana untuk berlangsungnya penilitian ini. references adib, m. 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(2001). gambaran kejadian hipertensi dan faktor-faktor yang berhubungan tahun 2001 (analisis data sekunder skrt 2001). depok: skripsi. fakultas kesehatan masyarakat. universitas indonesia. susilo, y., & wulandari, a. (2011). cara jitu mengatasi hipertensi. yogyakarta: andi offset. tortora, g., & derrickson, b. (2009). principles of anatomy and physiology. usa: jhon wiley http://www.depkes.go.id/article/view/18051600004/hipertensi-membunuh-diam-diam-ketahui-tekanan-darah-anda.html%20diakses%2024%20agustus%202018 http://www.depkes.go.id/article/view/18051600004/hipertensi-membunuh-diam-diam-ketahui-tekanan-darah-anda.html%20diakses%2024%20agustus%202018 http://www.depkes.go.id/article/view/18051600004/hipertensi-membunuh-diam-diam-ketahui-tekanan-darah-anda.html%20diakses%2024%20agustus%202018 http://www.depkes.go.id/article/view/18051600004/hipertensi-membunuh-diam-diam-ketahui-tekanan-darah-anda.html%20diakses%2024%20agustus%202018 indonesian journal of nursing practices 36 indonesian journal of nursing practices retha rizky fitransyah1 , ema waliyanti2 1 program studi ilmu keperaw atan, fakultas kedokteran dan ilmu kesehatan, universitas muhammadiyah yogyakarta, jalan braw ijaya, kasihan, bantul, daerah istimew a yogyakarta-55184, indonesia korespondensi: retha rizky fitransyah e-mail korespondensi: retharf it@gmail.com perilaku cyberbul lying dengan media ins tagram p ada rema ja di yogyakarta info artikel online issn doi : : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.2177 abstrak peri l aku cyberbullying remaj a di medi a s os i al menj adi s al ah s atu mas alah yang bel um teratasi. faktor yang mempengaruhi remaja dalam mel akukan cyberbullying mel i puti penggunaan media sosial yang ti nggi, ras a empati yang rendah, dan pengal aman pernah menj adi korban bullying. hal i ni dapat memberi kan dampak buruk terhadap ps ikologis korban. penel i ti an i ni menggunakan metode kual i tati f pendekatan fenomenol ogi . pengambi l an data di l akukan dengan wawancara mendal am dan observasi mel alui medi a s o s i al i ns tagr am. i n f or man pada penel itian i ni berj umlah 5 orang yang terdi ri dari s is wa s ma d a n smp s was ta di yogyakarta yang di tentukan dengan purposive sampling . keabs ahan data dilakukan menggunakan triangulasi metode d a n p eer debriefing. anal isa data penel iti menggunakan software open code 4.03. has i l penel i ti an mel al ui obs ervas i di medi a s os i al i ns tagram menunj ukkan j enis cyberbullying yang dilakukan remaja di yo gy a kar ta s eperti : 1). memberi kan komentar kas ar, 2). mengupdate instastory, 3). mengupload foto, dan 4). mengomentari foto. sel ai n i tu has i l penel i ti an mel al ui wawancara mendal am menunj ukkan peri l aku cyberbullying remaj a di pengaruhi ol eh beberapa faktor s eperti : 1). intens i tas penggunaan medi a sosial, 2).kemampuan empati pel aku, dan 3). karakter korban. peri l aku cyberbullying pada remaj a s eperti mengupload foto, berkomentar kas ar, mengupdate instastory, dan mengomentari foto denga n menggunakan kata -kata kasar memberi kan dampak negati f bai k pada pel aku maupun korban s ehi ngga mebutuhkan perhati an l ebi h bagi s ekol ah maupun or angtua. berdas arkan hasil penelitian dapat di sarankan bagi penel iti s elanjutn y a untuk dapat mel akukan i ntervensi mel alui promosi kes ehatan di med i a s os i al terkait perilaku cyberbullying s ehingga ti d ak a da p en i n gkata n cyberbullying di medi a sosial s elain itu bagi orangtua dapat membangun komuni kasi yang efekti f dan memberi kan dukungan moral agar r ema j a terhi ndar dari perilaku cyberbullying. kata kunci : cyberbullying, peri laku, remaja, instagram, medi a s osial mailto:retharfit@gmail.com 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/5166 vol. 2 no. 1 juni 2018 37 abstract adolescents cyberbullying behavior on social media has become o n e o f unresolved problems. factors that influence adolescents in cyberbullying includes high use of social media, low empathy, and experience of being bully victims. this situation can give a negative impact to victims psychological. this research use a qualitative method of the phenomenology approach. the data retrieval is done by deep interviews and observations through the social media instagram informants. the informant in this research amount 5 students consistin g of senior high school and junior high school in yogyakarta determined by purposive sampling. the validity of data is done by using triangulation methods and peer debriefing. the data analysis researchers usin g open code software 4.03. the results of research through observation on social media instagram showed the types of cyberbullying carried out by adolescents in yogyakarta such as : 1). make rude comments, 2). update instastory, 3).upload photos, and 4). c omment on photos. in addition, the results of the research through deep interviews showed that the behavior of adolescent cyberbullying was influenced by severa l factors such as 1). the intensity of social media use, 2). the ability of empathetic actors, and 3). character of the victim. cyberbullying behavior in adolescents such as uploading photos, rude comments, updating instastories, and commenting on photos by using harsh word s has a negative impact on both perpetrators and victims so they need more attention from schools and parents. based on the results of the research, it can be suggested for the future researchers to be able to intervene through health promotion on social media related to cyberbullying behavior so that there is no increase in cyberbu llying on social media besides that parents can build effective communication and provide moral support so that teens avoid cyberb ullying behavior. keywords : cyberbullying, behavior, adolescent, instagram, social media pendahuluan remaja merupakan periode transisi dari anak menuju dewasa yang melibatkan kematan gan proses berfikir, dan emosional (permatasari, 2016). pada periode tersebut, remaja mengalami krisis identitas diri sehingga pada masa ini tergolong dalam periode bermasalah khususnya dengan perilaku bullying (sistrany , 2016). bullying sebagai bentuk tindakan agresif yang dapat merugikan dan menyakiti orang lain (wolke, 2015). komisi perlindungan anak indonesia (kpai) tahun 2014 menyebutkan bentuk pelanggaran bullying dibagi menjadi 4 yaitu bullying fisik, bullying seksual, bullying verbal, dan bullying di me d i a sosial (cyberbullying). kpai (2014) juga menjelaskan bahwa bentuk pelanggaran kekerasan di media sosial (cyberbullying) menjadi permasalahan serius yang harus ditangani terutama pada remaja. cyberbullying merupakan penyalahgunaan teknologi di media sosial untuk mengancam, melecehkan, dan mempermalukan sese oran g (fisher, 2013). hasil studi united nations international children’s emergency fund (unicef) tahun 2016 menunjukkan hampir 30 juta remaja di indonesia mengakses internet, 80% remaja khususnya di kota jakarta dan daerah istimewa yogyakarya (diy) adalah pengguna aktif internet, 70% remaja menggunakan internet untuk bertemu te man online melalui media sosial (instagram), dan 30% melihat video melalui situs online, sehingga penggunaan internet pada remaja dapat berpengaruh terhadap peningkatan tindak penyalahgunaan media sosial seperti cyberbullying. hasil penelitian dalgeish (2010) menunjukkan remaja yang melakukan atau mengalami cyberbullying sebesar 50% usia 1014 tahun, 42% usia 15-18 tahun, dan 8% usian 19-25. presentase tertinggi menurut penelitian papalia (2014) cyberbullying dikalangan remaja terjadi pada usia 14 hingga 18 tahun. indonesian journal of nursing practices 38 faktor perilaku cyberbullying remaja dipengaruhi oleh frekuensi penggunaan media sosial yang tinggi, rasa empati yang rendah, dan memiliki pengalaman menjadi korban bullying (fabio sticca, dkk, 2013). faktor cyberbullying tersebut memberikan dampak terhadap psikologis korban, 37% mengalami kepercayaan diri rendah, 30% mengalami penurunan prestasi di sekolah, 28% mengalami depresi, dan 25% mengalami gangguan pola tidur (meodia, 2016). kementrian komunikasi dan informatika (kemkominfo) bekerjasama dengan unicef tahun 2014 menyatakan bahwa sebagi an besar remaja indonesia pernah menjadi korban cyberbullying. sebanyak 49% orang mengaku menjadi korban cyberbullying dalam bentuk pemberian nama negatif, 19% dijadikan objek gosip, 12% ancaman, 7% korban penipuan, 11% diposting gambar atau informasi pribadi korban, dan 6% merujuk pada konten seksual (sartana, afriyeni, 2017). perilaku cyberbullying yang terjadi dikalan gan remaja menimbulkan keresahan dan keprihatinan masyarakat terhadap perilaku tersebut di media sosial. hal ini didukung ol e h pengaduan masyarakat kepada kpai. pada tahun 2011 2014 kpai mencatat 369 pengaduan terkait cyberbullying. sekitar 25% dari total sebagian pengaduan di bidang pendidikan sebanyak 1.480 kasus. masyarak at khawatir kasus mengenai cyberbullying yang muncul ke ruang publik hanya sedikit sedangkan masih banyak kasus cyberbullying yang belum terlaporkan. upaya pemerintah dalam mengatasi masalah cyberbullying di indonesia diatur dalam undang-undang nomor 19 tahun 2016 tentang perubahan atas undang-undang nomor 11 tahun 2008 tentang informasi dan transaksi elektronik pasal 310 ayat (1) kuhp berisi tentang pencemaran nama baik sebagai perbuatan menyerang kehormatan atau nam a baik seseorang dengan menuduhkan sesuatu hal secara terang-terangan yang di ketahui oleh umum. berdasarkan latar belakang di atas, peneliti tertarik untuk melakukan penelitian mengenai perilaku cyberbullying pada remaja di sosial media instagram untuk mengeksplorasi perilaku cyberbullying di kalangan remaja di yogyakarta. metode penelitian ini menggunakan metode kuali tati f dengan pendekatan fenomenologi. peneli tian dilakukan pada beberapa sekolah swasta di yogyakarta. informan dalam penelitian ini berjumlah 5 orang yang terdiri dari 3 siswa sekolah menengah atas dan 2 siswa sekolah menengah pertama yang ditentukan dengan purposive sampling. kriteria inklusi pada informan yaitu siswa sma kelas x atau xi atau xii, siswa smp kelas vii atau viii atau ix di sekolah tersebut, dan menggunakan media sosial instagram. pengumpulan data dilakukan dengan wawancara mendalam dilakukan dengan menggunakan panduan wawancara untuk menggali informasi tentang perilaku cyberbullying remaja di media sosial instagram. observasi dilakukan selama 1 minggu melalui akun media instagram informan dengan dibantu asisten penelitian yang sebelumnya sudah melakuakn persamaan persepsi mengenai pokok bahasan cyberbullying. keabsahan data dilakukan dengan menggunakan triangulasi metode d an peer debriefing. hasil wawancara dan observasi kemudian dibuat transkrip dan dianalisis dengan bantuan software open co de 4.03. hasil a. kriteria partisipan informan dalam penelitian ini berjumlah 5 orang yang terdiri dari 3 siswa sekolah menengah atas dan 2 siswa sekolah menengah pertama dengan karakteristik masing-masing informan : vol. 2 no. 1 juni 2018 39 tabel 1. karakteristik informan kode informan jenis kelamin usia pendidikan sekarang status bullying i1 perempuan 18 tahun sekolah menengah atas (sma) pelaku dan korban i2 perempuan 19 tahun sekolah menengah atas (sma) pelaku dan korban i3 perempuan 16 tahun sekolah menengah atas (sma) pelaku dan korban i4 laki-laki 15 tahun sekolah menengan pertama (smp) korban i5 laki-laki 15 tahun sekolah menengan pertama (smp) pelaku dan korban b. jenis cyberbullying di instagram gambar 1. jenis cyberbullying di instagram hasil penelitian ini menunjukkan bahwa j e ni s cyberbullying di media instagram mempengaruhi remaja dalam melakukan cyberbullying. 1. mengupload foto di instagram dengan kalimat kasar remaja mengaku pernah mengunggah foto dengan memberikan komentar kasar ketika sedang merasa kesal dengan oranglain. hal ini didukung dengan pernyataan informan sebagai berikut : i: "yo pernah ada kalimat sarunya kek apa y a mbak sek mbak lupa...(mikir) oiya misal anjing gitu ada tapi yo gak semua fotoku". berikut bukti screenshoot caption foto yang diunggah oleh informan : gambar 2. screenshoot caption jenis cyberbullying di instagram mengomentari foto update instastory upload foto komentar kasar indonesian journal of nursing practices 40 foto yang di upload oleh remaja menggunakan caption dengan melontarkan kata-kata kasar untuk melecehkan ketika informan merasa sebal dengan orang lain seperti "ra dadi atimu po pie kok kementise poll (tidak jadi hati kamu atau gimana kok s o k tau banget), fuck anjing bangsat". 2. berkomentar kasar melalui instagram remaja menjelaskan bahwa sering mengomentari postingan milik temannya dengan menggunakan kalimat yang membuat temannya sakit hati karena teman remaja tersebut pernah mengejek remaja. hal ini didukung dengan pernyataan informan sebagai berikut : p:"tapi kamu pernah gak dek, misal kalo temen kamu upload foto terus kamu ngomentarin foto itu yang bikin temenmu sakit hati? i: perrnah mbak ..."jelek" gitu mbak..ssalahnya ngatain akku ga bisa mma in bola" (i5, laki-laki 15 tahun). selain itu remaja lain mengatakan bahwa temannya juga mengomentari akun instagram miliknya dengan menggunakan kata-kata kasar karena remaja mengupload foto dan menyisipkan caption yang menimbulkan teman-temannya berkomentar kasar pada foto tersebut. hal ini didukung dengan pernyataan infroman sebagai berikut : p: "terus gimana dek dia ngomentari pake katakata kasar itu ke foto yang kamu upload " i: "oh ini hahaha ya ini mbak bitch lah,apalah itu mba temenku komentare aneh-aneh hehehe" p:" tanggapanmu gimana, ini orang yang kamu upload fotonya tau dek kalo di komentarin kayak gini?" i:" ya lucu-lucuan aja mba pas temenku lew a t depan rumah ini tak foto, mereke juga tau kok mba hehehe". (i4, laki-laki 15 tahun). berikut bukti screenshoot teman informan yang mengomentari foto menggunakan k atakata kasar : gambar 3. screenshoot teman informan bukti screenshoot tersebut menunjukkan adanya upaya remaja untuk merendahkan oranglain melalui media instagram dengan mengupload foto temannya sehingga menyebabkan teman informan mencela foto tersebut dengan berkomentar menggunakan kata-kata kasar seperti bitches (perempuan jalang), kimcil (merupakan singkatan dari bahasa jawa "kimpet cilik" yang berarti alat kelamin perempuan), teman remaja juga mempelsetkan perkataan kasar seperti bajilak (bajingan). selain itu, bukti screenshoot juga menunjukkan adanya upaya seseorang u n tu k melecehkan remaja dengan mengirim komentar-komentar kasar yang dapat menyakiti perasaan remaja seperti kontol (kemaluan laki-laki), ngentot (melakukan hubungan badan), ada juga oranglain menyebut remaja dengan menggunakan k ata anjing, jingan (bajingan) mentel (genit). vol. 2 no. 1 juni 2018 41 memikirkan korban t idak memikirkan korban intensitas penggunaan instagram karakter korban cyberbullying kemamp uan emp ati pelaku faktor-faktor perilaku cyberbullying di instagram t eman dekat riwayat bullying 1. update instastory instagram remaja juga mengatakan sering mengup da te instastory di instagram dengan menggunak an kata-kata kasar. hal ini didukung dengan bukti screenshoot dari akun instagram informan : gambar 4. screenshoot instastory instastory yang dibuat oleh remaja merupakan perilaku cyberbullying, hal tersebut karena remaja mengupdate instastory berupa foto temannya yang ditambakan dengan kalimat tidak pantas di media sosial "bangke u", ada juga kata-kata yang di plesetkan "anying" yang bermakna anjing. c. faktor-faktor perilaku cyberbullying di instagram hasil penelitian menunjukkan faktor-faktor yang mempengaruhi remaja dalam perilaku cyberbullying adalah intensitas penggunaan media sosial, kemampuan empati pelaku, dan karakter korban cyberbullying. hasil penelitian tersebut dapat dilihat pada bagan berikut : gambar 5. faktor-faktor perilaku cyberbullying di instagram 1. intensitas penggunaan instagram remaja mengatakan sering membuka media instagram sehari minimal 2 kali sehari. remaja menjelaskan dapat membuka instagram lebih dari 7 kali sehari apabila memiliki kuota internet yang lebih banyak. hal indonesian journal of nursing practices 42 ini didukung oleh pernyataan informan sebagai berikut : "wah ya sering mbak..apalagi kalo kuotanya banyak sehari bisa 3-4 kali lebih paling mba buka instagram hehehe..." (i2, perempuan 19 tahun). "emmmm berapa ya mbak..sek mbaak..em m 7-15 kali bisalah aku mbak buka instagram hahaha..." (i4, laki-laki 15 tahun). 2. karakter korban cyberbullying a. teman dekat remaja menyebutkan bahwa orang yang dijadikan sasaran menjadi korban cyberbullying adalah teman dekat. remaja menganggap bahwa teman dekatnya tidak akan sakit hati atas tindakan yang dilakukan oleh remaja dan menganggap perilaku cyberbullying tersebut wajar dan hanya dijadikan sebagai bahan candaan. hal ini didukung dengan pernyataan informan sebagai berikut : "emmm cuma temen deketku aja mbak kayak aku bikin instastory pas mukanya lagi jelek banget gitu, cuma gitu doang.. bercandaan doang...masih wajarlah mbak soalnya uda biasaa..." (i1, perempuan 18 tahun). b. riwayat bullying remaja menyebutkan bahwa perilaku cyberbullying yang dilakukannya disebabkan karena sebelumnya remaja pernah menjadi korban cyberbullying, hal tersebut membuat remaja ingin membalas temannya dengan mempermalukan kembali di media instagram. hal ini didukung dengan pernyataan i nforman sebagai berikut : p: " bisa diceritain gak dek, memangnya yang kamu kata-katain di instagram itu orangnya seperti apa sih dek?" i: " ya pokokmen seng tau nyindir aku kae lo mbak.. salahe nganu aku yo tak nganu gentilah mba..wong wong seng koyo ngono diwanikke mbak..hehehe" (i2, perempuan 19 tahun). 3. kemampuan empati pelaku a. memikirkan korban remaja mengatakan bahwa setelah mempermalukan korban di media instagram remaja memikirkan perasaan korban dan menyesali perbuatannya sehingga hal yang dilakukan oleh remaja yaitu meminta maaf kepada korban. hal ini didukung dengan pernyataan informan sebagai berikut : "iya..emm mikir sih mbak...ya pas lagi emosinya sih kan lagi ga kekontorol gitu jadi gak mikirin tapi pas emosiku udah reda ya aku mikir mbak...wah ini pasti orangnya sakit ha ti pasti nih... ya terus aku minta maaf sih mbak..kasihan sama orangnya...hehehe." ( i 4, laki-laki 15 tahun). b. tidak memikirkan korban selain itu, ada juga remaja yang mengaku tidak mempedulikan perasaan korbannya karena remaja merasa orang tersebut telah mengganggu kehidupannya dan setelah mempermalukan korbannya di instagram remaja merasa lega. hal ini didukung dengan pernyataan informan sebagai berikut : "halah mbak... ngapain mikrin perasaannya...aku mah luweh luweh mba...la wong deknen ngusik hidupku...yo delok wae mbak..remuk-remuk tenan..hahaha seng pentingki deknen reti, aku yo lega nek wes koyo ngono..." (i3, perempuan 16 tahun). d. respon korban cyberbullying di instagram gambar 6. respon cyberbullying di instagram sakit hati respon korban r espon k orban di i ns tagram tidak peduli menganggap candaan vol. 2 no. 1 juni 2018 43 1. sakit hati hasil penelitian menunjukkan bahwa beberapa remaja yang menjadi korban cyberbullying di media instagram merasa tidak sakit hati atas perkataan yang disampaikan oleh oranglain. remaja menjelaskan bahwa sering dibully seti ap hari oleh teman-temannya. hal ini didukung dengan pernyataan informan sebagai berikut : p: "pas kamu dipermalukan orang lain di instagram, perasaanmu gimana sih dek?" i: "ya gimana ya mba..gak sakit hati sih mbak..soalnya emang udah sering aku digituin mba...." (i5, laki-laki 15 tahun). 2. tidak peduli hasil penelitian menunjukkan adanya remaja yang tidak peduli terhadap perkataan kasar oranglain. hal ini didukung dengan pernyataan informan sebagai berikut : "ah aku mah rapeduli mbak..biasa wae...diem wae mbak..owong aku ngerasa ratau golek masalah...benke wae mbak rapeduli.."(i3, perempuan 16 tahun). 3. menganggap candaan hasil penelitian menunjukkan remaja mengatakan bahwa mereka menganggap komentar teman kepadanya menggunakan kalimat yang berunsur seksual di media instagram hanya sebagai candaan saja sehingga remaja ketika membaca komentar tersebut merasa lucu. hal ini didukung dengan pernyataan informan sebagai berikut : p: "tadi kan kamu bilang kalau teman dekatmu pernah komentar pake kalimat saru..nah yang kamu rasain gimana sih dek" i: "yaaa ngakak aku mbak baca komen temenku sendiri..la aneh..aneh wae nek komentar mbak..lucu..nyeleneh pie gitu mbak..hahaha ha " (i2, perempuan 19 tahun). e. dampak cyberbullying di instagram hasil penelitian menunjukkan bahwa perilaku cyberbullying berdampak pada remaja. remaja mengatakan menjadi kurang memperhatikan di sekolah karena memikirkan apa yang sudah dialaminya. selain itu remaja juga merasa tidak percaya diri akibat perkataan oranglain yang menyakitinya di media instagram. . hal ini didukung dengan pernyataan informan sebagai berikut : p: "kamu tau gak dek alasan instagram itu karena apa" i:"emmm...yayyaa..tttau mbak..karna gggagap.. p: kalo setiap kamu di katain gitu ngaruh gak s ih dek buat kehidupanmu" i: "ngaruhh bbanget mbak..ya kayak kkurrang emmm emmmemmememperhatikan di sekolah.." (i5, laki-laki 15 tahun). f. koping korban cyberbullying di instagram hasil penelitian menunjukkan bahwa remaja yang pernah menjadi korban cyberbullying di media instagram untuk menghilangkan perasaan sedih dan sakit hatinya yaitu dengan pergi bersama temannya ke suatu tempat, ada juga remaja yang menjelaskan dengan bermain handphone dan bermain game dapat menghilangkan perasaan sedihnya. hal ini didukung dengan pernyataan informan sebagai berikut : "emmmm apa ya mbak.. ya paling ya mba nongkrong sama temen temenku.. ngumpul ngumpul gitulah kan njuk uwis ra bakalan mikirke meneh mbak..." (i3, perempuan 16 tahun). "emmm..pppaling akkk aaku mmain hp kalo ggak game biar aku gak sssedih gara -gara mmreka mba hehe.." (i5, laki-laki 15 tahun). pembahasan 1. jenis cyberbullying di instagram hasil penelitian ini menunjukkan bahwa informan sering mengomentari foto temannya menggunakan kata kata kasar dikarenakan infroman sudah merasa dekat dengan temanny a dan menganggap hal tersebut wajar. machackova dkk., (2013) menjelaskan aktifitas cyberbullying yang dilakukan oleh remaja di media sosial adalah menyebut temannya dengan sebutan lain, penghinaan, peretasan akun media sosial, mengalami pengucilan di media sosial, dan digosipkan. namun aktifitas cyberbullying yang paling sering terjadi di media sosial ialah pemanggilan dengan sebutan lain dan penghinaan yang dilakukan terhadap oranglain. kartono (2013) menyebutkan perilaku cyberbullying yang sering terjadi di media sos i al adalah harrasment yaitu perilaku cyberbullying dengan menuliskan kata-kata kasar di kolom indonesian journal of nursing practices 44 komentar akun media sosial dan mengirim atau memposting gambar seseorang yang bertujuan untuk menghina. hal ini didukung juga dengan hasil penelitian yang menyatakan bahwa informan mengupdate instastory dengan menggunakan foto orang lain dan menambahkan tulisan menggunakan kata-kata kasar. selain i tu , hasil penelitian ini juga menunjukkan informan mengupload foto dengan menambahkan caption menggunakan kata-kata kasar karena merasa sebal dengan orang lain. jacobs dkk., (2015) menjelaskan remaja memilih untuk menggunakan media sosial se cara tidak pantas seperti mengintimidasi, melecehkan oranglain, mengancam dan bisa juga dengan motif sen gaj a mengucilakan orang lain. mafazi (2017) menjelaskan remaja sering mengungkapkan d an mengekspresikan dirinya melalui media sosial, namun pengungkapan yang disampaikan remaja di media sosial tidak semuanya mempunyai efe k yang positif seperti mencela oranglain, berkata kotor, dan melakukan agresi. 2. faktor-faktor perilaku cyberbullying di instagram hasil penelitian ini menunjukkan perilaku cyberbullying pada remaja di yogyakarta dipengaruhi oleh intensitas penggunaan media sosial, kemampuan empati pelaku, dan karak te r korban. a. intensitas penggunaan media sosial hasil penelitian ini menunjukkan bahwa intensitas remaja dalam menggunakan media sosial memiliki pengaruh terhadap perilaku cyberbullying. hal tersebut ditunjukkan dengan wawancara siswa yang menyatakan bahwa siswa membuka instagram 2 kali hingga lebih dari 7 kali dalam sehari ketika memiliki kuota internet yang banyak. gibson (2015) menyebutkan bahwa remaja yang menggunakan internet melebihi batas frekuensi penggunaan media sosial akan mempengaruhi remaja dalam melakukan cyberbullying. remaja yang menghabiskan waktu lebih dari 40 jam perbulan di media sosial d ap at mendorong remaja untuk melakukan intimidasi dan penindasan terhadap oranglain (ariani d k k . , 2013). selain itu, kusumaardhiati (2012) menjelaskan intensitas penggunaan media sosial didukung juga oleh fasilitas untuk berlangganan internet yang memiliki akses lebih cepat dan kuota unlimited, hal tersebut membuat remaja dapat menghabiskan waktunya lebih dari dua j am ti ap harinya untuk sekedar mencari informasi, mencari kesenangan, dan berinteraksi dengan oranglain sehingga aktivitas yang dilakukan remaja di media sosial dapat mempengaruhi remaja untuk melakukan cyberbullying. b. kemampuan empati pelaku hasil penelitian ini menunjukkan bahwa kemampuan empati mempengaruhi remaja dalam melakukan cyberbullying. informan menunjukkan tidak adanya rasa bersalah terhadap korban, selain itu informan tidak menunjukkan adanya keinginan untuk memahami perasaan yang dirasakan oleh korban. empati merupakan kemampuan seseorang untuk memikirkan atau merasakan perasaan emosi yang dirasakan oleh oranglain baik secara afektif maupun kognitif. remaja yang terlibat dalam perilaku bullying secara langsung memiliki empati yang lebih rendah khususnya empati afektif (garandeaul dkk., 2016). kemampuan empati yang rendah pada pelaku cyberbullying membuatnya mendapatkan perasaan puas karena melihat korbannya tidak berdaya akibat perbuatan yang dilakukan oleh pelaku (faucher, jackson & cassidy, 2014). perkembangan kognitif remaja yang belum matang menyebabkan remaja belum memiliki kemampuan untuk mengatur diri nya sendiri ataupun menghormati oranglain sehingga tindakan yang dilakukan remaja di media sosial bisa menjadi tidak tepat dan dapat menyakiti oranglain tanpa memikirkan perasaan korbannya (deursen et al., 2015). selain itu dari hasil penelitian terdapat informan yang menunjukkan adanya rasa bersalah dan memahami perasaan korban. rachmah (2014) menjelaskan sikap empati pelaku cyberbullying dapat ditingkatkan dengan merubah persepsi pelaku terhadap korban dan merubah pola pikir pelaku dan mencoba menempatkan diri sebagai korban sehingga kemampuan empati yang dimili ki o l e h pelaku tinggi. vol. 2 no. 1 juni 2018 45 c. karakter korban hasil penelitian ini menunjukkan bahwa informan melakukan cyberbullying pada teman dekatnya karena menganggap bahwa temannya tidak akan marah dan menganggap perilaku cyberbullying merupakan hal yang wajar. sartana & helmi (2014) menjelaskan dalam berinteraksi dengan oranglain remaja mempertimbangkan karakter teman dan situasi untuk menentukan perilaku yang sesuai menurutnya. selain itu, ketika bersama teman remaja juga cenderung lebih merasa nyaman, bebas berekspresi, dan segala sesuatu yang dilakukan hanya dianggap sebagai bahan candaan. hasil penelitian ini juga menunjukkan informan melakukan cyberbullying disebabkan karena informan pernah dipermalukan juga oleh korbannya dan telah mengganggu kehidupan informan. kartono (2013) menjelaskan motivasi pelaku melakukan cybebrullying di media sosial adalah sebagai balas dendam karena pelaku merasa dendam yang dirasakannya tidak terselesaikan dan merasa tergganggu ketentramannya sehingga pelaku mebalasnya dengan perbuatan cyberbullying. kowalski et al. (2014) menjelaskan remaja yang pernah menjadi korban cyberbullying dapat beresiko untuk menjadi pelaku cyberbullying di media sosial. 3. respon korban cyberbullying di instagram hasil penelitian ini menujukkan bahwa remaja yang menjadi korban cyberbullying memberik an respon seperti sakit hati, tidak peduli, dan senang. informan mengatakan tidak peduli terhadap situasi yang dialaminya sebagai korban cyberbullying karena tidak ingin memperkeruh suasana dan memilih untuk tidak melakukan perlawanan apapun. menurut putra & ariana (2016) remaja yang menjadi korban cyberbullying berusaha untuk mengatur perasaan yang dialaminya dengan mengacuhkan stress yang ada dan menghindari kemungkinan untuk membalas tindakan cyberbullying yang dialaminya terhadap pelaku. hal tersebut menunjukkan bahwa kematangan emosi mempengaruhi perasaan remaja sebagai korban. bonanno & hymel (2013) menjelaskan strategi yang digunakan oleh para korban cyberbullying salah satunya adalah mengabaikan kejadiankejadianya yang dialaminya dan memfokuskan perhatian pada hal-hal lain yang membuatnya senang. selain itu, hasil peneli tian juga menunjukkan bahwa korban menganggap komentar-komentar pelaku yang ditujukan kepadanya di kolom komentar instagram hanya sebagai candaan. bottino dkk., (2015) menjelaskan bahwa perilaku cyberbullying memiliki respon negatif terhadap kesehatan mental individu. pandangan pelaku terhadap respon korban ataupun respon ko rb an terhadap perilaku cyberbullying yang dilakukan oleh pelaku hampir sama. baik pe laku ataupun korban menganggap respon yang muncul adal ah sedih, takut, dan marah akibat dari perilaku cyberbullying. namun ada juga pelaku atau korban yang merasa bahagia terhadap perilaku cyberbullying yang terjadi karena pelaku atapun korban menganggap perilaku cyberbullying tersebut hanya sekedar bahan untuk bercanda. 4. dampak cyberbullying pada korban di instagram hasil penelitian ini menunjukkan bahwa perilaku cyberbullying memberikan dampak terhadap remaja. informan menjelaskan bahwa cyberbullying yang dialami akan memberikan dampak terhadap sekolah yaitu remaja menjadi kurang memperhatikan pel ajaran di sekolah. anonim (2013) menjelaskan remaja yang sering menjadi korban cyberbullying akan mengubah pola pandangnya mengenai sekolah. sekolah yang tadinya dianggap remaja sebagai tempat untuk menuntut ilmu, menambah pengalaman bersosialisasi, dan mencari teman berubah menjadi tempat yang tidak disukai oleh remaja yang menjadi korban cyberbullying. remaja mengalami penurunan kemampuan untuk fokus dan aktif di kelas karena mereka memikirkan mengenai apa yang sudah mereka alami dan memikirkan akan kembali dijadikan sebagai objek cyberbullying oleh pelaku. hasil penelitian ini juga menunjukkan bahwa informan yang menjadi korban cyberbullying menjadi tidak percaya diri. cyberbullying memberikan damp ak yang negatif kepada remaja. remaja yang mengalami penurunan harga diri dapat dijadikan sebagai indikator dari dampak negatif bahwa remaja pernah menjadi korban cyberbullying (hinduja & patchin, 2015). indonesian journal of nursing practices 46 remaja yang tidak percaya diri selalu mengkhawatirkan apa yang akan dilakukan oranglain terhadap dirinya di media sosial. namun berbeda dengan remaja yang memiliki kepercayaan diri yang tinggi cenderung akan menghabiskan waktunya untuk tidak mengkhawatirkan perlakuan oranglain terhad ap dirinya di media sosial, remaja akan lebih membangun citra diri yang lebih positif di med ia sosial (fazriyati, 2013). selain itu bauman, toomey, & walker (2013) menjelaskan cyberbullying dapat memberikan dampak negatif yang lebih berat lagi terhadap korban seperti isolasi sosial, depresi, menyakiti dirinya s e n d iri, penggunaan narkotika, dan remaja bisa memilik i ide bunuh diri karena tidak kuat mengalami tekanan yang diterimanya. 5. koping korban cyberbullying di instagram hasil penelitian ini menunjukkan bahwa koping remaja sebagai korban cyberbullying di media instagram seperti bermain bersama teman, bermain handphone, dan bermain game. informan menjelaskan lebih memilih bermain handpohone, bermain game dan bermain bersama teman untuk menghilangkan perasaan sedihnya daripada membalas atau mempedulikan pelaku. adiyanti (2014) menjelaskan kemampuan remaja dalam mengelola emosi dapat membantunya untuk mengontrol diri agar tidak terlibat dalam perilaku yang negatif ketika sedang mengalami tekanan. machackova dkk. (2013) menyebutkan bahwa remaja lebih memilih strategi koping yang dapat menghilangkan emosi negatif pada dirinya. strategi koping positif yang dilakukan oleh remaja yaitu emotional-focused coping dengan distancing dimana remaja memfokuskan diri untuk menjauhi permasalahan yang dialaminya untuk mendapatkan perasaan positif bagi dirinya seperti bermain playstation, sepak bola, dan pergi bersama teman-temannya karena dapat membuat perasaan sedih yang sedang dialaminya menjadi hilang (putra & ariana, 2016). berbeda dengan perren.,dkk (2012) yang menyebutkan bahwa remaja melibatkan orangorang sekitar sebagai dukungan sosial seperti orang dewasa, guru, teman atau lembaga ekternal sebagai strategi remaja untuk mengatasi cyberbullying. kesimpulan perilaku cyberbullying dengan media sosial instagram di kalangan remaja seperti seperti mengupload foto, berkomentar kasar, mengupdate instastory, dan mengomentari foto dengan menggunakan kata-kata kasar. jenis cyberbullying tersebut dipengaruhi oleh faktorfaktor seperti intensitas penggunaan media sosial, karakter korban cyberbullying, dan kemampuan empati korban. sehingga respon remaja yang muncul akibat cyberbullying seperti sakit hati, tidak peduli, dan senang. remaja yang menjadi korban cyberbullying akan merasakan dampaknya seperti kurang memperhatikan di sekolah dan tidak percaya diri. remaja membuat koping untuk menghilangkan perasaan sedihny a dengan bermain bersama teman, bermain handphone, dan bermain game. saran bagi orangtua orangtua dapat membangun komunikasi yang efektif dengan remaja melalui pendekatan sehari-hari di rumah dan memantau kegiatan remaja di media sosial untuk mengetahui perkembangan dan permasalahan yang sedang dialami remaja sehingga orangtua dapat memberikan arahan dan nasihat kepada remaja agar terhindar dari perilaku cyberbullying. selai n itu, orangtua dapat memberikan dukungan moral terhadap remaja yang menjadi korban cyberbullying. bagi peneliti selanjutnya setelah dilakukan penelitian ini, diharapkan peneliti selanjutnya dapat melakukan interven si melalui promosi kesehatan di media sosial terkait perilaku cyberbullying sehingga dapat menekan tindakan cyberbullying yang terjadi di media sosial. daftar pustaka ariana, putra. 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(research press:2007). wolke d, skew a. family factors, bullying victimisation and well being in adilecents. longit life course stud 2012;3:101-119. jurnal mjn vol. 3 no. 1 juni 2016.indd 1 muhammadiyah journal of nursing yohanes andy rias1, elsye maria rosa2, falasifah ani yuniarti3 1) mahasiswa magister keperawatan universitas muhammadiyah yogyakarta 2) bagian fakultas kedokteran universitas muhammadiyah yogyakarta 3) bagian magister keperawatan universitas muhammadiayah yogyakarta pengembangan model konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer abstrak latar belakang: diabetic foot ulcer pada umumnya menyebabkan rendahnya self management behavior dan quality of life, yang memerlukan intervensi keperawatan untuk meningkatkan individual and family self management. intervensi ini merupakan proses perubahan perilaku pada penderita dan keluarga melalui pendidikan kesehatan. pendidikan kesehatan ini dilaksanakan melalui discharge planning dengan memberikan informasi, mengidentifi kasi kebutuhan dan merencanakan kepulangan serta mempersiapakan partisipan untuk meninggalkan pelayanan kesehatan dimulai saat masuk sampai pulang termasuk klien diabetic foot ulcer. tujuan penelitian: pengembangan model konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer. motode penelitian: penelitian ini menggunakan desain action research dengan pengumpulan data melalui the conceptual content cognitive map (3cm) dan triangulasi dilanjutkan dengan penyajian data secara deskriptif. jumlah partisipan sebanyak 4 pasien dan 4 keluarga untuk pre action research dengan accidental sampling, 6 perawat untuk action research dengan purposive sampling, 4 pakar untuk triangulasi dengan accidental sampling, dan 10 perawat dan praktisi dengan accidental sampling untuk validasi tools konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer. hasil: terdapat kategori kebutuhan partisipan dalam individual and family self management antara lain: (a) pengetahuan, (b) keyakinan, (c) regulasi diri, (d) fasilitas sosial, (e) self management behavior. hasil dari action research adalah tersusun tools konservasi discharge planning terstruktur dengan 4 siklus penelitian. kesimpulan dan saran: tersusun tools konservasi discharge planning terstruktur diharapkan dapat meningkatkan individual and family self management. perlu dilakukan penerapan dan validasi terhadap tools model konservasi discharge planning terstruktur. kata kunci: diabetic foot ulcer, tools, konservasi discharge planning terstruktur, individual and family self management. abstract background : diabetic foot ulcers generally causing low self management behaviors and quality of life, requiring of nursing intervention to improve individual and family selfmanagement. the intervention is the process of behavioral changes in patients and families through health education. health education for participants and families can be implemented through discharge planning to provide the information, to identify needs and to plan the return and to prepare participants to leave the health service, beginning at admission until discharge, including diabetic foot ulcers client. objective: to develop a model of the structured discharge planning conservation for individual and family self-management of diabetic foot ulcers. research methodology: this study using action research design by collecting data through the conceptual content cognitive map (3cm) and triangulation followed by presenting descriptive data. the number of participants in this study are 4 patient and 4 family for pre action research with accidental sampling, 6 nursing for action research with purposive sampling, 4 experts for triangulation with accidental sampling, and 10 nursing and practitioners with accidental sampling for validation of structured discharge planning conservation tools for individual and family selfmanagement of diabetic foot ulcers. results: there are categories of participants needs in the individual and family selfmanagement, which are: (a) knowledge, (b) beliefs, (c) self-regulation, (d) social facilities, (e) self management behaviors. the results of action research is the completion of discharge planning conservation tools that structured by four cycles of study. conclusion: the presence of structured discharge planning conservation tools expected to increase individual and family self management. necessary to implementation and validatin of tools model structured discharge planning conservation keywords: diabetic foot ulcers, tools, structured discharge planning conservation, individual and family self management. 2 muhammadiyah journal of nursing pendahuluan diabetes mellitus (dm) merupakan penyakit g a n g g u a n m e t a b o l i s m e k a r b o h i d r a t ya n g berlangsung kronis dengan komplikasi diabetic foot ulcer 1. diabetic foot ulcer (dfu) merupakan kerusakan jaringan akibat gangguan neurologis (neuropati) dan vaskuler pada tungkai yang pada akhirnya menjalani amputasi dan mempengaruhi quality of life penderita 2,3,4. quality of life (qol) dipengaruhi pengetahuan, dukungan sosial, regulasi diri dan self behavior 5,6,7,8. h a s i l k o n s e n s u s i n t e r n a s i o n a l t e n t a n g manajeman dan pencegahan dfu dari beberapa negara seperti di inggris insiden dfu sebesar 7,4%, di belanda 2,1%, swedia 3,6% dan 5,8% di amerika serikat dari partisipan dm 9,10. insiden dfu di negara berkembang mencapai 2-4% kenaikan lebih tinggi dibandingkan dengan negara maju 11. insiden dfu tahun 2005 mencapai 25% dengan rentang kenaikan 1,9%-2,6% setiap tahunnya 12. kenaikan jumlah partisipan dfu di indonesia belum tercatat dengan jelas, namun dapat terlihat dari kenaikan prevalensi dm. world health organization (who) menyebutkan penderita dm pada tahun 2000 berjumlah 8,4 juta jiwa dan diprediksi meningkat menjadi 21,3 juta jiwa pada tahun 2030. berdasarkan angka tersebut dapat diprediksi jumlah penderita dm yang mengalami dfu dengan tingkat resiko 25% mencapai 5,3 juta jiwa 13. berdasarkan profil dan informasi layanan rsud dr. moewardi surakarta tahun 2006 terdapat penderita dm sebesar 13.968 pada tahun 2005 dan meningkat tahun 2006 menjadi 15.365 penderita, diantaranya menderita dfu pada tahun 2005 sebesar 362 penderita dan meningkat pada tahun 2006 menjadi 487 penderita. data di bangsal dan poli bedah rsu dr. saiful anwar malang, menyebutkan bahwa dfu mengalami peningkatan sebanyak 11,8 % dari 118 kasus pada 6 bulan pertama menjadi 132 kasus pada 6 bulan kedua tahun 2011. data yang diperoleh di pku muhammadiyah unit ii terdapat 29 penderita dfu pada tahun 2012, 40 penderita dfu pada tahun 2013, dan pada tahun 2014 (januari-maret) terdapat 8 penderita dfu yang menjalani pengobatan rawat inap. pengobatan dfu berfungsi untuk mencegah dan meminimalisasi komplikasi akut maupun kronik yang berdampak pada self behavior dan qol 4, 6,7,8, 16. berdasarkan penelitian wijanarko (2012) dari 23 partisipan dfu sebanyak 15 partisipan (65,22%) dalam kategori pengetahuan kurang. penelitian souza (2013) menyatakan bahwa partisipan dfu memiliki keterbatasan aktifi tas dan kemauan yang rendah dalam melakukan kegiatan seharihari. pengetahuan dan kemauan yang rendah dapat digunakan sebagai tolak ukur dalam menilai self behavior. berdasarkan penelitian costa (2011) 10 partisipan dfu merasa kurang mendapatkan pendidikan tentang pengelolahan penyakitnya, presepsi negatif terhadap status kesehatan dan kesejahteraannya sehingga qol dalam kategori rendah. hasil penilaian qol partisipan dfu dari kategori dimensi fi sik sebesar 50%, dimensi sosial sebesar 25%, dimensi lingkungan sebesar 24%, dan dimensi psikologis sebesar 65% masing masing dalam kategori rendah. studi pendahuluan telah penulis lakukan pada 26 maret 2014, pukul 09.00 wib melaui wawancara 4 partisipan dfu beserta keluarga partisipan di ruang rawat jalan pku muhammadiyah unit ii yogyakarta, partisipan berusia rata-rata 56 tahun terdiri dari 2 pria dan 2 wanita yang menderita dm lebih dari 3 tahun dan mengalami dfu satu tahun terakhir. keluarga partisipan berumur rata-rata 33 tahun kesemuanya wanita. seluruh partisipan dalam pengobatan menggunakan obat oral, keseluruhan tidak pernah berolahraga, akan tetapi satu partisipan rajin memeriksakan kadar gula darah dan satu partisipan merasa terkadang bosan dalam pengobatan. ketiga partisipan mengalami masalah dalam pengaturan nutrisi dan merasa dibatasi untuk makan sesuai dengan keinginan. partisipan merasa menjadi beban keluarga dan rendah diri. partisipan dfu 3 muhammadiyah journal of nursing dan keluarga mengalami kebingungan tentang perawatan di rumah setelah keluar dari rumah sakit dan terkadang merasa letih serta bosan dalam pengelolahan dfu. hasil dari wawancara di atas bahwa partisipandfu mengalami masalah bosan dalam pelaksanaan pengobatan, merasa menjadi beban keluarga dan rendah diri, sedangkan keluarga terkadang merasa letih dan bosan dalam merawat partisipan serta kebingungan dalam melakukan perawatan di rumah. kesimpulan dari hasil wawancara adalah self management individu dan keluarga pada partisipan dfu dalam kategori rendah. menurut ryan & sawin (2009) individual and family self management merupakan proses perubahan perilaku pada penderita dan keluarga melalui pendidikan kesehatan meliputi proses self management (pengetahuan dan kepercayaan), hasil proksimal (self behavior) dan hasil distal (qol). pendidikan kesehatan bagi partisipan dan keluarga dapat dilaksanakan melalui discharge planning untuk memberikan informasi, mengidentifi kasi kebutuhan dan merencanakan kepulangan serta mempersiapakan partisipan untuk meninggalkan pelayanan kesehatan dimulai saat masuk sampai pulang dari rumah sakit 7,17, 18. layanan keperawatan di indonesia telah merancang format discharge planning, namun format dan pelaksanaanya hanya dalam bentuk pendokumentasian resume partisipan pulang, berupa informasi seperti intervensi medis dan non medis, jadwal kontrol, gizi yang harus dipenuhi setelah di rumah. cara tersebut merupakan pemberian informasi ke partisipan dan keluarga hanya untuk sekedar tahu dan mengingatkan, namun tidak menjamin partisipan dan keluarga mengetahui serta memahami faktor resiko yang dapat membuat penyakitnya kambuh, penanganan kegawatdaruratan terhadap kondisi penyakitnya, perawatan maintenance di rumah yang menyebabkan tingginya angka rehospitalisasi 19. terkait dengan individual and family self management serta pelaksanaan discharge planning di atas, maka peneliti memberikan solusi alternatif dengan mengembangkan konservasi discharge planning terstruktur. konservasi discharge planning terstruktur merupakan modifikasi discharge planning dengan konservasi myra e. levine yang meliputi 4 tahap yaitu knowledge analyse, discusion of needs, role play dan integrated evaluation. knowledge analyse yaitu item tools yang bertujuan bagaimana perawat mampu untuk mengetahui dan mampu menganalisis pengetahuan dan keyakinan partisipan dan k e l u a r g a t e n t a n g d f u s e p e r t i k o n s e r va s i integritas energi (pengunaan dan efek samping obat, penggunaan obat alternatif, program diet, dan istirahat), konservasi integritas struktural (rom, penilaian vaskularisasi, perawatan luka, personal hygine, dan manajemen nyeri), konservasi integritas personal (pengertian penyakit, tanda dan gejala, komplikasi, klasifikasi wagner, pengelolahan kecemasan dan spritual, fl eksibilitas diri serta autonomi), konservasi integritas sosial (peranan keluarga, hubungan sosial dan modifi kasi lingkungan). berdasarkan uraian di atas maka peneliti tertarik untuk melaksanakan pengembangan model konservasi discharge planning terstruktur yang merupakan strategi kombinasi kekuatan individu dan keluarga serta perawat sebagai educator diharapkan dapat memperbaiki self management individu dan keluarga meliputi proses self management (pengetahuan dan kepercayaan, kemampuan regulasi diri, dan fasilitas sosial), hasil proksimal (self behavior ) dan hasil distal (qol) pada partisipan dfu dan keluarga sebagai penelitian dengan action research. rumusan masalah b a g a i m a n a k a h p e n g e m b a n g a n m o d e l konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer di pku muhammadiyah unit ii yogyakarta. 4 muhammadiyah journal of nursing tujuan penelitian tujuan umum pengembangan model konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer di pku muhammadiyah unit ii yogyakarta. tujuan khusus 1) mengetahui kebutuhan partisipan dan keluarga terhadap individual and family self management diabetic foot ulcer di pku muhammadiyah unit ii yogyakarta. 2) mengetahui dan menyusun format tools discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer. 3) mengetahui tingkat pengetahuan praktisi dan perawat luka tentang konsep discharge planning dan individual and family self management diabetic foot ulcer. 4) mengetahui review format tools konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer kepada praktisi dan perawat luka. 5) mengetahui validasi kebutuhan partisipan dan keluarga terhadap individual and family self management diabetic foot ulcer yang telah dilengkapi dengan kebutuhan praktisi dan perawat. 6) mengetahui hasil triangulasi tools konservasi discharge planning terstruktur. 7) memberikan rekomendasi untuk meningkatkan self management individu dan keluarga pada partisipan diabetic foot ulcer di pku muhammadiyah unit ii yogyakarta. metode penelitian desain yang digunakan dalam penelitian ini terdiri dalam dua tahap, rancangan tahap pre action research menggunakan penelitian kualitatif dengan metode the conceptual content cognitive map (3cm) dilanjutkan dengan wawancara dan penyajian data secara deskriptif dan tahap kedua adalah action research dengan 4 tahapan siklus. lokasi dan waktu penelitian dilakukan di pku muhammadiyah unit ii gamping dan wilayah kabupaten bantul pada tanggal 05 juni 2014 sampai dengan 05 april 2015. variabel bebas dalam penelitian ini adalah konservasi discharge planning terstruktur, sedangkan variabel terikat adalah individul and family self management. adapun defi nisi operasional dalam penelitian ini antara lain: 1) konservasi discharge planning terstruktur adalah paket belajar mandiri yang meliputi materi pembelajaran yang dirancang dan dilaksanakan s e c a r a s i s t e m a t i s u n t u k m e m e n u h i s e l f management individu dan keluarga dalam mempersiapkan kepulangan melaui 4 tahap meliputi: knowledge analyse, needs of discusion, role play dan integrated evaluation pada klien diabetic foot ulcer (dfu) di ruang medikal bedah pku muhammadiyah unit ii gamping. 2) individual and family self management adalah informasi pengelolahan diri dan keluarga dalam membentuk perilaku self management penderita diabetic foot ulcer yang meliputi: a. p r o s e s s e l f m a n a g e m e n t , m e l i p u t i pengetahuan dan kepercayaan (selfeffi cacy, outcome expectancy, dan keselarasan tujuan); kemampuan regulasi diri (penetapan tujuan (goal sett ing), pengambilan keputusan dan kontrol emosi); fasilitasi sosial (pengaruh sosial, dukungan sosial, dan kolaborasi) b. hasil proksimal: self behaviour adalah aktivitas responden dalam perawatan mandiri penderita dfu dalam 7 hari terakhir meliputi penilaian meliputi : diet, aktivitas fi sik, pengobatan, kontrol gula darah dan perawatan dfu. c. h a s i l d i s t a l : q u a l i t y o f l i f e a d a l a h kemampuan responden untuk melakukan f u n g s i h i d u p n ya s e c a r a n o r m a l d i masyarakat menurut persepsi penderita dfu dengan penilaian berdasarkan who tahun 2003, meliputi: aspek fi sik (nyeri dan kenyamanan, kekuatan dan kelemahan, 5 muhammadiyah journal of nursing aktivitas seksual, istirahat dan tidur, fungsi sensoris); aspek psikologis (pikiran positif, pikiran, belajar, ingatan dan konsentrasi, harga diri, penampilan, perasaan negatif); h u b u n g a n s o s i a l ( h u b u n g a n s o s i a l , d u k u n g a n s o s i a l , a k t i v i t a s p e m b e r i pelayanan); lingkungan (kenyamanan fi sik, lingkungan rumah dan kondisi rumah, kepuasan kerja). instrumen dan metode yang digunakan dalam penelitian ini untuk menangkap kebutuhan partisipan dan keluarga dalam penatalaksanaan dfu adalah sebagai berikut: 1) wawancara dengan metode 3cm untuk mengklarifikasi dan menemukan secara mendalam isi dari persepsi kebutuhan partisipan. partisipan ditanya pertanyaan berdasarkan data respon mereka yang terdaftar pada metode 3cm. wawancara ini bertujuan untuk meningkatkan pemahaman peneliti tentang persepsi kebutuhan partisipan terhadap penatalaksanaan dfu. selama wawancara, peneliti mencatat temuan baru terkait dengan konten 3cm pada selembar kertas terpisah. pada akhir wawancara, lembar-lembar yang didapat ditempelkan ke peta 3cm. 2) perekam suara digunakan untuk merekam data dalam sesi wawancara tipe voice recorder 3gpp. 3) format konservasi discharge planning terstruktur yang akan dilakukan perbaikan format melalui action research a. knowledge analyse yaitu bagaimana seorang p e r a wa t m a m p u u n t u k m e n g e t a h u i dan mampu menganalisis pengetahuan partisipan dan keluarga tentang dfu seperti konservasi integritas energi (diet, aktivitas terkontrol, obat dan efek samping), konservasi integritas struktural (rom, perawatan luka, personal hygine, manajemen nyeri), konservasi integritas personal (goal congruence, outcome expectancy, self effi cacy, self regulation dan menjaga privasi partisipan), konservasi integritas sosial (sosial influence, sosial support, negotiated collaboration, rekreatif). b. discusion of needs yaitu melakukan diskusi antara perawat dengan partisipan dfu d a n k e l u a r g a m e n g e n a i k e b u t u h a n perawatan baik di rs maupun di rumah sesuai dengan penilaian dalam knowledge analyse karena juga merupakan kebutuhan yang dikehendaki sesuai konservasi energi, integritas struktural, integritas personal dan integritas sosial sesuai dengan knowledge analyse. c. role play dilakukan dengan melakukan demonstrasi dan skill pada partisipan dan keluarga dalam manajemen dfu seperti konservasi integritas energi (menu praktis dfu, pemaparan obat dan efek samping, jadwal kegiatan dan pengaturan istirahat), konservasi integritas struktural (rom ankle, perawatan luka, membalut luka, terapi suntik insulin, relaksasi nafas dalam, dzikir khafi , seterilisasi alat), konservasi integritas personal (goal congruence, outcome expectancy, self effi cacy, self regulation), dan konservasi integritas sosial (berkeluh kesah kepada orang terdekat yang dipercayai, keluarga mampu menfasilitasi emosional, dan instrumental, dan dapat melakukan kerjasama antara perawat, kelurga dan partisipan). d. integrated evaluation merupakan tahap terakhir yang berfungsi untuk mengevaluasi atau menilai tingkat kesiapan partisipan dan keluarga dalam manajemen perawatan dfu. dirumah yang dilihat dari nilai knowledge analyse, discusion of needs dan role play yang telah dilaksanakan selama perawatan serta skrining faktor resiko pasien pulang. 4) kuesioner a. pengetahuan dan kepercayaan k u e s i n e r a ya n g t e r d i r i d a r i 2 0 i t e m pertanyaan, yang terdiri dari 7 item pertanyaan 6 muhammadiyah journal of nursing tentang self effi cacy, 6 item pertanyaan tentang harapan hasil dan 7 item pertanyaan tentang keselarasan tujuan. pertanyaan tentang self effi cacy dan harapan hasil diadaptasi dari the multidimensional diabetes questionnaire section iii yang dirancang untuk menilai faktor sosial dan kognitif terkait diabetes. pertanyaan tentang self-efficacy yang telah dimodifikasi oleh peneliti terdiri dari tujuh item pengukuran kepercayaan pasien dalam kemampuan mereka untuk melakukan perilaku khusus untuk aktivitas perawatan diri diabetes (yaitu, diet, olahraga, obat-obatan, pemantauan glukosa darah, perawatan kaki dengan foot ulcer dan manajemen diabetes). tanggapan didasarkan pada skala 1 (tidak yakin) sampai 4 (sangat yakin). pertanyaan tentang outcome expectancy (harapan hasil) dari mdq yang telah dimodifikasi peneliti terdiri dari enam item penilaian persepsi pasien dari efek perilaku perawatan diri diabetes pada kontrol metabolik dan pencegahan komplikasi diabetes. tanggapan didasarkan pada skala 1 (tidak berharap sama sekali) sampai 4 (selalu berharap). pertanyaan tentang keselarasan tujuan dari the goal instability scale yang telah dimodifi kasi oleh peneliti terdiri dari 7 pertanyaan untuk menilai kemampuan seseorang dalam menyelesaikan kebingungan dan kecemasan terkait dengan tujuan kesehatan. jawaban didasarkan pada skala 1 (selalu) sampai 4 (tidak pernah) 21. 5) kuesioner b. kemampuan regulasi diri kuesioner kemampuan egulasi diri telah dimodifikasi dari the short self regulation questionnaire (ssrq) terdiri dari 25 item pertanyaan dengan skala likert 1-4 22. pertanyaan positif dengan nilai 1 : sangat tidak setuju; 2 : tidak setuju; 3 : setuju; dan 4 : sangat setuju. pertanyaan negatif dengan nilai 4 : sangat tidak setuju; 3 : tidak setuju; 2 : setuju; dan 1 : sangat setuju. 6) kuesioner c. fasilitasi sosial kuesioner fasilitasi sosial terdiri dari 26 item pertanyaan yang terdiri dari 5 item pertanyaan tentang pengaruh sosial, 14 pertanyaan tentang dukungan sosial keluarga dan 7 pertanyaan tentang kolaborasi pasien perawat. pertanyaan tentang pengaruh sosial dimodifi kasi dari social infl uence on health behaviors questionairre yang berisi tentang utilitarian influence dan informational infl uence. nilai 1 ; sangat tidak setuju, 2; tidak setuju, 3 : setuju, 4 : sangat setuju23. pertanyaan tentang dukungan sosial keluarga dimodifikasi dari diabetes family behaviour checklist 24. nilai 1 ; tidak pernah, 2; jarang, 3 : sangat sering, 4 : selalu. pertanyaan tentang kolaborasi dengan. nilai 1 ; tidak pernah, 2; jarang, 3 : sangat sering, 4 : selalu. 7) kuesioner d. self management behavior kuesioner sdsca digunakan untuk mengukur self care behavior atau perilaku perawatan mandiri pada penderita dm tipe 2 25. kuesioner ini terdiri dari 12 item pertanyaan dengan nilai tiap item 1-7. skor berada pada rentang 1284. kuesioner ini berisi tentang kemampuan perawatan mandiri pasien dm tipe 2 meliputi : diet (3 item), aktivitas fi sik (2 item), pengobatan (1 item), pengecekan gula darah (2 item) dan perawatan kaki (4 item). 8) kuesioner e. kualitas hidup (quality of life) kuesioner quality of life dari who yang dimodifi kasi terdiri dari 26 item pertanyaan dengan skala likert 1-4. nilai11; tidak yakin, 2; cukup yakin, 3 : yakin,4; sangat yakin. rentang skor adalah 26-104. kuesioner ini meliputi aspek fi sik (7 item), aspek psikologis (6 item), aspek hubungan sosial (5 item) dan aspek lingkungan (8 item) penderita diabetes melitus 26. berdasarkan hasil uji validitas oleh gitawati (2013) pada kuesioner a (pengetahuan dan kepercayaan) didapatkan nilai p < α (0,05) namun terdapat 5 item pertanyaan yang tidak valid, yaitu item pertanyaan 1, 4, 9, 10 7 muhammadiyah journal of nursing dan 16. hasil uji validitas pada kuesioner b (kemampuan regulasi diri) didapatkan nilai p < α (0,05) namun terdapat 7 item pertanyaan yang tidak valid, yaitu item pertanyaan 2, 9, 11, 14, 15, 17 dan 20. hasil uji validitas untuk kuesioner c (fasilitasi sosial) didapatkan nilai p < α (0,05) namun terdapat 5 item pertanyaan yang tidak valid yaitu pertanyaan 9, 12, 14, 23 dan 25. hasil uji validitas untuk kuesioner e (kualitas hidup) didapatkan nilai p < α (0,05) namun terdapat 5 item pertanyaan yang tidak valid yaitu pertanyaan 2, 5, 8, 10 dan 18. pertanyaan pada kuesioner yang tidak valid di keluarkan dari daftar pertanyaan pada kuesioner tersebut. uji reliabilitas kuesioner dalam penelitian ini adalah: tabel 1. hasil uji reliabilitas kuesioner kuesioner nilai peneliti uji cronbach reliabilitas alpha kuesioner a 0,900 kuesioner b 0,880 gitawati kuesioner c 0,923 (2013) kuesioner d 0,917 kuesioner e 0,917 pre action research the conceptual content cognitive map (3cm) draf tools i konservasi discharge planning terstruktur action research siklus i melalui tahapan x siklus (pelatihan dan diskusi konservasi dp terstruktur) siklus ii (review tools konservasi dp terstruktur) siklus iii (validasi kebutuhan partisipan terhadap ifmst) siklus iv draf tools ii (triangulasi) konservasi discharge planning terstruktur siklus v (uji coba tools ii a1 dan a2) siklus vi (uji coba tools ii b1 dan b2) siklus vii tools ii c (uji coba tools knowladge analyse) tools konservasi discharge siklus viii tools ii c planning terstruktur (uji coba tools discussion of needs) siklus ix tools ii c (uji coba tools role play) siklus x (uji coba tools ii d integreted evaluation) model konservasi discharge planning keterangan : batas penelitian terstruktur : penelitian selanjutnya gambar 1 : kerangka kerja action research: pengembangan model konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer. 8 muhammadiyah journal of nursing hasil dan pembahasan berdasarkan hasil penelitian tahap pre action research, maka dapat diketahui karateristik informan penderita dfu (p) dan keluarga (k) berdasarkan jenis kelamin, umur, tingkat pendidikan, pekerjaan dan lama menderita dfu dapat dilihat di tabel 4.1. tahap action research dibagi menjadi 3 kelompok informan yaitu : kelompok perawat sebagai analisis kebutuhan informan pre action research, kelompok triangulasi sebagai analisis dari pakar, dan kelompok perawat sebagai uji validitas dan rehabilitas tools yang di action researchkan. tabel 2. karateristik informan tahap pre action research no kode informan jenis karateristik jenis kelamin pendidikan usia pekerjaan lama dfu 1 p1 (l) slta 36 pegawai negeri 6 bulan k1 (p) sarjana 32 guru 2 p2 (p) slta 43 pedagang 6 bulan k2 (l) slta 23 pedagang 3 p3 (l) diploma 40 pensiunan 6 bulan k3 (p) slta 37 rumah tangga 4 p4 (p) slta 52 pedagang 6 bulan k4 (p) s-1 ekonomi 24 wiraswasta * sumber primer peneliti, 2014 tabel 3. karateristik informan tahap action research (perawat) no kode informan jenis karateristik jenis kelamin pendidikan usia lama jabatan pekerjaan 1 p1 (l) ners 26 3 tahun perawat luka 2 p2 (p) ners 26 3 tahun perawat luka 3 p3 (p) ners 32 3 tahun perawat luka 4 p4 (p) diploma 34 3 tahun kepala ruang 5 p5 (p) ners 41 8 tahun manager keperawatan 6 p6 (l) ners 39 6 tahun perawat luka sumber primer peneliti, 2014 tabel 4. karateristik informan tahap triangulasi no kode informan jenis karateristik jenis kelamin pendidikan usia lama jabatan pekerjaan 1 p1 (l) prof.spbp (k) 59 32 tahun praktisi 2 p2 (l) doktoral 46 19 tahun praktisi keperawatan 3 p3 (l) magister 40 18 tahun praktisi keperawatan 4 p4 (p) magister 39 16 tahun dosen keperawatan * sumber primer peneliti, 2014 9 muhammadiyah journal of nursing tabel 5. karateristik informan tahap validitas dan rehabilitas tools no kode informan jenis karateristik jenis kelamin pendidikan usia lama jabatan pekerjaan 1 p1 (l) ners 33 13 tahun kepala ruang 2 p2 (p) ners 41 25 tahun perawat luka 3 p3 (p) ners 37 11 tahun perawat luka 4 p4 (p) ners 29 3 tahun perawat luka 5 p5 (p) ners 27 2 tahun perawat luka 6 p6 (l) ners 39 6 tahun perawat luka 7 p7 (l) ners 35 3 tahun perawat luka 8 p8 (l) ners 26 2 ,5 tahun perawat luka 9 p9 (l) ners 33 4 tahun perawat luka 10 p10 (l) ners 35 7 tahun dosen dan perawat luka * sumber primer peneliti, 2015 setelah dilakukan penelitian kepada informan yaitu penderita dfu dan keluarga diperoleh hasil action research dengan 5 point kategori kebutuhan dengan 26 sub kategori dengan total 106 frekuensi peryataan kebutuhan individual and family self management diabetic foot ulcer dengan metode 3 cm (conceptual content cognitive map) 10 muhammadiyah journal of nursing kategori 1 : pengetahuan kategori kebutuhan individual and family self management diabetic foot ulcer ke 1 adalah pengetahuan antara lain konsep dasar penyakit, kegunaan obat yang dipakai, penggunaan obat alternatif dan komplementer, cara ganti balutan, cara suntik insulin, cara test gula darah dan tata cara tayamum dengan total frekuensi 11 peryataan. berikut quotasi informan mengenai kebutuhan pengetahuan konsep dasar penyakit yang di “ nggih bingung mas boten ngertos pencegahane kajenge boten parah” (p4) terdapat satu quotasi tentang menginginankan informasi kegunaan obat terhadap informan yaitu: “ beberapa obat yang saya terima dari perawat itu saya juga masih bingung” (p1) obat alternatif dan komplementer juga muncul dalam quotasi informan meskipun dengan frekuensi satu peryataan “ daun insulin niku digodhog dulu, dimasak, direbus njuk nanti diminum” (k3) “ ke ustadz-ustadz orang pintar gitu malah dikasih apa itu, pakai air minum gitu lah” (p1) berikut merupakan quotasi informan bahwa membutuhkan cara suntik insulin dengan quotasi sebagai berikut: “ ngenehi contohe nek disuntik ki ngene ki lho pak” (p1) cara menganti balutan juga menjadi salah satu kebutuhan dengan quotasi partisipan meskipun hanya terdapat 2 peryataan dengan 1 quotasi sebagai berikut: “ pengin ganti dhewe, penak teles apa...apa lukane bernanah, tur ganti lan ngobati dhewe” (p2) cara cek gula darah secara mandiri juga menjadi salah satu kebutuhan partisipan meskipun hanya terdapat 3 peryataan dengan 1 quotasi sebagai berikut: “ tahu darahnya naik turun, butuh diajari carane ngetes….” (p2) tata cara tayamum juga muncul dalam pernyataan informan meskipun dengan frekuensi satu peryataan dengan 1 quotasi sebagai berikut: “ tayamum, ngak ngerti carane ngono lho, lupa caranya” (p1) kategori 2 : keyakinan kategori kebutuhan individual and family self management diabetic foot ulcer ke 2 adalah keyakinan meliputi kepercayaan terhadap budaya dan orang lain, kemauan diri sendiri (niat), tawakal (pasrah dan berusaha), dan keyakinan untuk sembuh dengan total 7 frekuensi peryataan. percaya kepada orang lain dan budaya menjadi salah satu kebutuhan partisipan dengan total frekuensi 1 peryataan dengan 1 quotasi sebagai berikut: “ ana tangga sing omong coba alternatif ndhana aku ki yo ndhana saya juga ke sana, wis tak lakoni orang pintar” (p1) kemauan diri sendiri (niat) menjadi salah satu kebutuhan partisipan dengan total frekuensi 1 peryataan dengan 1 quotasi sebagai berikut: tawakal menjadi salah satu peryataan dalam kategori kepercayaan ini sebanyak 2 frekuensi dengan 1 quotasi sebagai berikut: “ …..yang penting saya berusaha aja, saya berusaha, pasrah itu tawakal gitu lah sampai sekarang ini” (p1) berikut merupakan peryataan informan bahwa menginginkan keyakinan untuk sembuh sebanyak 3 peryataan dengan 1 quotasi sebagai berikut: “ kalau punya penyakit itu kan harus optimis harus sembuh ya” (k4). kategori 3 : fasilitas sosial berikut merupakan peryataan informan bahwa membutuhkan dukungan sosial meliputi dukungan keluarga, kunjungan teman sebanyak 4 peryataan dengan quotasi sebagai berikut: “ butuh dikunjungi sama keluarga, sama temen dan itu kan napa nggih saged nambah semangat kula ngaten lho.” (p1) dukungan spritualitas juga muncul dalam peryataan informan tetapi 1 frekuensi saja berupa doa kesembuhan untuk partisipan baik dari keluarga maupun dari pemuka agama dengan quotasi, yaitu: 11 muhammadiyah journal of nursing “ doa dari keluarga, lah kemaren itu juga apa saya sampai ke kyai-kyai, ke ustadz-ustadz” (p1) dukungan perawat juga menjadi salah satu kebutuhan partisipan meskipun hanya terdapat 4 peryataan “ perawate niku, sing mbake niku mbok sing sumeh, terus nek apa ngenehi penjelasan, napa-napa ngaten niku sing sumeh lah, seng alus” (k1) “ nggih penjelasan dokter napa perawat kajenge boten tambah parah “ (p4) dukungan dokter juga menjadi salah satu kebutuhan partisipan meskipun hanya terdapat 3 peryataan “ ...kalih dijak omong-omong, bapake keluhannya apa gitu, penyakitnya gimana ho o” (k3) b e r i k u t p e r ya t a a n i n f o r m a n m e n g e n a i kebutuhan negoisasi kolaboratif 2 terdiri dari intimasi intelektual dan konfl ik peryataan dengan 1 quotasi sebagai berikut: “ obat wae kayak gitu. saya pengennya kaya gitu. lah sapa ngerti nek aku seneng diombe ngono kan malah cepet mari, nek disuntik ngono kan yo rung karuan juga to, wong aku wis wedi dhisik. lha karepku ki doktere terbuka gitu lho, sama dokternya terbuka” (p1) b e r i k u t p e r ya t a a n i n f o r m a n m e n g e n a i kebutuhan akan alas kaki yang sesuai dengan kondisi kaki sebanyak 2 peryataan dengan 1 quotasi sebagai berikut: “…..sandal biasa tu ndhak muat gitu, kalau ada sandal yang lebih besar” (k3) glukometer pribadi juga menjadi salah satu kebutuhan partisipan meskipun hanya terdapat 2 peryataan dengan 1 quotasi sebagai berikut: “ lebih enak gadhah alat piyambak, kangge cek priksa gula darahe” (p4) pelindung perban anti air menjadi salah satu kebutuhan partisipan namun hanya terdapat 1 pernyataan dengan 1 quotasi “ mau perban seng ndak tembus air, anti air, ada gak ya…” (p1) berikut merupakan peryataan informan bahwa menginginkan perkembangan luka melalui foto sebanyak 1 peryataan dengan 1 quotasi sebagai berikut: “ … diweruhke lah fotone napa kan enten buktine wis marine sepira” (k1) akses pelayanan kesehatan dan home care juga menjadi kebutuhan dari partispan yang mempunyai 4 peryataan dengan 1 quotasi sebagai berikut: “ ke puskesmas jauh, daripada jauh-jauh repot, perawat suruh dateng ke rumah ngerawat di rumah” (k2) standart kegiatan yang terdiri dari 1 peryataan dengan quotasi sebagai berikut “ …dadi mbok ada, apa jenenge kuwi aturan sing padha ki apa jenenge, dadine ki le mengerjakan pekerjaan ki bisa sama” (k1) catatan tes darah merupakan peryataan partisipan sebanyak pemantauan gula darah, kolesterol, asam urat dan tekanan darah diperoleh sejumlah 7 peryataan, berikut salah satu quotasi informan: “ kepengin ngertos mas perkembangan gula darah, terus kalih tensi, terus kalih kolesterol” (p4) pemantauan asam urat diperoleh sejumlah 2 peryataan, berikut adalah salah satu quotasi informan: “ pengennya tau asam uratnya, biar kakinya tidak kesemutan dan cekot-cekot” (p3). kategori 4 : regulasi diri kategori kebutuhan individual and family self management diabetic foot ulcer ke 5 adalah regulasi diri yang terdiri dari penetapan tujuan, fl eksibilitas diri, autonomi, salutogenesis (mengenali masalah, mencari solusi, dan mengambil keputusan) dan kontrol pikiran (percaya diri, pikiran positif, pengelolahan stress: melihat tv, pergi berlibur, keliling rumah sakit). penetapan tujuan dan fleksibilitas menjadi salah satu kebutuhan partisipan dengan gabungan quotasi sebagai berikut: “ pengen mari, kepengin sembuh. dadi aku ki yo golek obat ki yo kepiye carane saya di rumah sakit sana kok nggak sembuh saya pindah” (p1). salutogenesis meliputi mengenali masalah, mencari soslusi, dan menetapan solusi menjadi 12 muhammadiyah journal of nursing salah satu kebutuhan partisipan dengan gabungan quotasi sebagai berikut: “ dadi aku ki yo golek obat ki yo kepiye carane saya di rumah sakit sana kok nggak sembuh saya pindah, saya di rumah sakit ngendi to kae, ning pku terus ning kono rada mendhing ning kok yo nggak kelong-kelong. ana tangga sing omong coba alternative ndhana aku ki yo ndhana saya juga ke sana. pernah tak coba kon mangan godhong kon mangan apa yo wis tak lakoni. yo intine ki ngene lho apa eee kita pandai-pandai, pandai-pandai mencari obat, mencari tempat pengobatan yang bagus, yo istilahe apa yo nek diomongke ki, nah berusaha, berusaha mencari tempat pengobatan yang bagus yang baik (p1) autonomi menjadi salah satu kebutuhan partisipan yaitu sebagai berikut: “ mbok pendapatku itu yo dihargailah karo doktere apa kepiye dihormatilah” (p1) berpikir positif dan percaya diri juga menjadi salah satu kebutuhan partisipan meskipun hanya terdapat 2 peryataan dengan gabungan 1 quotasi yaitu: “ banyak pikiran bikin gula darah naik juga, jadi gini lho pikirannya tu nggak optimis” (k4) “ isa tak suntik dhewe apa bojoku sing nyuntik ngono kuwi ki aku isa tambah pede” (p1) pengelolahan stres juga menjadi salah satu kebutuhan partisipan meskipun hanya terdapat 1 peryataan melalui 1 quotasi berikut ini: “ pengin keluar, main itu apa jalan-jalan, makan malam bersama ndhak stres” (p2). kategori 5 : self management behavior kategori kebutuhan individual and family self management diabetic foot ulcer ke 5 adalah self management behavior yang terdiri dari olahraga, seks, istirahat, jadwal minum obat, rawat luka seperti manajemen balutan (membuang jaringan mati, kontrol bau, dan kontrol eksudat) serta pola makan meliputi jadwal makan dan menu makanan (tinggi protein, pengganti nasi/rendah karbohidrat dan rendah gula). kategori kebutuhan individual and family self management diabetic foot ulcer salah satunya adalah olahraga yang terdiri dari 1 quotasi “ kaki nak untuk tiduran bengkak ta malahan, enake ta jalan-jalan” (p2) kebutuhan seks dengan total frekuensi 1 peryataan menjadi salah satu kebutuhan partisipan dalam individual and family self management diabetic foot ulcer dengan quotasi sebagai berikut: “ ya intinya saya pengen berhubungan kaya gitu, hubungan suami istri ngono lho.” (p1) kategori kebutuhan individual and family self management diabetic foot ulcer adalah istirahat yang terdiri dari 1 peryataan saja. berikut peryataan informan mengenai kebutuhan akan istirahat sebanyak 1 quotasi “ soale kalau terlalu banyak jalan lukanya nganu lagi buka lagi” (k4). kebutuhan akan adanya jadwal obat juga diperlukan oleh para informan, salah satunya adalah berikut merupakan quotasi: “ perawat ngasih ngertos mas, nggih minum obat sami jam pinten kajenge teratur” (p4). rawat luka dalam manajemen balutan meliputi membuang jaringan mati, kontrol bau dan eksudat didapatkan sejumlah 1 quotasi, berikut ini peryataan informan: “ buang item-item sama itu perawatnya sama mas febinya ya buang yang hitamhitam biar bau dan yang iku apa kering item itu jadi putih, ho o meskipun disisakke yang sehat, ho o, sama itu yang ada lendirnya, lendir kuning ta itu dibuang, ho o itu biar bersih dan cepet kering nggak bau ” (p2). penanganan nyeri didapatkan 4 peryataan, berikut salah satu quotasi informan: “ langsung cekot-cekot tak kasih minum asam mefamat, antalgin itu bisa tho mas ” (p2). pola makan menjadi kebutuhan partisipan meliputi dua sub tema yaitu jadwal makan dan menu makanan. berikut merupakan peryataan informan bahwa membutuhkan jadwal makanan dengan quotasi sebagai berikut: “ jam segini udah nggak boleh makan juga harus tau kan kalau dm itu” (k4). 13 muhammadiyah journal of nursing menu makanan berdasarkan kebutuhan partisipan meliputi pengganti nasi atau rendah karbohidrat, tinggi protein, rendah gula dan resep makanan dm dengan total frekuensi sebanyak 9 peryataan. terdapat 2 peryataan tentang pengganti nasi didapatkan 1 quotasi dari informan yaitu: “ nasinya cuma terbatas, cuma berapa...berapa kali berapa sendok gitu ya” (k4). terdapat 1 peryataan akan kebutuhan akan protein yang tinggi dengan 1 quotasi: “ kan harusnya itu lho kayak, tuna, udang, cumi itu kan disaranin malahan” (k4). rendah gula juga muncul dalam peryataan informan dengan quotasi , yaitu: “ gula putih nggak. ho o.buah yang tidak terlalu manis ” (k4). resep makanan juga muncul dalam peryataan informan dengan 3 frekuensi berikut quotasi dari partisipan, yaitu: “ disuda napa boten dingge dhaharan ngaten mawon... oo niku resepe makanan sik boleh dimakan” (k3). draf tools konservasi discharge planning terstruktur tools mengacu pada teori konservasi myra e levine yang dikombinasikan dengan teori individual & family self management. draf ini belum dilakukan tahapan action research, hanya disusun berdasarkan telaah literatur dan hasil kualitatif (pre action). tools konservasi discharge planning terstruktur terdiri dari 3 bagian yaitu skrinning awal, implementasi dan evaluasi yang akan dipaparkan dalam paragraf-paragraf berikutnya. berdasarkan hasil wawancara dan literatur dalam formulir a (skrining konservasi discharge planning terstruktur) yang meliputi skrining, tinggi resiko perawatan, resiko jatuh, resiko dekubitus, dan pic. skrining awal diperlukan orientasi oleh anggota tim medis yang menangani, hak dan kewajiban klien serta penjelasan terhadap tindakan medis. skrining digunakan menentukan tindak lanjut lebih dini dalam penyusunan program pencegahan dan pembatasan yang dapat diimplikasikan pada discharge planning. discharge planning bertujuan mengidentifi kasi kebutuhan dalam mempertahankan fungsi maksimal setelah pulang melalui proses pengkajian berkelanjutan 19, 27. m e m p e r k e n a l k a n t i m m e d i s d e n g a n mengorientasi, menjelaskan hak dan kewajiban klien merupakan langkah awal dari perawatan prosedur discharge planning, kemudian dilakukan pengkajian terhadap keluhan utama yang dirasakan klien. hal tersebut difungsikan untuk menentukan tindakan umum yang akan dilakukan sebagai dasar pelaksanaan spesifi k dalam mereduksi keluhan utama. sistem pendukung sosial diperlukan dalam skrining awal yaitu mengenai kondisi tempat tinggal, pelayanan home care, dan akses pelayanan kesehatan. resiko tinggi perawatan untuk mengetahui intervensi yang akan dilakukan. resiko tinggi perawatan merupakan hambatan dalam pelaksanaan discharge planning 28. resiko tinggi perawatan dalam klien dfu seperti keadaan psikologis, fi sik, dan psikososial. resiko jatuh dan resiko dekubitus akan mempengaruhi kondisi pada klien dfu dalam perawatan dan proses persiapan dp. hal ini sesuai dengan penelitian rahmi (2011) bahwa dalam melakukan discharge planning perlu diperhatikan kondisi sosial dan keluarga dalam penangganan di rumah atau hal-hal yang mempengaruhi hambatan dan keberhasilan perawatan di rumah, sehingga dalam skrining awal diperlukan langkah-langkah pengkajian umum yang berhubungan dengan kesiapan klien dan keluarga terhadap kesiapan pulang. pencatatan tools implementasi konservasi discharge planning terstruktur dilakukan perbaikan format melalui action research dalam sub kategori knowledge analyse. knowledge analyse merupakan item untuk mengetahuai seorang perawat mampu mengetahui dan menganalisis pengetahuan 14 muhammadiyah journal of nursing partisipan serta keluarga tentang dfu seperti konservasi integritas energi (diet, aktivitas terkontrol, obat dan efek samping), konservasi integritas struktural (rom, perawatan luka, personal hygine, manajemen nyeri), konservasi integritas personal (goal congruence, outcome expectancy, self effi cacy, self regulation dan menjaga privasi partisipan), dan konservasi integritas sosial (sosial infl uence, sosial support, negotiated collaboration, rekreatif). berdasarkan hasil pre action research di atas disesuaikan dengan pembahasan sebelumnya mengenai kategori pengetahuan. pengetahuan yang baik merupakan kunci keberhasilan dari manajemen dfu secara mandiri didapatkan dengan knowledge analyse. knowledge analyse digunakan untuk meningkatkan pengetahuan dengan menganalisis pengetahuan dasar dari perubahan perilaku individu dan keluarga, serta menentukan tingkat kemampuan individu dalam melakukan perawatan secara mandiri. peningkatan pengetahuan pasien dan keluarga diketahui berkaitan dengan perbaikan perilaku, peningkatan kemampuan, serta kontrol yang lebih baik terhadap penyakit. discusion of needs merupakan panduan melakukan diskusi antara perawat dengan partisipan dfu dan keluarga mengenai kebutuhan perawatan baik di rs maupun di rumah. item knowledge analyse merupakan kebutuhan yang dikehendaki sesuai konservasi energi, integritas struktural, integritas personal dan integritas sosial. integritas personal meliputi keyakinan, harapan hasil, keselarasan tujuan, penetapan tujuan, self monitoring & pemikiran refl ektif, pengambilan keputusan, perencanaan, evalusi diri, kegiatan spritual, management of responses and behavior dan kualitas hidup. integritas energi meliputi jadwal dan resep menu, obat yang dikonsumsi, jadwal istirahat, cara mempermudah melakukan istirahat (tidur) dan integritas struktural meliputi penentuan manajemen nyeri baik farmakologis d a n o n f a r m a k o l o g i s , s e r t a m e n e n t u k a n kegiatan rom yang tepat. integritas sosial meliputi peran keluarga, hubungan sosial, serta penetapan modifi kasi lingkungan. berdasarkan penelitian muplihun (2013) bahwa diskusi dapat meningkatkan prestasi belajar dan motivasi. data di atas diperlukan diskusi untuk memudahkan klien dalam manajemen dfu yang terbagi dalam 4 pokok yaitu integritas struktural, energi, personal dan sosial. role play merupakan pelaksanaan demonstrasi dan skill dalam manajemen dfu seperti konservasi integritas energi (menu praktis dfu, pemaparan obat dan efek samping, jadwal kegiatan dan pengaturan istirahat), konservasi integritas struktural (rom ankle, perawatan luka, membalut luka, terapi suntik insulin, relaksasi nafas dalam, dzikir khafi , seterilisasi alat), konservasi integritas personal (goal congruence, outcome expectancy, self effi cacy, self regulation), dan konservasi integritas sosial (berkeluh kesah kepada orang terdekat yang dipercayai, keluarga mampu menfasilitasi emosional, dan instrumental, dan dapat melakukan kerjasama antara perawat, kelurga dan partisipan). integrated evaluation merupakan tahap terakhir dari item tools implementasi yang berfungsi untuk mengevaluasi atau menilai tingkat kesiapan partisipan dan keluarga dalam manajemen perawatan dfu di rumah yang dilihat dari nilai knowledge analyse, discusion of needs dan role play yang telah dilaksanakan selama perawatan serta skrining faktor resiko pasien pulang. berdasarkan analisis di atas dapat diperoleh bahwa penyusunan tools konservasi discharge planning terstruktur dapat digunakan sebagai langkah-langkah persiapan pulang klien dfu yang dimulai saat klien masuk sampai pulang dari rumah sakit. tools konservasi discharge planning terstruktur pada tahap ini bersumber dari kebutuhan partisipan dfu dengan penambahan dari literatur-literatur yang disesuaikan dengan kondisi partisipan, oleh karena itu diharapkan perawat melaksanakan persiapan pulang secara komperhensif dengan langkah-langkah yang tepat dan terstruktur. 15 muhammadiyah journal of nursing tahap action research a. tahap 1 (pertama) tahap pertama ini dilakukan diskusi konservasi discharge planning terstruktur dan konsep ifsmt dengan partisipan adalah 6 orang perawat rs pku ii muhammadiyah yogyakarta. hasil menunjukkan bahwa seluruh partisipan aktif dalam proses diskusi, memperhatikan, antusias, dan melakukan evaluasi serta memvalidasi hasil diskusi. partisipan mampu menerangkan kembali tentang konsep dasar konservasi discharge planning terstruktur dan konsep ifsmt dengan tujuan, serta tahapan proses. berdasarkan penelitian sukardjo (2007) menunjukkan hasil bahwa dengan diskusi dan memecahkan problem solving efektif meningkatkan pengetahuan sekaligus dapat memecahkan suatu masalah. diskusi suatu pengelihatan dua atau lebih individu yang berinteraksi secara verbal atau sasaran yang sudah ditentukan melalui cara tukar-menukar informasi mempertahankan pendapat atau pemecahan masalah 29. diskusi pada umumnya bertujuan memberikan informasi dan terjalin komunikasi interaksi dengan saling menukar informasi dan pada akhirnya memberikan kesimpulan dalam proses akhir diskusi. awal proses diskusi beberapa partisipan mengungkapkan bahwa discharge planning merupakan persiapan pasien pulang dengan memberikan informasi kepada pasien berupa obat, jadwal kontrol dan yang harus dihindari sebelum pasien pulang dan biasanya dilaksanakan selama kurang lebih 5 menit sampai 10 menit sesaat sebelum pulang. hasil action research menyimpulkan bahwa konservasi discharge planning terstruktur merupakan paket belajar mandiri dari awal sampai sebelum klien pulang meliputi materi pembelajaran yang dirancang dan dilaksanakan secara sistematis untuk memenuhi self management individu dan keluarga dalam mempersiapkan kepulangan melalui 4 tahap meliputi: knowledge analyse, needs of discusion, role play dan integrated evaluation pada klien diabetic foot ulcer (dfu). b. tahap ii (kedua) tahap ini dilakukan review dengan mengkaji dan mengevaluasi dengan memberikan masukan. hasil tahap ini partisipan menjelaskan perlu ditambahkan penilaian diantaranya skrinning nutrisi, keluhan utama dengan format pilihan, foto perkembangan luka minimal 3 kali, serta menghilangkan role play yoga. penambahan dan pengurangan item-item tersebut sesuai hasil review, bisa dilakukan atau tidak, dikaji perlu atau tidaknya penambahan yang harus dilakukan sesuai dengan literatur manajemen dfu. masukkan yang diberikan oleh partisipan mulai dari tata bahasa serta urutan item yang ada pada skrining awal dan partisipan melakukan evaluasi kebutuhan yang partisipan harus lakukan dalam pelaksanaan konservasi discharge planning terstruktur. menurut witt en, et al (2004) bahwa review adalah mentelaah dan memberikan masukkan terhadap sesuatu berdasarkan pengalaman dan literatur yang diketahui pereview. fungsi dari tahap dua ini adalah perawat sebagai partisipan dalam mereview tools konservasi discharge planning terstruktur mampu untuk memperbaiki dan menganalisis kebutuhan yang harus dipenuhi dalam pelaksanaan tools. c. tahap iii (ketiga) tahap ketiga dilakukan validasi kebutuhan partisipan individual and family self management dfu (pre action research). berdasarkan pemaparan hasil, maka dapat diketahui bahwa dengan validasi untuk meyakini kebenaran dan ketepatan data dalam kebutuhan individual and family self management. va l i d a s i p e n t i n g d a l a m p e l a k s a n a a n d f u sehingga mampu sebagai acuan dan bahan utama penyusunan tools. tools ini mampu dipertanggung jawabkan hasil luaran dari penelitian ini. tahap ini dilakukan validasi dengan teknik statistik deskriptif sederhana dalam penelitian kuantitatif meliputi kuesioner pengetahuan dan kepercayaan, kemampuan regulasi diri, fasilitas sosial, self management behavior, dan quality of life yang akan 16 muhammadiyah journal of nursing dipaparkan pada paragraf-paragraf selanjutnya. te r d a p a t 3 r e s p o n d e n d a l a m k a t e g o r i pengetahuan dan kepercayaan cukup dan 1 partisipan dalam kategori baik. pengetahuan dan kepercayaan dalam self managemen individu dan keluarga memiliki tiga subvariabel yaitu self effi cacy, outcome expectancy dan goal congruence. penderita dfu sebagian besar memiliki self effi cacy, outcome expectancy dan goal congruence pada kategori cukup dan kurang. self effi cacy menentukan bagaimana seseorang merasa, berpikir dan memotivasi dirinya sendiri untuk bertindak dan berperilaku. outcome expectancy memberikan keyakinan bahwa keterlibatan dalam perilaku tertentu akan menghasilkan hasil yang diinginkan dan goal congruence membantu seseorang menyelesaikan kebingungan dan kecemasan terkait dengan tujuan kesehatan (ryan & sawin, 2009). self effi cacy yang tinggi mendorong pembentukan pola pikir untuk mencapai outcome expectancy dan pemikiran untuk mencapai outcome expectancy akan memunculkan outcome expectancy yang nyata, namun hal ini harus didukung dengan goal congruence yang baik. pengetahuan dan kepercayaan merupakan komponen yang mendasari pelaksanaan self management individu dan keluarga, karena pengetahuan dan kepercayaan memberikan dampak pada perilaku yang lebih spesifik yaitu self efficacy, outcome expectancy dan goal congruence namun pengetahuan tidak mengarah secara langsung kepada perubahan perilaku self management, peningkatan pengetahuan terkait dengan peningkatan perilaku self regulation dan fasilitasi sosial 5. penelitian sebelumnya menyebutkan bahwa meningkatkan pengetahuan melalui edukasi dapat meningkatkan self effi cacy dan self management behavior pada penderita dm tipe 2 7. lorig (2001) menyebutkan pengetahuan dan kepercayaan sebagai bagian terpenting dari keberhasilan seseorang untuk melakukan self management. pengetahuan merupakan domain yang penting dalam membentuk perilaku seseorang. self effi cacy, outcome expectancy dan goal congruence yang kurang optimal pada partisipan dikarenakan penderita memiliki pengetahuan dan kepercayaan yang belum optimal. hal ini dibuktikan dalam hasil 3 cm sebagian partisipan meyatakan bahwa akses mendapatkan informasi untuk meningkatkan pengetahuan masih terbatas, belum ada penyuluhan secara terstruktur. pendidikan mempengaruhi proses belajar, makin tinggi pendidikan seeorang makin mudah orang tersebut untuk menerima informasi. seseorang dengan pendidikan tinggi, maka cenderung mendapatkan informasi dari orang lain maupun dari media massa. semakin banyak informasi yang masuk semakin banyak pula pengetahuan yang didapat tentang kesehatan. sebagian besar responden memiliki tingkat pendidikan slta. pengetahuan sangat erat kaitannya dengan pendidikan dimana diharapkan seseorang dengan pendidikan tinggi, maka akan semakin luas pengetahuannya. perlu ditekankan bahwa seorang yang berpendidikan rendah tidak berarti mutlak berpengetahuan rendah pula, tetapi peningkatan pengetahuan tidak mutlak diperoleh di pendidikan formal, tetapi juga non formal. responden dalam penelitian ini sebagian besar memiliki status ekonomi yang cukup. status ekonomi seseorang juga akan menentukan tersedianya suatu fasilitas yang diperlukan untuk kegiatan tertentu, sehingga status sosial ekonomi ini akan mempengaruhi pengetahuan seseorang. lingkungan berpengaruh terhadap proses masuknya pengetahuan ke dalam individu yang berada dalam lingkungan tersebut. hal ini terjadi karena adanya interaksi timbal balik sebagai pengetahuan oleh setiap individu. pengalaman memberikan pengetahuan, mengembangkan k e m a m p u a n d a n m e n g a m b i l k e p u t u s a n . berdasarkan data-data diatas maka pengetahuan dan kepercayaan merupakan hal yang penting dalam pelaksanaan konservasi discharge planning terstruktur untuk meningkatkan individual and family self management dfu. k e m a m p u a n r e g u l a s i d i r i d a l a m s e l f 17 muhammadiyah journal of nursing management individu dan keluarga memiliki enam subvariabel yaitu menetapkan tujuan, monitoring diri, pengambilan keputusan, perencanaan tindakan, evaluasi diri dan kontrol emosi. kemampuan regulasi diri dari partisipan belum optimal. enam sub variabel dalam kemampuan regulasi diri sebagian besar berada pada kategori cukup dan kurang. kemampuan self regulation seseorang dapat mengubah respon seseorang, seperti mengendalikan impuls perilaku (dorongan perilaku), menahan hasrat, mengontrol pikiran dan mengubah emosi 7. kemampuan self regulation meliputi menetapkan tujuan, monitoring diri, pengambilan keputusan, perencanaan tindakan, evaluasi diri dan kontrol emosi berhubungan dengan perubahan perilaku kesehatan. regulasi diri merupakan penggunaan suatu proses yang mengaktivasi pemikiran, perilaku dan perasaan yang terus menerus dalam upaya untuk mencapai tujuan yang telah ditetapkan 5. penelitian sebelumnya yang dilakukan oleh rubin (1999) diperoleh kesimpulan bahwa diabetes education efektif untuk meningkatkan kemampuan self regulation pada penderita dm tipe 2 karena melakukan self regulation dengan edukasi memungkinkan seseorang memperoleh penguatan secara langsung, mengetahui perubahan kondisi kesehatan dengan segera dan dapat merasakan efek atau manfaat dari pengobatan dengan cepat. pada penelitian ini sebagian besar partisipan jarang dan belum melaksanakan perencanaan target dan strategi pencapaian serta evaluasi diri dan kontrol emosi. hal ini dikarenakan partisipan belum mengenal proses self regulation. kemampuan regulasi diri yang belum optimal pada responden menyebutkan bahwa masalah pribadi terkadang mempengaruhi pencapaian target yang telah ditetapkan salah satunya adalah masalah ekonomi. penjelasan yang diberikan oleh petugas kesehatan (dokter, perawat atau bidan) terkadang juga masih membingungkan sehingga keluarga dan responden merasa kesulitan untuk membuat target dan menyusun strategi serta enggan untuk bertanya kembali meskipun belum jelas. kemampuan regulasi diri menurut bandura (1997) dipengaruhi oleh faktor eksternal dan faktor internal. faktor eksternal terdiri dari standar dan penguatan, sedangkan faktor internal terdiri dari observasi diri, proses penilaian, dan reaksi diri. seseorang dapat mencapai standar tingkah laku tertentu, maka perlu penguatan agar tingkah laku semacam itu menjadi pilihan untuk dilakukan lagi. kemampuan regulasi diri yang kurang optimal pada responden memerlukan contoh standar perilaku kesehatan yang dapat disosialisasikan oleh para petugas kesehatan melalui media-media pembelajaran seperti melalui penyuluhan. fasilitas sosial dari partisipan belum optimal. tiga subvariabel dalam fasilitasi sosial sebagian besar berada pada kategori cukup dan kurang. teori individual and family self management menyebutkan bahwa self management yang baik memerlukan pengetahuan dan kepercayaan, kemampuan regulasi diri dan fasilitasi sosial yang baik pula. interaksi dari ketiganya dapat membentuk self management behavior yang baik pula 7. social infl uence berisi pesan yang menyarankan dan mendorong individu dan keluarga untuk terlibat dalam perilaku kesehatan tertentu. social support berisi dukungan emosional, instrumental, atau informasi yang diberikan kepada seseorang dengan tujuan eksplisit membantu atau memfasilitasi keterlibatan seseorang dalam perilaku kesehatan. kolaborasi merupakan kerjasama, interaksi, kompromi beberapa elemen yang terkait baik individu, atau pihak-pihak yang terlibat secara langsung dan tidak langsung yang menerima akibat dan manfaat 7. nilai-nilai yang mendasari sebuah kolaborasi adalah tujuan yang sama, kesamaan persepsi, kemauan untuk berproses, saling memberikan manfaat, kejujuran, dan kasih sayang 31. fasilitasi sosial dapat diartikan sebagai dampak dari kinerja yang berasal dari orang lain. dampak yang dihasilkan bisa positif (meningkatkan kinerja) maupun negatif (menurunkan kinerja). dampak yang dihasilkan dari fasilitasi sosial dipengaruhi 18 muhammadiyah journal of nursing oleh ketiga elemen dari fasilitasi sosial yaitu social infl uence, social support dan collaboration. seseorang yang telah memperoleh influence, support dan kolaborasi yang efektif akan dihasilkan fasilitasi sosial yang baik pula. penelitian sebelumnya oleh zajonc 1996 dalam gitawati, 2013 menyebutkan bahwa kerjasama dan interaksi dengan orang lain dapat meningkatkan fasilitasi sosial seseorang. hal ini dikarenakan kehadiran orang lain dapat meningkatkan reaksi tubuh akan meningkatkan kecenderungan untuk menampilkan respon yang sesuai dengan situasi sosial. fasilitasi sosial pada responden belum optimal dikarenakan social infl uence, social support dan collaboration yang belum optimal pula. aspek social support yang belum optimal dibuktikan pada 3cm dimana responden sering salah paham apabila keluarga bermaksud untuk mengatur m e n u d i e t r e s p o n d e n a t a u m e n g i n g a t k a n responden, sehingga keluarga sering mengalah pada keinginan responden. aspek collaboration pada responden masih ada rasa segan, malu dan takut ketika berhadapan dengan petugas kesehatan sehingga sulit terbentuk keterbukaan dan kerjasama, selain itu belum terlaksananya kegiatan home visit sebagai salah satu sarana untuk mendekatkan petugas kesehatan dengan responden serta keluarga. dukungan dari keluarga dapat meningkatkan fasilitasi sosial dan dapat diperkuat dengan k o l a b o r a s i o l e h t e n a g a k e s e h a t a n k a r e n a keduanya dapat meningkatkan kecenderungan untuk menampilkan perilaku yang sesuai dengan perilaku kesehatan yang seharusnya. berdasarkan hasil 3cm dan kuesioner diketahui bahwa self management pada respoden belum optimal karena pengetahuan yang kurang, kemampuan regulasi diri yang belum optimal dan kurangnya fasilitasi sosial. atas dasar itu disusun pembelajaran yang terstruktur yang berusaha merangkum ketiga aspek dalam proses self management agar dapat diaplikasikan kepada responden sehingga dapat meningkatkan self management behavior. edukasi dengan knowledge analyse, diskusi, role play dan integrasi evaluasi dilakukan dengan tujuan lebih mempererat kolaborasi antara penderita, keluarga dan petugas kesehatan. quality of life (qol) adalah persepsi individu terhadap posisi mereka dalam kehidupan dalam konteks budaya dan nilai dimana mereka hidup dan dalam hubungannya dengan hidup, harapan, standart dan perhatian. hal ini merupakan konsep yang sangat luas yang mempengaruhi kesehatan fisik seseorang, keadaan psikologis, hubungan sosial dan hubungannya dengan keinginan dimasa yang akan datang terhadap lingkungan mereka 33. hal ini karena dfu adalah penyakit kronis yang tidak dapat diobati secara tuntas, namun apabila terkontrol dengan baik dapat menghambat atau mencegah keluhan fi sik akibat komplikasi akut maupun kronisnya. penderita dfu dengan kualitas hidup yang rendah dapat memperburuk gangguan metabolik baik secara langsung melalui stres hormonal maupun tidak langsung melalui compliance yang buruk. pengelolaan dfu melalui berperilaku positif dalam menjalani penyakitnya, maka penderita mampu mempertahankan dietnya, dan mampu melakukan pola hidup yang sehat sesuai dengan diet. penderita bisa mengontrol kadar gulanya dengan baik, secara tidak langsung kualitas hidup penderita akan meningkat karena dengan keinginan yang konsisten untuk tetap mempertahankan kadar gula darah dalam rentang normal maka quality of life nya juga akan meningkat. d. tahap iv (keempat) ta h a p k e e m p a t m e n g g u n a k a n m e t o d e triangulasi untuk mengurangi bias dengan triangulasi sumber dan metode. triangulasi sumber dilakukan cross check data dengan fakta dari partisipan dan hasil dari penelitian lain. metode dilakukan dengan wawancara dan observasi pada partisipan-partisipan. tahap triangulasi penelitian ini menggunakan 4 pakar sesuai dengan keahliannya masing-masing untuk 19 muhammadiyah journal of nursing memberikan masukkan dan kemudian dilakukan revisi tools kembali sesuai masukkan pakar serta disesuaikan dengan literatur baik buku maupun jurnal penelitian dan di refleksikan dengan mengkonfi rmasi kembali ke pakar. tahap ini setelah dilakukan triangulasi awal maka banyak perubahan yang terjadi dalam draf tools konservasi discharge planning terstruktur meliputi formulir a1 (formulir skrinning awal), a2 (formulir skrinning fokus), b1 (pengkajian singted), b2 (treatmen plan), c (pencatatan intervensi konservasi discharge planning terstruktur) dan d (integrated evaluation konservasi discharge planning terstruktur). formulir a berisi tentang screening awal yang meliputi kesiapan partisipan untuk pulang, terdapat item resiko tinggi perawatan, pengkajian resiko jatuh, pengkajian dekubitus, penilaian tingkat nyeri, penilaian nutrisi (formulir mna), penilaian individual and family self management, hasil kultur bakteri, hasil laboratorium dengan format pilihan (√). formulir a2 berisi tentang formulir skrinning focus yang meliputi identitas dengan alergi obat, situation, foot screnning tool, masalah keperawatan, dan rencana keperawatan. pada formulir a1 dan a2 merupakan tools yang digunakan untuk melakukan deteksi awal pada klien dalam persiapan pulang dan tidakan yang akan dilakukan kedepannya. hal di atas sesuai dengan penelitian siahaan (2008) bahwa diperlukan untuk mendeteksi kesiapan pulang perlu dilakukan pengkajian untuk mengetahui sejak awal kesiapan klien pulang. formulir a diharapkan dapat mengetahui kesiapan klien dalam mempersipan tingkat kemandirian setelah dirumah sedini mungkin. formulir b1 merupakan pengkajian singted yang dikembangkan oleh dr. suriadi., bsn, mns, rn, awcs terdiri dari item size, inflammation, granulation, necrotic, tunneling, wound edge dan depth. singted lebih mudah diaplikasikan oleh perawat klinik kitamura dari pada penggunaan pengkajian design dan bwat dengan reliabelitas 0,978. berdasarkan penelitian fachrurrozi (2014) bahwa reliabelitas design 0,759 sedangkan reliabelitas bwat 0,978, namun dalam penggunaan tools ini hendaknya disesuaikan dengan kondisi tempat kerja dan harus dilakukan penelitian lebih lanjut untuk membandingan ketiga tools tersebut, sehingga dapat digunakan oleh perawat setempat. f o r m u l i r b 2 m e r u p a k a n t r e a t m e n t p l a n digunakan untuk mencatat intervensi perawatan luka berdasarkan time manajemen dan digunakan sebagai perhitungan biaya yang akan dikeluarkan terhadap barang habis pakai dalam pemilihan balutan, terdapat frekkuensi ganti balut serta prosentase luka secara umum. fungsi catatan digunakan sebagai catatan kendala waktu perawatan seperti adanya bledding, jaringan mati yang sulit diangkat, nyeri yang berlebihan waktu pengangkatan serta ketidakoperatifan dari klien. formulir c pada dasarnya ini masih sama dengan draf tools (hal 154) namun ada bebarapa penambahan sesuai dengan hasil evaluasi triangulasi seperti salutogenese dan pengahapusan dari yoga sebagai proses penurunan kecemasan dan nyeri. formulir d memiliki banyak perubahan dengan beberapa pengurangan item dikarena itemitem yang di hapus sudah tercantum dalam formulir item a dan b, namun dengan pengurangan tersebut juga terdapat penambahan item obat yang dibawa pulang dengan rekap nilai singted dari awal sampai akhir pengkajian. lembar evaluasi ini dapat dibawa pulang oleh klien dan digunakan sebagai data untuk pasien kontrol di poli luka. tahap keempat didapatkan bahwa dari semua partisipan mampu untuk memahami tools yang disusun akan tetapi ada beberapa kata yang kurang dipahami. hal ini dikarenakan masih awam tentang kelainankelainan medis pada anatomi kaki, namun hal ini akan bisa mudah dipahami dengan mengatahui kelainan anatomi kaki melalui gambar dan terdapat petunjuk dalam pelaksanaan tools yang disusun. beradasarkan hasil evaluasi dan refl eksi triangulasi didapatkan bahwa tools yang dibuat sudah sesuai dengan teori dan literatur yang ada dengan berbagai tahapan dalam penyusunan. 20 muhammadiyah journal of nursing implikasi bagi keperawatan hasil penelitian ini memberikan gambaran kebutuhan partisipan terhadap individual and family self management dfu. penelitian ini memberikan informasi masalah-masalah dan kebutuhan yang dihadapi partisipan dfu hasil penelitian ini dapat menjadi dasar peneliti selanjutnya untuk menerapkan konservasi discharge planning terstruktur degan penelitian kuantitatif sebagai valiadasi analitik. konservasi discharge planning t e r s t r u k t u r m e r u p a k a n wa d a h ya n g t e p a t untuk mengembangkan program pendidikan kesehatan baik individu maupun keluarga untuk meningkatkan kemampuan diri, dan belajar koping atau regulasi diri, fasilitas sosial, pengetahuan dan kepercayaan yang baru dalam mengatasi masalah, menemukan strategi dalam menejemen behavior dimana untuk peningkatan kualitas hidup. peneliti berharap hasil akhir penelitian ini tersusun model pengembangan konservasi discharge planning terstruktur. model konservasi discharge planning terstruktur yang peneliti susun diharapkan dapat dilakukan kajian ulang melalui penelitian grounded theory. berikut ini merupakan gambar model konservasi discharge planning terstruktur keterangan gambar contens level quadrant integreted pattern of needs 1 : knowing analyse p: personal kb : knowledge & believe 2 : discussion of needs e : energy sc : social facilies 3 : role play st : structure sr : self regulation 4 : integreted evaluation so : social mb : management behaviors gambar 3 model konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer 21 muhammadiyah journal of nursing tabel 6. definisi konsep model konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer content component i : core conservation structured discharge planning paket belajar mandiri meliputi materi pembelajaran yang dirancang dan dilaksanakan secara sistematis untuk memenuhi self management individu dan keluarga dalam mempersiapkan kepulangan melaui 4 tahap meliputi: knowledge analyse, discussion of needs, role play dan integrated evaluation pada klien. content component 2 : metaparadigma of nursing theory nurse profesi yang autonomi secara profesional keperawatan. fungsi profesional yaitu membantu mengenali, menemukan dan membantu kebutuhan klien dan keluarga berkaitan dengan proses keperawatan dengan dukungan informasi, emosioanal, intelektual, dan pengahargaan. diperhatikan tentang disiplin proses keperawatan mengandung elemen dasar, yaitu pengetahuan dan kepercayaan klien dan keluarga, fasilitas sosial, regulasi diri, dan self management behavior serta reaksi perawat dan tindakan perawatan yang dirancang untuk kebaikan klien dan keluarga berdasarkan spritual dan budaya. health terpenuhinya kebutuhan individual and family self management, sehingga bebas dari ketidaknyamanan fisik dan mental dan merasa adekuat. sehat dipengaruhi oleh karakteristik individu dan keluarga dalam peningkatan atau pengurangan manajemen diri. person seseorang yang bertindak atau berperilaku secara verbal dan nonverbal, terkadang dalam situasi tertentu manusia dalam memenuhi kebutuhannya membutuhkan pertolongan, dan mengalami distress jika mereka tidak dapat melakukannya serta memerlukan pengelolahan diri atau dengan kata lain individual and family self management. manusia dipengaruhi oleh kondisi spesifik. society situasi keperawatan yang terjadi ketika perawat dan klien berinteraksi, dan keduanya mempersepsikan, berfikit, dan merasakan dan bertindak dalam situasi yang bersifat segera. klien dapat mengalami distress terhadap lingkungan therapeutik dalam mencapai tujuannya, perawat perlu mengobservasi perilaku kline dikarenakan kondisi lingkungan untuk mengetahui tanda-tanda distress lingkungan. 22 muhammadiyah journal of nursing content component 3 : pattern of needs knowladge & belief 1. pengetahuan merupakan informasi factual dan persepsi tentang kondisi atau perilaku kesehatan 2. keyakinan adalah suatu kepercayaan terhadap segala informasi baik yang bersifat factual maupun non faktual yang dipengaruhi oleh spiritualitas dan kebudayaan dalam perilaku kesehatan social facilities merupakan dukungan baik instrumen, penghargaan, emosional, informasi dan spiritual untuk membantu atau memfasilitasi keterlibatan klien dan keluarga dalam perilaku kesehatan yang terdiri dari dukungan sosial, pengaruh sosial, negosiasi kolaboratif dan laporan perkembangan self regulation merupakan proses individu untuk mencapai perubahan dalam perilaku kesehatan dengan keterampilan dan kemampuan yang dimiliki antara lain penetapan tujuan, fleksibelitas diri, autonomi, salutogenese, dan kontrol pikiran self management perilaku perawatan mandiri yang harus dilaksanakan oleh behaviors individu dan keluarga meliputi aktivitas fisik, seks, istirahat, jadwal minum obat, rawat luka (management balutan & penanganan nyeri) dan pola makan (jadwal makan dan menu makanan) content component 4 :contextual factors individual and karakteristik individu dan keluarga yang meningkatkan atau family mengurangi manajemen diri, misalnya, status kognitif individu, perspektif, pengolahan informasi, tahap perkembangan, kemampuan dan kohesi individu dan keluarga, spesific conditions dan akal fisiologis, struktural, kondisi karakteristik fungsional, pengobatan, atau pencegahan yang mempengaruhi jumlah, jenis, dan sifat kritis perilaku yang diperlukan untuk mengelola kondisi pada saat stabilitas atau transisi. physical and faktor fisik atau sosial termasuk akses ke pelayanan kesehatan, environment transisi dalam penyedia atau seting layanan kesehatan, transportasi, lingkungan, sekolah, pekerjaan, budaya, dan modal sosial yang meningkatkan atau menghambat individu dan keluarga untuk melaksanakan manajemen diri adaptive pattern proses dimana individu mempertahankan integritas dalam menghadapi realitas lingkungan internal dan eksternal meliputi riwayat masa lalu, stimulus, pilihan akan keadaan. 23 muhammadiyah journal of nursing content component 5 : levels knowledge analyse bagaimana seorang perawat mampu untuk mengetahui dan mampu menganalisis pengetahuan partisipan dan keluarga tentang dfu seperti konservasi integritas energi (diet, aktivitas terkontrol, obat dan efek samping), konservasi integritas struktural (rom, perawatan luka, personal hygine, manajemen nyeri), konservasi integritas personal (goal congruence, outcome expectancy, self efficacy, self regulation dan menjaga privasi partisipan), konservasi integritas sosial (sosial discusion of needs influence, sosial support, negotiated collaboration, rekreatif). melakukan diskusi antara perawat dengan partisipan dfu dan keluarga mengenai kebutuhan perawatan baik di rs maupun di rumah sesuai dengan penilaian dalam knowledge analyse karena juga merupakan kebutuhan yang dikehendaki sesuai konservasi energi, integritas struktural, integritas personal dan role play integritas sosial sesuai dengan knowledge analyse. melakukan demonstrasi dan skill pada partisipan dan keluarga dalam manajemen dfu seperti konservasi integritas energi (menu praktis dfu, pemaparan obat dan efek samping, jadwal kegiatan dan pengaturan istirahat), konservasi integritas struktural (rom ankle, perawatan luka, membalut luka, terapi suntik insulin, relaksasi nafas dalam, dzikir khafi, seterilisasi alat), konservasi integritas personal (goal congruence, outcome expectancy, self efficacy, self regulation), dan konservasi integritas sosial (berkeluh kesah kepada orang terdekat yang dipercayai, keluarga mampu menfasilitasi emosional, dan instrumental, dan dapat melakukan kerjasama antara perawat, integrated evaluation kelurga dan partisipan). tahap terakhir yang berfungsi untuk mengevaluasi atau menilai tingkat kesiapan partisipan dan keluarga dalam manajemen perawatan dfu dirumah yang dilihat dari nilai knowledge analyse, discusion of needs dan role play yang telah dilaksanakan selama perawatan serta skrining faktor resiko pasien pulang. 24 muhammadiyah journal of nursing content component 6 : quadrants integrated energy 1. individu membutuhkan keseimbangan energi dan pembaharuan konstan dari energi untuk mempertahankan aktivitas hidup. konservasi energi bertujuan untuk menjaga keseimbangan energi sehingga input dan output sesuai atau seimbang untuk menghindari kelelahan yang berlebihan. 2. setiap orang membutuhkan keseimbangan energi tetapi ada faktor-faktor dalam pribadi dan lingkungan eksternal yang dapat menyebabkan menipisnya energi. mengacu pada masukan menyeimbangkan energi dan output untuk menghindari kelelahan berlebihan dan termasuk istirahat, gizi dan olahraga jantung. contoh: istirahat dan pemeliharaan gizi yang cukup. structure 1. perawat dapat membatasi jumlah jaringan yang terlibat dalam penyakit dengan deteksi dini terhadap perubahan 2. fungsi dan dengan intervensi keperawatan konservasi integritas struktur bertujuan untuk mempertahankan atau memulihkan struktur tubuh sehingga mencegah terjadinya kerusakan fisik dan meningkatakan proses penyembuhan. contoh: membantu pasien dalam latihan rom dan pemeliharaan kebersihan diri. personal konservasi integritas personal bertujuan untuk mengenali individu sebagai manusia yang mendapatkan pengakuan, rasa hormat, kesadaran diri, dan dapat menentukan nasibnya sendiri. setiap orang memiliki rasa sendiri senilai identitas dan diri. contoh: regulasi diri. social 1. seorang individu diakui sebagai anggota keluarga, anggota komunitas atau masyarakat, kelompok keagamaan, 2. kelompok etnis, dan sistem politik suatu bangsa melibatkan keberadaan dan pengakuan dari interaksi manusia, khususnya dengan orang lain yang signifikan dengan klien sebagai sistem dukungannya. contoh: posisi pasien di tempat tidur, mempromosikan penggunaan pasien dari surat kabar, majalah, dan sosial media. kesimpulan berdasarkan hasil penelitian dapat disimpulkan pengembangan konservasi discharge planning terstruktur sebagai berikut: 1. kebutuhan individual and family self management dfu terdiri dari pengetahuan dan keyakinan, regulasi diri, fasilitas sosial dan self management behavior. 2. tersusun draf tools konsevasi discharge planning terdiri dari 3 bagian yaitu skrinning awal, implementasi dan evaluasi. 3. peningkatan pengetahuan praktisi dan perawat luka tentang konsep discharge planning dan individual and family self management diabetic foot ulcer 4. terdapat hasil review format tools konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer kepada praktisi dan perawat luka. 5. tervalidasi kebutuhan partisipan dan keluarga terhadap individual and family self management diabetic foot ulcer yang telah dilengkapi dengan 25 muhammadiyah journal of nursing kebutuhan praktisi dan perawat. 6. triangulasi tools konservasi discharge planning terstruktur oleh 4 pakar. 7. adanyarekomendasi untuk meningkatkan self management individu dan keluarga pada partisipan diabetic foot ulcer di pku muhammadiyah unit ii yogyakarta melalui format tools dan rancangan model konservasi discharge planning terstruktur. saran 1. berbagai bentuk model intervensi perlu diteliti dan dikembangkan guna meningkatkan individual and self management diabetic foot ulcer. diperlukan studi lanjutan yang mengkaji secara lebih mendalam pengalaman-pengalaman partisipan yang telah teridentifikasi dari penelitian ini, misalkan pengalaman keluarga dalam merawat anggota keluarga, pengalaman menghadapi kondisi hambatan-hambatan pada klien diabetic foot ulcer. 2. hasil penelitian ini menekankan pentingnya asuhan keperawatan yang berkesinambungan bagi penderita dfu. oleh karenanya institusi penyedia pelayanan keperawatan perlu menyusun suatu model yang mengintegrasikan perawatan di rumah sakit dan perawatan lanjut pasca hospitalisasi. hal ini dapat dicapai melalui beberapa cara, misalnya membentuk unit follow up care, atau bekerja sama dengan penyedia jasa pelayanan keperawatan yang berdekatan dengan tempat tinggal pasien sehingga memudahkan akses. 3. peneliti selanjutnya bisa menerapkan tools konservasi dan mengembangankan model discharge planning terstruktur untuk mengetahui p e n g a r u h n ya t e r h a d a p k u a l i t a s h i d u p baik melalui penelitian kualitatif maupun kuantitatif. daftar pustaka agustin, r. (2013). pengembangan model discharge planning dalam pelayanan keperawatan. tesis. fkp universitas airlangga, surabaya. austin, l.p. (2011). the nurse’s knowledge of blood conservation as a part of blood management. retrieved september 12, 2013, from published online proquest llc. ayele, k., tesfa, b., abebe, l. (2012). self care behavior among patients with diabetes in harari, eastern ethiopia: the health belive model perspective. plos one. 7 (4), 1-6 april, 2012. retrieved september 12, 2013, from http www.plosone.org/.../ info%3adoi%2f10.1371. bandura, a. (1997). self efficacy. diunduh tanggal 12 september 2013, dari http://www.des. emory.edu/mfp/banency.html. bryant, r & nik, d. 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(2013). model self management individu dan keluarga terhadap quality of life penderita diabetes mellitus (dm) 26 muhammadiyah journal of nursing tipe 2. tesis fkp universitas airlangga, surabaya. hager, j.s. (2010). effects of a discharge planning intervention on perceived readiness for discharge. doctor of nursing practice systems change projects nursing, st. catherine university. handayani, t.w. (2010). pengaruh pengelolahan depresi dengan latihan pernafasan yoga terhadap perkembangan proses penyembuhan ulkus diabetikum di rumah sakit pemerintah aceh. tesis, fik universitas indonesia. jakarta. holt, cl, clark, em, roth, d, crowther, m, kohler, c, fouad, m, foushee, r, lee, p & southward, p (2011). development and validation of an instrument to assess perceived social influence on health behaviors, journal of health psychology, 2010 15: 1225 originally published online 3 june 2010, diperoleh pada tanggal 11 januari 2014, dari http://hpq.sagepub.com/ hussein, r.n, et al. (2010). impact of diabetes on physical and psychological aspects of quality of life of diabetes in erbil city, iraq. duhok med j. 4 (2), 4559, retrieved september 12, 2013. from http://www. uod.ac/articles_files/no6.9.pdf. iversen, m.m.,et al. (2009). the association bettwen history of diabetic foot ulcer, perceived health and psychological distress: the nord trondelag health study. jeffcoate, w.j., harding, k.g. (2003). diabetic foot ulcer: a review. retrieved september 12, 2013, from http://www.epodiatry.com/ diabeticfoot.htm. misnadiarly. (2005). permasalahan kaki diabetes dan upaya penanggulangan. http://www. honson_kaki diabetic.htm. diunduh tanggal 01 oktober 2013. perkumpulan endokrinologi indonesia. (2006). konsesus: pengelolahan dan pencegahan diabetes mellitus tipe 2 di indonesia. perkeni: jakarta. perry, a. g. & potter, p. a. (2005). buku ajar fundamental keperawatan: konsep, proses, dan praktik. volume 1, edisi 4. egc: jakarta. rekam medik pku muhammadiyah ii yogyakarta. (2014). laporan tahunan diagnosa pasien. pku muhammadiyah yogyakarta. rondhianto. (2011). pengaruh diabetes self management education dalam discharge planning terhadap self efficacy dan self behaviour pasien diabetes mellitus tipe 2, tesis fkp universitas airlangga, surabaya. rosyad, y.s (2014). persepsi gay terhadap stigmatisasi gay oleh petugas kesehatan. skripsi stikes a.yani yogjakarta. ryan, polly & sawin, kathlen j. (2009). the individual and family selfmanagement theory: background and perspectives on context, process, and outcomes’, nurs outlook, vol. 57, no. 4, p. 217–225, retrieved september 12, 2013, from http://www. ncbi.nlm.nih.pdf. sarwono & meinarno (2009). psikologi sosial: individu dan teori-teori psikologi sosial, balai pustaka: jakarta. skarbek, edyta anna. (2006). psychosocial predictors of self-care behaviors in type 2 diabetes mellitus patients: analysis of social support, selfefficacy, and depression. a disertation’, diperoleh pada tanggal 13 januari 2014, dari http:/citeseerx.ist.psu.edu/ viewdoc/download?doi=10.1.1.118. souza, d., et al. (2013). quality of life and selfesteem of patients with chr onic ulcers. retrieved january 02, 2014. from acta paul enferm journal 26(3):283-8. tang, ts, brown, mb, funnell, mm & anderson, rm (2008). social support, quality of life and self-care behaviors among african americans with type 2 diabetes’, 27 muhammadiyah journal of nursing the diabetes educator, vol. 34, p. 266, retrieved september 12, 2013, from http:// tde.sagepub.com/content/34/2/266. short. wijanarko, yeni. (2012). hubungan tingkat pengetahuan penderita diabetes tipe ii tentang perawatan kaki diabetes dengan kejadian ulkus kaki diabetes di rsu dr. saiful anwar malang. skripsi unibraw, malang. wijaya dodi. (2013). flow chart perencanaan pulang. tesis universitas indonesia, jakarta. world health organization. (2012). health topics: diabetes. retrieved september 12, 2013. from http://www.who.int/topics/ diabetes_mellitus. wu, sf. (2007). effectiveness of self management for persons with type 2 diabetes following the implementation of a self efficacy enhancing intervention program in taiwan’, quensland university of technology schooll of nursing, retrieved september 12, 2013. from http://eprints.qut.edu.au/. indonesian journal of nursing practices 22 ijnp (indonesian journal of nursing practices) vol 3 no 1 juni 2019 : 22-27 dian nur adkhana sari1, galih adi saputro1, marista fiana1, nurul hanafi1 1 program studi ilmu keperaw atan stikes surya global korespondensi: dian nur adkhana sari email: dian.adkhana@gmail.com faktor yang mempengaruhi breasfeeding self eff icacy (bse) d alam pemberian asi eksklusif pada ibu h amil trimester 3 info artikel online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.3188 abstrak latar belakang: pemberi an ai r sus u ibu (asi) merupakan cara yang pal i ng efekti f untuk memas ti kan kes ehatan dan kes el amatan anak. asi memi l i ki manfaat nutri s i onal dan non nutri s i onal bai k untuk kes ehatan anak dan ibu. who merekomendas i kan asi eks kl us i f s ampai us i a 6 bul an di l anj utkan s ampai 2 tahun. data who menyatakan pemberi an asi eks kl us i f di asi tenggara s eperti myanmar mencapai 23,6%, kamboj a 65,2% indones i a 41,5% j uml ah penurunan pemberi an asi eks kl us i f ti dak hanya terj adi di negara maj u namun j uga terj adi di negara berkembang s eperti di indones ia. breastfeeding self-efficacy merupakan faktor yang pal i ng kuat yang dapat mempengaruhi pros es menyus ui dan keberhas i l an pemberi an asi eks kl us i f. tujuan: mengetahui faktor yang mempengaruhi breasfeending self efficacy (bse) dal am pemberi an as i eks kl us i f pada ibu hami l tri mes ter 3. metode: penel i ti an i ni merupakan penel i ti an des kri ptif analiti k n o n eks peri mental , rancangan cross sectional. juml ah res ponden s ebanyak 58 res ponden dengan tekni k accidental sampling. ins trumen dal am penel i ti an i ni menggunakan kues i oner. anal i s i s penel i ti an dengan uj i kendall,s tau dan uj i chi-square. hasil: has i l s tati s ti c menunj ukkan bahwa factor yang berhubun gan dengan breasfeending self efficacy (bse) adal ah moti vas i i bu, dukungan s uami dan dukungan petugas kes ehatan. kesimpulan: adanya hubungan antara moti vas i i bu, dukungan s uami dan dukungan petugas kes ehatan dal am breasfeeding self efficacy (bse). pel aj aran i ni memberi kan bukti bahwa faktor yang mempengaruhi breasfeeding self efficacy (bse) adal ah di butuhkannya moti vas i dari i bu, dukungan s uami dan dukungan tenaga kes ehatan. breasfeeding self efficacy (bse) merupakan factor yang pal i ng berpengaruh terhadap pros es menyus ui dan tercapai nya keberhas i lan pemberi an asi eks kl us i f di kemudi an hari . kata kunci: breasfeeding self efficacy, moti vas i , dukungan s uami , dukungan tenaga kes ehatan abstract background: the provision of breast milk is the most effective way to ensure children's health and safety. asi has nutritional and non nutritional benefits both for the health of children and mothers. who recommends exclusive breastfeeding until the age of 6 months is continued for up to 2 years. who data states that exclusive breastfeeding in southeast asi such as myanmar reaches 23.6%, 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/5437 vol. 3 no. 1 juni 2019 23 cambodia 65.2% indonesia 41.5%, the decrease in exclusive breastfeeding does not only occur in developed countries but also occurs in developing countries such as indonesia. breastfeeding selfefficacy is the most powerful factor that can affect the breastfeeding process and the success of exclusive breastfeeding. objective: to find out the factors that influence breasfeending self efficacy (bse) in giving exclusive breastfeeding to trimester 3 pregnant women. method: this study is a non-experimental analytic descriptive study, cross sectional design. the number of respondents is 58 respondents with accidental sampling technique. the in strument in this study used a questionnaire. research analysis with kendall test, s tau and chi-square test. results: statistical results show that the factors associated with breasfeending self efficacy (bse) are mother's motivation, husband's support and support from health workers. conclusion: there is a relationship between maternal motivation, husband's support and support of health workers in breedingfeeding self efficacy (bse). this lesson provides evidence that the factors that affect self-efficacy breeding (bse) are the need for motivation from the mother, husband's support and support from health workers. breasfeeding self efficacy (bse) is the most influential factor in the breastfeeding process and the achievement of the success of exclusive breastfeeding in the future. keywords: breasfeeding self efficacy, motivation, husband support, health personnel support pendahuluan asi merupakan sumber kehidupan bagi sang bayi pada periode extro-gestate atau pasca kelahiran. setiap anak memiliki hak untuk dapat tumb u h d an berkembang secara optimal. pemberian air susu ibu (asi) secara eksklusif merupakan salah satu modal dasar pembentukan manusia berkualitas (kementrian kesehatan republik indonesia., 2014). fase terpenting dalam pertumbuhan dan perkembangan anak adalah masa bayi. bayi di u s i a 0-6 bulan dapat tumbuh dan berkembang hanya dengan mengandalkan asupan gizi asi. tetapi kenyataanya di dunia jumlah ibu yang memberikan asi eksklusif kepada bayinya sampai umur 6 b u l an masih rendah, yaitu hanya 38%. hal tersebut disebabkan antara lain pengetahuan ibu tentang pentingnya asi masih rendah serta dukungan sekitar, promosi susu formula yang banyak, dan sistem kesehatan di fasilitas kesehatan dan ru mah sakit. world health organization (who) menyampaikan bahwa 800.000 bayi meninggal pada tahun 2016 karena pemberian asi eklusif yang tidak optimal. oleh karena itu who menargetkan pemberian asi eksklusif 6 bulan sebanyak 50% pada tahun 2025 (who, 2016). united nations childrens emergency fund (unicef) merekomendasikan pemberian asi paling sedikit selama 6 bulan, sejalan dengan itu unicef juga menargetkan 80% sampai tahun 2025 bagi setiap negara untuk melakukan pemberian asi ek s k lu s if . prevalensi asi pada tahun 2016 kurang dari 10 negara yang mencapai target salah satu negara yang mencapai target adalah timor leste 93,6%, rwanda bagian afrika 81% dan yang terendah adalah somalia 5,3% dan korea 18%. hal ini menggambarkan bahwa pemberian asi eksklusif masih rendah sedangkan praktek pemberian asi non eksklusif di berbagai negara masih tinggi (unicef, 2017). penelitian di beberapa negara berkembang mengungkapkan bahwa penyebab utama terjadinya kurang gizi dan hambatan pertumbuhan dan perkembangan pada anak-anak usia balita berkaitan dengan rendahnya pemberian asi. sejalan dengan hal tersebut, world health organization (who) dalam global data bank (gdb) indonesian journal of nursing practices 24 on infant and young child feeding menyatakan bahwa pencapaian pemberian asi eksklusif di a s i a tenggara seperti myanmar masih mencapai 23,6% , kamboja 65,2% indonesia 41,5% dan yang terendah vietnam 24,3% jumlah penurunan pemberian asi eksklusif tidak hanya terjadi di negara-negara maju saja namun juga terjadi di negara berkembangn seperti di indonesia (unicef, 2017). hasil survei demografi dan kesehatan indonesia (sdki) 2007 menunjukkan cakupan asi eksklusif bayi 0-6 bulan sebesar 32% yang menujukkan kenaikkan yang bermakna menjadi 42% pada tahun 2012. cakupan pemberian asi eksklusif 0-6 bulan indonesia menurut data dari provinsi tahun 2013 bahwa terdapat 19 provinsi yang mempunyai presentasi asi eksklusif diatas angka nasional (54,3%), dimana presentase tertinggi terdapat pada provinsi nusa tenggara barat (79,7%) dan terendah pada posisi maluku (25%). provinsi di yogyakarta sebesar 67,9% , dimana hal tersebut masih berada dibawah target pencapain indonesia pada tahun 2013 sebesar 75%. maka dari itu perlunya dilakukan upaya agar provinsi dengan presentase dibawah angka nasional agar dapat ditingkatkan cakupan pemberian asi eksklusif (kementrian kesehatan republik indonesia., 2014). bayi yang tidak disusui secara eksklusif dapat berisiko meninggal karena diare atau pneumonia yang jauh lebih besar daripada orang yang menderita. selain itu, menyusui meningkatkan sistem kekebalan bayi dan dapat melindungi mereka di kemudian hari dari kondisi kronis seperti obesitas dan diabetes. selain itu, menyusui melindungi ibu terhadap beberapa jenis kanker dan kondisi kesehatan lainnya. terlepas dari semua potensi manfaatnya, hanya sekitar dua per lima bayi di seluruh dunia yang disusui secara e k s k l u si f selama enam bulan pertama kehidupan (unicef, 2016). breastfeeding self-efficacy mempengaru h i inisiasi menyusui, tercapainya asi eksklusif dan durasi menyusui, dimana semakin tinggi pula tingkat keberhasilan asi eksklusif pada ibu postpartum vincent (2015). breastfeeding selfefficacy merupakan faktor yang paling kuat yang dapat mempengaruhi proses menyusui dan tercapainya keberhasilan asi eksklusif dikemu d ian hari (pradanie, 2015). berdasarkan uraian tersebut maka peneliti tertari k untuk melakukan penelitian tentang faktor yang mempengaruhi breastfending self efficacy pada ibu primipara. metode penelitian ini menggunakan metode studi deskriptif. jumlah sampel dalam penelitian ini sebanyak 58, metode pengambilan sampel secara accidental sampling. instrument yang digunakan menggunakan kuesioner, berupa kuesioner breastfending self effycacy (bse), kuesioner motivasi, kuesioner dukungan suami dan kuesioner dukungan petugas kesehatan. data yang diperol eh dianalisis menggunakan analisis data, kendall,s tau dan chi square. lokasi penelitian dilakukan diwilayah kerja puskesmas umbulharjo i. hasil a. hasil breastfending self effycacy (bse) tabel 1. distribusi frekuensi breastfeeding self efficacy kategori breastfeeding self efficacy frekuens i (f) pres entas e (%) bai k 38 65,5 cukup 18 31,0 kurang 2 3,4 total 58 100,0 sumber : data pri mer, di ol ah (2018) berdasarkan table 1 menunjukkan bahwa dari 58 responden mayoritas memiki breasfeeding self efficacy dalam ketegori baik yaitu sebanyak 38 responden (65,5%). b. hasil motivasi tabel 2. distribusi frekuensi motivasi kategori moti vas i frekuens i (f) pres entas e (%) bai k 41 70,7 cukup 16 27,6 kurang 1 1,7 total 58 100 sumber : data pri mer, di ol ah (2018) berdasarkan tabel 2 terlihat bahwa 58 responden mayoritas memiliki motivasi dalam kategori baik yaitu sebanyak 41 responden (70,7%). vol. 3 no. 1 juni 2019 25 hasil dukungan suami tabel 3. distribusi frekuensi dukungan suami dukungan suami frekuens i (f) pers entas e (%) buruk 4 6.9 bai k 54 93.1 total 58 100 sumber : data primer tahun 2018 berdasarkan tabel 3 menunjukkan bahwa 58 responden mayoritas memiliki mayoritas kategori baik yaitu sebanyak 54 responden (93,1%). hasil dukungan petugas kesehatan. tabel 4. distribusi frekuensi dukungan petugas kesehatan dukungan petugas kes ehatan frekuens i (f) pres entas e (%) mendukung 56 96,6 ti dak mendukung 2 3,4 total 58 100,0 sumber :data primer tahun 2018 berdasarkan tabel 4 menunjukkan bahwa 58 responden mayoritas kategori mendukung sebanyak 56 orang (96,6%). c. hubungan motivasi dengan breastfeeding self efficacy (bse) tabel 5. uji kendall’s tau motivasi dengan breastfeeding self efficacy (bse) vari abel koefi s i en korel as i kendall’s tau_b ni l ai si gni fi kansi keterangan breastfeeding self efficacy 0,439 0,001 si gni fi kan moti vas i sumber : has i l spss (2018) berdasarkan tabel 4. didapatkan hasil uji kendall’s tau_b sebesar 0,439 yang artinya memiliki koefisien korelasi dalam kategori agak ren d ah d an pada signifikan yaitu 0,001 hal ini menunjukkan bahwa nilai p value <0.01 maka terdapat hubungan antara motivasi dengan breastfeeding self effica cy (bse). hubungan dukungan suami dengan breastfeeding self efficacy (bse) tabel 6. uji chi-square crosstabulation hubungan dukungan suami dengan breastfeeding self efficacy (bse) bse dukungan suami juml ah ni l ai korel as i si gn buruk bai k f % f % f % 7,361 0.025 bai k 1 25.0% 37 68.5% 38 65,5% cukup 2 50.0% 16 29.6% 18 31,0% kurang 1 25.0% 1 1.9% 2 3,4% total 4 100% 54 100% 58 100% sumber :data primer tahun 2018 berdasarkan table 6, dapat diketahui hasil uji chi-square yaitu nilai p 0,025 (nilai p < 0,05), mak a te rd ap at hubungan antar dukungan suami dengan breastfeeding self efficacy dalam pemberian asi eksklusif , (ha diterima dan ho ditolak). hubungan dukungan petugas kesehatan dengan breastfeeding self efficacy tabel 7. uji chi-square crosstabulation hubungan dukungan petugas kesehatan dengan breasfeeding self efficacy (bse) breasfeeding self efficacy dukungan petugas kes ehatan juml ah ni l ai korel asi si gn mendukung ti dak mendukung f % f % f % bai k 37 63.8 1 1.7 38 65.5 0.438 0.001 cukup 18 31.0 0 0 18 31.0 kurang 1 1.7 1 1.7 2 3.4 total 56 96.6 2 3.4 58 100 sumber :data primer tahun 2018 indonesian journal of nursing practices 26 berdasarkan table 7, diketahui hasil uji chi square dengan nilai p 0,001 (nilai p < 0,05). maka terdapat hubungan dukungan petugas kesehatan dengan breasfeeding self efficacy dalam pemberian asi eksklusif pada ibu hamil trimester ke iii di w i l ay ah kerja puskesmas umbulharjo 1 yogyakarta. pembahasan hubungan motivasi dengan breastfeeding self efficacy (bse) ada hubungan yang signifikan antara motivasi dengan breastfeeding self efficacy dalam pemberian asi eksklusif ibu hamil trimester 3 di puskesmas umbulharjo i. hasil ini didasarkan p ad a uji kendall tau dengan ρ value = 0,001 (ρ value <0,01). penelitian amir (2016) menyatakan tentang korelasi pengaruh faktor efikasi diri dan manajemen diri terhadap motivasi berprestasi hasil penelitian menunjukkan efikasi diri sebagai variabel bebas mempengaruhi motivasi mamiliki arah hubungan positif. ini membuktikan bahwa efikasi diri berpengaruh secara signifikan dan linier terhadap motivasi. semakin baik dan tinggi e f i kas i diri maka akan diikuti dengan peningkatan motivasi, dan sebaliknya. self efficacy merujuk pada keyakinan individu bahwa mampu mengerjakan tugas, mencapai sebuah tujuan, atau mengatasi sebuah hambatan (baron dalam sriramayanti, 2018). merideth dal am purnamasari (2014) menyatakan bahwa selfefficacy merupakan penilaian seseorang akan kemampuan pribadinya untuk memulai dan berhasil melakukan tugas yang ditetapkan pada tingkat yang ditunjuk, dalam upaya yang lebih besar, dan bertahan dalam menghadapi kesulitan. hubungan dukungan suami dengan breastfeeding self efficacy (bse) hasil uji chi-square terdapat hubungan dukun gan suami dengan breastfeeding self efficacy dalam pemberian asi eksklusif pada ibu hamil trimester ke iii . sesuai dengan teori bahwa ibu menyusui membutuhkan dukungan dan pertolongan, baik karena memulai maupun melanjutkan menyusui. sebagai langkah awal ibu hamil trimester ke iii membutuhkan bantuan sejak kehamilan dan setelah melahirkan. ibu hamil trimester ke iii membutuhkan dukungan pemberian asi hingga 2 tahun, perawatan kesehatan maupun dukungan dari keluarga dan lingkungannya (proverawati, 2010). chaplin (2014) menyatakan bahwa dukungan dapat diartikan sebagai memberikan dorongan /motivasi atau pengobaran semangat atau nasihat kepada oran lain dalam situasi pembuatan keputusan. dukungan menurut ratna (2010) merupakan faktor penting yang dibutuh k an seseorang ketika menghadapi masalah kesehatan . hasil ini sejalan dengan penelitian hapitaria (2017), dengan hasil : dengan hasil paling banyak suami memberikan dukungan terhadap pemberian asi eksklusif sebanyak 112 dengan presentase (64%). hasil ini sejalan dengan penelitian larasati, dkk (2016) dengan hasil : hubungan dukungan suami dengan praktik pemberian asi eksklusif . hubungan dukungan petugas kesehatan dengan breastfeeding self efficacy (bse) hasil uji chi-square terdapat hubungan dukungan petugas kesehatan dengan breasfeeding self efficacy dalam pemberian asi eksklusif pada ibu hamil trimester ke iii. penelitan yang sama dilakukan oleh setiawati (2014), meneliti tentang hubungan antara karakteristik ibu, peran petugas kesehatan dan dukungan keluarga dengan pemberian asi eksklusif bahwa terdapat hubungan antara peran petugas kesehatan dengan pemberian asi eksklusif. novianti (2016) yang dalam hasil penelitiannya bahwa ada hubungan antara dukungan informasi dengan pemberian asi eksklusif pada bayi . hasil ini menunjukan bahwa semakin bertambah dukungan informasi semakin baik pemberian asi eksklusif bada bayi. melihat dari hasil penelitian, diupayakan selain adanya dukungan dari tenanga kesehatan, dan dukungan dari dalam diri ibu sendiri tentang pentingnya asi eksklusif dan manfaatnya juga harus ditingkatkan terutama dalam memberikan informasi tentang pentingnya asi. sebesar ap ap u n dukungan dan kerja keras tenaga kesehatan terhadap pemberian asi ekslusif bagi ibu, penen tu utamanya tetap ibu itu sendiri yang didukung o l eh keluarga yang mendampingi selama proses laktas i. hal ini sebagai dasar apabila keluarga mendukun g, begitu pula tenaga kesehatan, namun dalam diri ibu sendiri tidak mendukung, maka hak ini bisa saja menjadi penyebab gagalnya pemberian asi eksklusif. dukungan tenaga kesehatan yang baik tidak akan bermakna jika tidak didukung dengan vol. 3 no. 1 juni 2019 27 komitmen dari ibu dan keluarga (nurlinawati, 2016). ucapan terima kasih keberhasilan penyusunan artikel ini tidak lepas dari bantuan dan dorongan dari berbagai pihak. ucapan terimakasih kami ucapkan kepada: 1. stikes surya global yang telah mendukung dalam pendanaan penelitian ini 2. dwi suharyanta, s.t., m.m., m.kes., selaku ketua stikes surya global yogyakarta 3. supriyadi, s.kep., ns., m.kes., selaku ketua program studi ilmu keperawatan stikes surya global yogyakarta 4. rekan rekan program studi ilmu keperawatan stikes surya global referensi amir, hermansyah. (2016). korelasi pengaruh faktor efikasi diri dan manajemen diri terhadap motivasi berprestasi pada mahasiswa pendidikan kimia unversitas bengkulu. naskah publikasi. prodi pend kimia fkip unib. bengkulu sriramayanti, cut ila., dan devi darliana. (2018). self efficacy dengan motivasi dalam menjalani terapi pada pasien stroke. jurna l. program studi ilmu keperawatan fakultas keperawatan, universitas syiah kuala banda aceh. aceh chaplin. (2014). kamus lengkap psikologi. jakarta: rajagrafindo persada hapitaria, shafira. (2017). hubungan dukungan suami dengan petugas kesehatan dalam pemberian asi eksklusif di desa sumbersari kecamatan ngampel kabupaten kendal. kementrian kesehatan republik indonesia. (2014) . situasi dan analisis asi ekslusif. pusat dan data informasi. jakarta selatan larasati, rohmah. (2016). hubungan dukungan suami dengan keberhasilan asi eksklus if d i wilayah kerja puskesmas jetis bantul. digilib.unisayogya.ac.id purnamasari. mega isvandiana. (2014). hubungan self-efficacy, dan motivasi berprestasi dengan kecemasan mahasiswa yang sedan g mengerjakan skripsi. naskah publikasi. program pasca sarjana, universitas muhammadiyah surakarta. surakarta novianti et.al. (2016). dukungan tenaga kesehatan terhadap pelaksanaan imd: studi kasus di rumah sakit swasta x dan rsud y di jakarta. jurnal kesehatan reproduksi. pusat. pradanie, retnayu. (2015). paket dukungan terhadap breastfeeding self efficacy dan keberhasilan menyusui pada ibu postpartum. jurnal ners vol. 10 no.1 april 2015: 20-29 kementrian kesehatan republik indonesia. (2014) . buku profil kesehatan indonesia. www.depkes.go.id proverawati. (2010). gambaran dukungan suami dalam keberhasilan pemberian asi eksklusif di puskesmas turi sleman yogyakarta. respiratory.unjaya.ac.id ratna, wahyu. (2010). sosiologi dan antropologi kesehatan dalam perspektif ilmu keperawatan. yogyakarta: pustaka rihama. setiawati et.al. (2014). hubungan sikap dan peran bidan terhadap program pemberian asi eksklusif di wilayah kerja puskesmas jambu burung kabupaten banjar. skripsi. poltekkes kemenkes banjarmasin jurusan kebidanan unicef. (2017). infant and young child feeding. global database. https://data.unicef.org/topic/nutrition/i nf a nt-and-young-child-feeding/ who. (2016). global nutrition report from promise to impact ending malnutrition by 2030. international food policy research institute. washington,dc http://www.depkes.go.id/ https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/ https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/ indonesian journal of nursing practices 42 ijnp (indonesian journal of nursing practices) vol 3 no 1 juni 2019 : 42-51 noormailida astuti1, bahrul ilmi2, ruslina wati3 1 sekolah tinggi ilmu kesehatan cahaya bangsa 2 politeknik kesehatan banjarmasin 3 universitas muhammadiyah banjarmasin korespondensi: noormailida astuti email: noormailida.astuti@gmail.com penerapan komunikasi situation, background, assesment, recomendation (sbar) pada perawat dalam melaksanakan handover di rsud banjarmasin info artikel online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.3192 abstrak latar belakang: rumah s aki t yang terakredi tas i dal am s i s tem akredi tas i kars 2012 mengarahkan kegi atan rs agar memberi kan pel ayanan yang memenuhi s tandar kual i tas j ami nan ras a aman. keamanan pel ayanan di rs s al ah s atunya peni ngkatan komuni kas i efekti f antar perawat, s ehi ngga ti dak terj adi kes al ahan i nformas i s aat handover dan menj ami n kes el amatan pas i en karena bel um maks i mal nya penerapan komuni kas i sbar. tujuan: penel i ti an i ni bertuj uan untuk mengeks pl oras i penerapan komuni kas i sbar pada perawat dal am mel aks anakan handover di rsud banj armas in. method: penel i ti an i ni di l akukan dengan menggunakan metode kual i tati f dengan pendekatan fenomenol ogi . hasil: has i l penel i ti an mengi denti fi kas i s ebanyak enam tema, yai tu pengal aman penerapan komuni kas i sbar dal am handover; manfaat penerapan komuni kas i sbar dal am handover; hambatan penerapan komuni kas i sbar dal am handover; tantangan penerapan komuni kas i sbar dal am handover; cara beradaptas i penerapan komuni kas i sbar dal am handover; harapan penerapan komuni kas i sbar dal am handover. kesimpulan: rekomendas i penel i ti s ebai knya pi hak manaj emen khus us nya bi dang keperawatan mel akukan perbai kan fas i litas pa d a format dokumentas i sbar dan mel akukan s os i al i s as i manfaat komuni kas i sbar ke ruangan yang bel um menerapkan komuni kas i sbar dal am mel a ks anakan handover. kata kunci : handover, pengal aman, sbar abstract background: accredited hospitals in kars 2012 accreditation system direct rs activities to provide services that meet safety assurance standards. safety of service in the hospital one of them is increasing the effective communication between nurses, so that there is no information error when handover and guarantee patient safety because not maximal application of sbar communication. objective: the purpose of the study explored the application of sbar communication to nurses in implementing handover at banjarmasin general hospital. method: the research was conducted using qualitative method with phenomenology approach. result: the research results identify as many as six themes, namely : experience of sbar communication implementation in handover; benefits of implementing sbar communication in handover; barriers 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/5429 vol. 3 no. 1 juni 2019 43 to the implementation of sbar communication in handover; challenges of implementing sbar communication in handover; how to adapt the implementation of sbar communication in handover; expectations of sbar communication in handover. conclusion: recomendation management, especially in the field of nursing should make facility improvements on the sbar documentation format and socialize the benefits of sbar communication to a room that has not implemented sbar communication in implementing handover. keywords: experience, sbar, handover pendahuluan salah satu upaya yang dilakukan oleh pemerintah indonesia untuk menjaga kualitas layanan di rumah sakit melalui kementrian kesehatan dengan mengeluarkan undang – undang no. 44 pasal 43 ayat (1) yang menyebutkan bahwa rumah sakit menerapkan keselamatan pasien. hal ini juga sejalan dengan peraturan menteri kesehatan nomor 11 /menkes/ per/ ii / 2017 pasal 5 ayat 4 tentang keselamatan pasien di rumah sakit salah satu nya menyebutkan bahwa komunikasi merupakan kunci bagi staf untuk mencapai keselamatan pasien. menurut komite akreditasi rumah sakit (2012) maksud dan tujuan sasaran keselamatan pasien dengan peningkatan komunikasi yang efektif, tepat waktu, akurat, lengkap, jelas dan di pahami oleh pasien/penerima maka dapat mengurangi kesalahan dan menghasilkan peningkatan keselamatan pasien. komunikasi dapat secara elektronik, lisan, atau tertulis. pengaturan keselamatan pasien bertujuan untuk meningkatkan mutu pelayanan fasilitas dan pelayanan kesehatan melalui penerapan standarisasi komite akreditasi rumah sakit (kars) versi 2012. rumah sakit yang terakreditasi sistem akreditasi kars 2012 mengarahkan seluruh kegiatan pelayanan rumah sakit agar memberikan pelayanan yang memenuhi standar kualitas serta jaminan rasa aman. keamanan pelayanan di rumah sakit salah satunya di lihat dari peningkatan komunikasi efektif antar perawat, sehingga tidak terjadi kesalahan dalam informasi saat handover dan menjamin keselamatan pasien. standar joint commision international (jci) edisi 5 tahun 2014 menyatakan bahwa international patient safety goal (ipsg) 2.2 atau sasaran keselamatan pasien (skp) kedua yaitu rumah s ak i t mengembangkan dan menerapkan suatu proses untuk komunikasi serah terima, sebagai upaya untuk mengurangi dampak akibat penyampaian dan penerimaan informasi yang tidak tepat yaitu dengan memperkenalkan komunikasi efek tif y an g dapat digunakan dalam handover. sbar merupakan alat komunikasi yang direkomendasikan oleh world health organizatio n untuk mengkomunikasikan informasi penting y an g membutuhkan perhatian dan tindakan segera, komunikasi sbar tidak hanya meningkatkan mutu pelayanan, tetapi juga dapat meningkatkan kualitas handover yang akan menekan angka medical error (cynthia d. & gayle, 2009, raymond & harrison, 2014). komunikasi isbar dan s-bar (introduction, situation, background, assesment, recomendation) adalah komunikasi dengan menggunakan alat yan g logis untuk mengatur informasi sehingga dapat ditransfer kepada orang lain secara akurat, efisien untuk mencapai ketrampilan berfikir kritis, e fek tif , terstruktur dan menghemat waktu serta tercapai peningkatan keselamatan pasien. gangguan komunikasi antar perawat dapat mengakibatkan proses keperawatan terhenti, kinerja asuhan keperawatan juga akan menurun, bahkan menghambat pemenuhan tujuan asuhan keperawatan, komunikasi yang tidak efektif akan berdampak buruk bagi pasien, hampir 70 % kejadian sentinel di rumah sakit disebabkan karen a kegagalan komunikasi dan 75 % nya mengakibatkan kematian, (linda 2006, lisbeth blom, et al, 2015, tamsuri 2016) kesalahan dalam komunikasi merupakan peny eb ab utama peristiwa yang dilaporkan ke komisi bersama amerika serikat 2006 yaitu dari 25000 -30000 indonesian journal of nursing practices 44 kejadian buruk yang dapat dicegah, menyebabkan 11% cacat permanen, kejadian buruk ini dikarenakan 6% masalah perbedaan komunikasi dan juga karena tidak memadai tingkat keterampilannya. dari data hasil root cause analisis (rca) salah satu rs di amerika 90% penyebab kejadian tidak diharapkan yaitu komunikasi dan 50% terjadi kejadian tidak diharapkan pada saat serah terima informasi pasien. keselamatan p as i e n merupakan masalah kesehatan masyarakat global yang serius, angka insiden kejadian tidak di harapkan (ktd) dari berbagai negara ditemukan rentang 3,2 % 16,6 % sedangkan di eropa angka resiko infeksi 83% dan bukti kesalahan medis 50 – 72,3 % (who, 2007, who, 2014, jci, journal and patient safety,vol.32,march 2006). data insiden kejadian nyaris cedera (knc) di indonesia yaitu 53,33 % sedangkan kejadian tidak di harapkan (ktd) 46,67 % (kkp-rs 2010). hal ini membuktikan bahwa pelaksanaan keselamatan pasien di indonesia belum maksimal. angood (2007) dalam dewi (2012) mengungkapkan berdasarkan hasil kajian data penyebab utama dari kejadian tidak di harapkan (ktd) dan kejadian nyaris cedera (knc) di rumah sakit adalah komunikasi. mustikawati, 2011 dalam triwibowo, 2016 menyatakan bahwa keselamatan dalam asuhan keperawatan yang berkualitas. transfer informasi pada saat pergantian shift disebut dengan handover. informasi terkait keadaan klinis pasien, kebutuhan pasien, k e adaan personal pasien, sampai pada faktor sosial p as i en . terdapat hubungan motivasi dengan pelaksanaan komunikasi sbar dalam handover pada perawat pelaksana, karena perawat yang mampu berkomunikasi yang baik akan meningkatkan citra profesionalisme pada dirinya. (mc cloughen et al 2008, dewi 2012, singgih 2015, triwibowo, 2016) dampak apabila tidak di laksanakan komunikasi sbar pada saat handover maka terjadi peningkatan resiko insiden keselamatan pasien, komunikasi antar perawat tidak efektif sehingga berpengaruh terhadap mutu asuhan keperawatan, selain itu peningkatan kesinambungan pelayanan dalam mendukung keselamatan pasien akan berkurang serta penurunan kepercayaan masyarakat terhadap pelayanan kesehatan di rumah sakit. (alvarado 2006, cahyono 2008, supinganto 2015, qomariah 2015). teori keperawatan yang terkait dengan penerapan komunikasi sbar pada perawat dalam melaksanakan handover untuk mencapai tujuan terlaksananya komunikasi yang efektif antar perawat yaitu teori imogine king, myra estrine levine dan sister calista roy yang menjelaskan bahwa manusia sebagai sistem interpersonal y an g mampu berinteraksi, berkomunikasi, dan saling terikat untuk beradaptasi terhadap perubahan yang terjadi pada lingkungan. (alligood, 2014) berdasarkan hasil studi pendahuluan peneliti p ad a bulan agustus 2017 di rsud banjarmasin, menggunakan metode observasi dan wawancara didapatkan bahwa metode handover yang saat ini dilakukan di rsud banjarmasin sudah 40% menggunakan komunikasi sbar, namun penerapannya belum maksimal karena masih ada unit perawatan lainnya yang belum melaksan ak an handover menggunakan metode komunikasi sbar, selain itu penerapan dan pelaksanaan komunikasi sbar dalam handover baru berjalan 2 bulan sehingga perawat perlu beradaptasi terhadap perubahan tersebut. banyak informasi yang belum terisi mengenai kondisi pasien terkini, perawat hanya menuliskan keadaan umum pasien, seharusnya pada komponen ini dijelaskan kondisi klinik lain yang mendukung keadaan pasien seperti hasil pemeriksaan tanda – tanda vital, laboratorium, rontgen, dan ultrasonografi. bagian pendidikan dan pelatihan (diklat) rsud banjarmasin sudah melaksanakan pelatihan komunikasi efektif untuk petugas kesehatan pada tahun 2016, semua perawat di rsud banjarmasin sudah mengikuti sosialisasi pelaksanaan dan pendokumentasian handover menggunakan komunikasi sbar yang disampaikan oleh manajemen dan komite keperawatan. rsud banjarmasin menetapkan kebijakan menggunakan komunikasi sbar pada pelaksan aan handover dalam rangka meningkatkan komun i kas i antar perawat di unit keperawatan. menurut manajemen keperawatan perubahan dokumentas i keperawatan yang di laksanakan dikarenakan vol. 3 no. 1 juni 2019 45 format sbar lebih lengkap dan mencakup itemitem keselamatan pasien, sehingga diharapkan semua perawat mengetahui keadaan pasien saat pelaksanaan handover. berdasarkan permasalahan tersebut maka pertanyaan pada penelitian ini adalah “bagaimana penerapan komunikasi sbar pada perawat dalam melaksanakan handover di rsud banjarmasin ? “ metode penelitian ini menggunakan metode kualitatif dengan pendekatan fenomenologi. pengu mp u lan data dilakukan dengan wawancara mendalam ( in depth interview) atau wawancara semi terstruktur. tujuan penelitian mengeksplorasi penerapan komunikasi sbar pada perawat dalam melaksanakan handover di rsud banjarmasin. subjek penelitian adalah seluruh perawat di unit keperawatan rawat inap di rsud banjarmasin, pengambilan sampel dilakukan dengan teknik purposive sampling, partisipan dalam penelitian ini berjumlah 7 orang sesuai tingkat kejenuhannya. kriteria partisipan pada penelitian ini adalah bersedia menjadi partisipan yang dibuktikan dengan menandatangani surat pernyataan persetujuan penelitian, mampu mengeksp re si kan pengalamannya, pernah mengikuti kegiatan sosialisasi komunikasi sbar dan bekerja di ruang rawat inap yang menerapkan pelaksanaan handover menggunakan komunikasi sbar. instrumen utama (instrumen penelitian) dalam penelitian ini adalah peneliti sendiri. uji kredibilitas (kepercayaan) di lakukan dengan cara pengecekan kembali kepada partisipan tentang transkrip verbatim yang telah dibuat gu n a melihat kesesuaian antara hasil rekaman, tran s k ip verbatim dan field note. proses selanjutnya menanyakan kepada partisipan, apakah ada data yang perlu di klarifikasi sesuai maksud oleh partisipan. semua partisipan pada penelitian menyebutkan bahwa data pada transkip verbatim dan field note sudah sesuai. hasil partisipan merupakan perawat yang memenuhi kriteria dan bekerja di ruangan yang menerapkan metode komunikasi sbar yaitu ruang rawat inap syaraf, ruang rawat inap bedah, ruang rawat inap vip lantai 2 dan ruang rawat inap vip lantai 3 di rsud banjarmasin. adapun jumlah partisipan 7 (tujuh) orang yang terdiri dari 6 orang wanita dan 1 orang laki-laki dengan usia termuda 30 tahun dan usia tertua 40 tahun. tingkat pendidikan partisipan 4 (empat) orang s.kep ners dan 3 (tiga) orang d3 keperawatan. pengalaman bekerja partisipan rata-rata 617 tahun. hasil analisis data kualitatif yang di kumpulkan melalui wawancara mendalam terhadap 7 (tujuh) partisipan terdapat 6 (enam ) tema dan 16 (enam belas) subtema yang teridentifikasi. adapun penjelasan dari tema tersebut yaitu : (1) pengalaman penerapan komunikasi sbar dalam melaksanakan handover. (2) manfaat penerapan komunikasi sbar dalam melaksanakan handover. (3) hambatan penerapan komunikasi sbar dalam melaksanakan handover. (4) tantangan penerapan komunikasi sbar dalam melaksanakan handover. (5) cara beradaptasi terhadap penerapan komunikasi sbar dalam handover. (6) harapan penerapan komunikasi sbar dalam handover. adapun penjelasan masing-masing tema berdasarkan ungkapan-ungkapan partisipan sebagai berikut : tema 1 : pengalaman penerapan komunikasi s ba r dalam melaksanakan handover. menurut pernyataan dari 7 partisipan dalam melaksanakan handover menggunakan komunikas i sbar menghasilkan subtema memudahkan pekerjaan dan memudahkan pertanggung jawaban keperawatan. a. memudahkan pekerjaan berdasarkan hasil wawancara kepada tujuh partisipan di dapatkan kategori yaitu pekerjaan terkoordinir dengan baik, pendokumentasian menjadi lebih sistematis, pendokumentasian menuntut ketelitian. berikut penjelasan partisipan: “instruksi tercatat cukup jelas”, “keluhan-keluhan pasien mudah di catatnya” (p1) “jadi sbar ini lebih sistematis cara kerjanya”, “assesment nya pun sangat komprehensif”,data fokus, juga rekomendasi dan intervensi untuk mengatasi diagnosa keperawatan jadi lebih spesifik” (p2) indonesian journal of nursing practices 46 “kalo menurut saya pakai sbar..lebih teliti dan berurutan kalo tulisan atasnya betul otomatis nya tulisan bawahnya pasti ngikutin” (p1) “kalo pakai sbar..ga bisa mengarang, kita harus jeli dan ga bisa bila tidak melihat langsung kepasien nya.jadi perawat bisa benar2 fokus kepasien apalagi timbang terimanya membawa status pasien” (p1) b. memudahkan pertanggung jawaban keperawatan. berdasarkan hasil wawancara kepada tujuh partisipan di dapatkan kategori yaitu melaksanakan peraturan seperti yang diungkapakan partisipan sebagai berikut: “ya, kita laksanakan, karena merupakan acuan dan protap” (p2) “apalagi penilaian jci (joint commision international) memakai ini, kalo ditanya kamu ngelakuin apa sama pasiennya udah tinggal tunjukin aja dokumentasi, ada aspek legalnya juga”(p4) tema 2: manfaat penerapan handover menggunakan komunikasi sbar menurut pernyataan dari 7 partisipan terdapat banyak manfaat dalam melaksanakan handover menggunakan komunikasi sbar, menghasilkan subtema yaitu manfaat ke perawat, manfaat ke patient safety, dan manfaat ke pasien. adapun manfaatmanfaat tersebut akan di uraikan di bawah ini sesuai pernyataan partisipan. a. manfaat ke pasien. berdasarkan hasil wawancara dengan tujuh partisipan di dapatkan kategori pekerjaan terdokumentasi dengan baik, memudahkan perencanaan ke pasien, efisien dalam menjalankan tanggung jawab, lebih mengetahui keadaan pasien, dan meningkatkan mutu timbang terima. berikut ungkapan partisipan : “kita jadi tahu pasien itu sudah diapain seharian itu terus eeee (nada panjang) yang tidak dan yang belum dikerjain apa, jadi tinggal dilihat di sbar ini sudah terdokumentasi semuanya” (p4) “karena sudah tercantum disini, sama itu lo eeee (nada panjang) untuk melaksanakan intervensi yang sebelumnya atau yang akan dilakukan leb i h mudah” (p7) “waktunya lebih efisien ,karena tiap masingmasing tim jadi lebih tahu tanggung jawabnya, lebih efisien sih menurut saya, kita juga lebih tahu kondisi pasien kita masing2” (p3) “kita lebih tahu kondisi setiap pasien secara rinci ” (p5) “antara perawat yang jaga dan perawat yang selanjutnya terjadi peningkatan timbang terima..jadi lebih mengetahui keadaan pasiennya”(p5) b. patient safety bedasarkan hasil wawancara didapatkan kategori dalam patient safety yaitu mengevaluasi keselamatan pasien, memonitor keselamatan pasien, meningkatkan mutu perawatan dalam patient safety, terhindar dari resiko kejadian tidak diharapkan dan mengevaluasi keselamatan p as i e n. seperti yang diungkapkan patisipan sebagai berikut: “..kalau ke pasien sih saya rasa efektif, lebih safety, pagar, roda tempat tidur. sebelumnya kita tidak pernah seperti itu kalo dulu soap kita tidak memperhatikan itu..jadi sekarang ada .”(p6) “terus kalo yang untuk keselamatan pasien jadi meningkat, dengan melihat gelang identitas dan checklist pasien safety yang lain misalnya gantungan penanda resiko jatuh (p1) “yang kita rasakan memang meningkat, otomatis.. karena setiap kita melaksanakan timbang terima ada ceklist patient safety yang harus diisi.. (p1) “mengurangi resiko terjadi hal-hal yang tidak diinginkan kepasien”(p5) c. manfaat ke pasien berdasarkan hasil wawancara didapatkan kategori kategori yaitu pasien merasa senang, memudahkan dokumentasi dan menegakkan diagnosa keperawatan. vol. 3 no. 1 juni 2019 47 “iya, pasiennya malah senang kalo di validasi” (p4) “karena misal tiba-tiba suhu pasien tinggi maka tidak terdokumentasi jam berapa pasien suhunya tinggi tapi kalau menggunakan sbar terdokumentasi secara lengkap dan menggunakan sbar diagnosa pagi bisa berbeda dengan diagnosa sore” (p4) tema 3: hambatan dalam penerapan handover menggunakan komunikasi sbar dalam melaksanakan handover. berdasarkan hasil wawancara di dapatkan tema ketiga yang menggambarkan hambatan dalam penerapan handover menggunakan komunikasi sbar, adapun hambatan yang di dapatkan yaitu perbedaan persepsi perawat pada pendokumentasian, fasilitas yang kurang memadai, perawat kurang teliti, penggunaan waktu yang belum efektif, dan psikologis perawat. hamb atan hambatan tersebut akan di uraikan di bawah ini sesuai pernyataan partisipan. “kendalanya sempat terjadi perbedaan persepsi...tentang pengisian format implementasi dan intervensi...” (p1) “kolom terbatas, karena kekecilan”(p1) “yang kolaboratif nya kadang tertinggal ga ada di masukkan..kadang disitu sih biasanya yang miss nya, rencana ke pasien hari itu tidak ditulis disitu ..paling itu sih bu”(p1) “hambatannya lebih kepada ketepatan waktu penerapan timbang terima tersebut”(p3) “jenuh... (bosan) itu efek nya mba, kita jenuh, karena ini terus yang kita tulis kan jenuh...”(p2) tema 4: tantangan penerapan komunikasi sbar dalam melaksanakan handover. berdasarkan hasil wawancara di dapatkan tema keempat yang menggambarkan tantangan penerapan komunikasi sbar dalam melaksan ak an handover, adapun kategori yang di dapatkan yai tu menambah ilmu pengetahuan dan teknologi di bidang keperawatan serta mengikuti prosedur tetap rumah sakit. tantangan tersebut akan di uraikan sesuai pernyataan partisipan dibawah ini : “ya ini tertantang untuk membuka buku nanda lagi karena memvalidasi datanya mengangkat diagnosanya berdasarkan ini juga data yang muncul dipasien”(p4). “tantangannya berarti harus update, update tentang ilmu keperawatannya”(p4). “sudah harus pakai ini, ya kita laksanakan, karena merupakan acuan dan protap” (p2) tema 5: cara beradaptasi terhadap penerapan komunikasi sbar dalam handover. berdasarkan hasil wawancara di dapatkan tema kelima yang menggambarkan cara beradaptasi terhadap penerapan komunikasi sbar dalam handover, adapun cara beradaptasi yang di dapatkan antara lain tanpa subtema dengan kategori melakukan supervisi tindakan yang dilakukan perawat pelaksana, dengan subtema pengisian format sbar sesuai instruksi, penyesuaian dengan perubahan dan mengikuti sosialisasi. cara beradaptasi tersebut akan di uraikan di bawah ini sesuai pernyataan partisipan : “awalnya..kalau saya kemarin itu dari perawat pelaksana yang mengisi format komunikasi sbar jadi saya sebagai ketua tim hanya memonitornya.. jadi saya lihat lagi pada pasien itu, betul tidak yang dikerjakan perawat pelaksana” (p1) “saya menerima perubahan dan sambil belajar lah juga perlahan -lahan saya menjalani sesuai dengan apa yang ada di situ” (p5) “karena ada perubahan itu kita dikumpulkan di ruang rapat oleh kepala ruangan, kita saling belajar dan mendiskusikan tentang sbar ini” (p2) “dari manajemen dan komite keperawatan juga datang kesini sosialisasi dan menjelaskan tentang sbar ini “p6) tema 6: harapan terkait penerapan komunikasi sbar dalam melaksanakan handover.berdasarkan hasil wawancara di dapatkan tema keenam yang menggambarkan harapan terkait penerapan komunikasi sbar, adapun harapan yang di dapatkan meliputi harapan terhadap rumah sakit, harapan terhadap pasien, harapan terhadap perawat. harapan-harapan tersebut akan di uraikan sesuai pernyataan partisipan berikut: “harapan saya seluruh ruangan bisa memakai sbar juga”(p6) “dikembangkan lebih lanjut secara terus menerus karena merupakan acuan dan protap”(p2) indonesian journal of nursing practices 48 “kalo bisa kotak penulisan intervensi dan implementasi ini di perlebar“ (sambil menunjuk k e format sbar) (p2) “kalo menurut saya kotak penulisan ini di perbesar,(sambil menunjuk ke format sbar) misalnya kan kotak penulisan assesment ini b is a d i perkecil hasil pemeriksaan ini dan kolom recomendasi ini di besarin” (p6) “catatan perkembangan keperawatan itu berkesinambungan nanti nya, asal memang dilihat dari shift ke shift berikutnya jadi pelayanan kepasien nya tetap berlanjut pakai sbar” (p1) “keselamatan pasien meningkat., mutunya juga meningkat tingkat kepuasan pasien terhadap pelayanan meningkat.”(p1) pembahasan tema pertama pada penelitian ini yaitu tentang pengalaman penerapan komunikasi sbar pada perawat dalam melaksanakan handover. tema ini didukung hasil penelitian yang dilakukan oleh catherine d, et.al. (2011). improving patient safety though provider communication strategy enhancements yaitu sbar telah menjadi standar untuk berkomunikasi dalam perawatan pasien, sbar efektif dalam menjembatani perbedaan dalam gaya komunikasi dan membantu untuk mendapatkan persamaan persepsi antar tim medis. komunikasi sbar merupakan suatu tekhnik informasi dan komunikasi yang sangat efektif dalam pelaksanaan handover yang membantu perawat dalam melaksanakan pekerjaan dan memudahkan mengidentifikasi kesalahan serta memfasilitasi perawatan pasien yang berkesinambungan sehingga memberikan informasi yang jelas pada tim perawat setiap pergantian shift karena semua informasi yang telah tercatat dalam status pasien, disampaikan secara berurutan dan ringkas. tema kedua dalam penelitian ini yaitu manfaat penerapan komunikasi sbar pada perawat dalam melaksanakan handover. tema ini didukung teori yang di uraikan oleh parry, j. (2012) tentang improving clinical communication using sbar “improving care, delivering quality yaitu komunikasi sbar dapat meningkatkan informasi, meningkatkan keefektifan pemberian pelayanan, dan dapat meningkatkan keselamatan pasien dan mencakup semua aspek dalam asuhan keperawatan yang diberikan kepada klien. sbar merupakan alat komunikasi yang efektif dalam meningkatkan patient safety dimana terdapat proses memonitor, mengevaluasi keselamatan pasien dan terbukti dapat meningkatkan mutu patient safety di rumah sakit, dengan penerapan komunikasi sbar ini kepercayaan masyarakat terhadap citra rumah sakit sebagai pelayanan kesehatan juga semakin baik. tema ketiga dalam penelitian ini adalah hambatan penerapan handover menggunakan komunikasi sbar tema ini didukung teori yang diuraikan oleh amirah. (2013). hubungan komunikasi (mendengarkan, menjelaskan dan kompetensi) dengan kepercayaan, kepuasan dan loyalitas pasien instalasi rawat jalan rumah sakit di makassar yaitu faktor yang mempengaruhi komunikasi adalah persepsi, nilai, emosi, latar belakang, peran, pengetahuan dan hubungan. perawat yang memiliki sikap dan persepsi baik dalam pekerjaannya akan memiliki kinerja yang baik dalam pendokumentasian keperawatan, apabila komunikasi dan pengetahuan perawat baik, maka layanan yang diberikan akan efisien dan efektif. tema keempat dalam penelitian ini yaitu tantangan penerapan komunikasi sbar pada perawat dalam melaksanakan handover, tema ini didukung hasil penelitian yang dilakukan oleh fitria, n.c. (2013) efektifitas pelatihan komunikasi sbar dalam meningkatkan motivasi dan psikomotor perawat di ruang medikal bedah rs pku muhammadiyah surakarta, pelatihan komunikasi sbar dapat meningkatkan motivasi dan psikomotor perawat dan meningkatkan budaya kerja perawat dalam melakukan asuhan keperawatan sehingga dapat meningkatkan keselamatan pasien. perawat professional mempunyai tugas memberikan asuhan keperawatan yang bermutu dengan cara meningkatkan pengetahuan, sikap dan keterampilannya. perawat dituntut memiliki kemampuan dalam meningkatkan mutu asuhan keperawatan dengan memanfaatkan ilmu pengetahuan dan teknologi, bisa didapat pada vol. 3 no. 1 juni 2019 49 pendidikan formal maupun non formal, hal ini dilakukan sebagai upaya untuk menghilangkan kesenjangan pengetahuan, sikap dan keterampilan perawat, selain itu terlaksananya pentingnya komunikasi yang efektif dengan teknik komunik asi sbar saat handover dapat meningkatkan efisiensi dalam pelayanan keperawatan. tema kelima dalam penelitian ini yaitu cara beradaptasi dalam penerapan komunikasi sbar pada perawat dalam melaksanakan handover. tema ini didukung oleh teori yang di uraikan oleh dewi.m (2012) tentang pengaruh pelatihan timbang terima pasien terhadap penerapan keselamatan pasien oleh perawat pelaksana di rsud raden mattaher jambi, menyatakan upaya nyata yang dapat dilakukan untuk meningkatkan kemampuan perawat dalam mengkomunikasikan keselamatan pasien salah satunya melalui pengintegrasian keselamatan pasien, dalam aktivitas operan jaga yang disosialisasikan me l alu i kegiatan pelatihan lanjutan terkait patient safety dan disediakannya format pemeriksaan keselamatan pasien pada medical record sehingga dapat memudahkan perawat pada saat melakuk an pemeriksaan keselamatan pasien. upaya yang dilakukan untuk meningkatkan kemampuan perawat melalui sosialisasi dalam bentuk ke giatan sosialisasi secara langsung di lapangan, langsung dari pimpinan ke perawat pelaksana, pelatihan lanjutan, dan disediakannya format sbar yang mendukung. sehingga perawat akan lebih fokus dan terarah dalam melakukan asuhan keperawatan. tema keenam yang diidentifikasi dalam peneli ti an ini adalah harapan terkait penerapan komunikasi sbar pada perawat dalam melaksanakan handover. tema ini didukung oleh penelitian triwibowo dan harahap (2016) bahwa penyebab utama adverse event, near miss, dan sentinel event dirumah sakit adalah faktor komunikasi. keselamatan pasien meningkat dengan adanya handover yang baik. baik buruknya pelaksanaan handover dapat mempengaruhi patient safety. sbar merupakan alat yang dapat digunakan pada saat handover untuk memberikan kualitas transf e r informasi dan dokumentasi asuhan keperawatan yang bermutu, pencatatan data klien yang lengk ap dan akurat, akan memberi kemudahan bagi perawat dalam menyelesaikan masalah pasien. sehingga dalam proses komunikasi tersebut juga terjadi peningkatan mutu asuhan keperawatan dan keselamatan pasien. kesimpulan makna yang di dapatkan dari penelitian ini menyatakan bahwa penerapan komunikasi sbar pada perawat dalam melaksanakan handover di rsud banjarmasin sudah terlaksana dengan baik namun belum berjalan secara maksimal dan mas i h terdapat banyak hambatan-hambatan yang di rasakan oleh perawat. adapun hambatan ters e b ut perbedaan persepsi, fasilitas format sbar yang kurang memadai, perawat yang kurang teliti, penggunaan waktu pengisian dokumentasi yang belum efektif dan terdapat psikologis perawat berupa perasaan jenuh efek dari pendokumentasian sbar. diperlukan upaya manajemen keperawatan meningkatkan penerapan metode sbar dan melakukan perbaikan format sbar untuk mengurangi hambatan yang dirasakan perawat sehingga pelayanan keperawatan berkelanjutan dan kepuasan pasien meningkat. referensi afiyanti & rachmawati. 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(2014). the structured communication tool sbar (situation, background, assesment and recommendation) improves communication in neonatology. sout african medical journal. https://e-resources.perpusnas.go.id/ http://www.biomedcentral.com/ http://www.ncbi.nlm.nih.gov/pubmed/19813557 http://www.ncbi.nlm.nih.gov/pubmed/19813557 http://www.1000livesplus/ https://journal.unigres.ac.id/ vol. 3 no. 1 juni 2019 51 stewart, k. r. (2016). sbar, communication, and patient safety : an integrated literature review.university of tennese at chattanooga.available from: <scholar.utc.edu> wahyuni. i. (2014). efektifitas pelatihan komunikasi s-bar dalam meningkatkan mutu operan jaga (handover) di bangsal wardah rs pku muhammadiyah yogyakarta unit ii. tesis. universitas muhammadiyah yogyakarta. terdapat dalam: <thesis.umy.ac.id> zees. r.f (2011). analisa faktor budaya organisasi yang berhubungan dengan perilaku caring perawat pelaksana di ruang rawat inap rsud prof. dr. aloei saboe kota gorontalo. tesis. universitas indonesia. http://thesis.umy.ac.id/ vol. 3 no. 2 december 2019 67 ijnp (indonesian journal of nursing practices) vol 3 no 2 december 2019 : 67-74 rahayu rahayu1, azizah khoiriyati1 1universitas muhammadiyah yogyakarta corresponding author: rahayu rahayu email: rahayu120496@gmail.com earthquake preparedness among nursing students article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.3295 abstract background: nursing science students are prospective nurses who have an important role in disaster management, including disaster mitigation, disaster response, and post-disaster rehabilitation. objective: this study aimed to investigate the earthquake disaster preparedness in nursing science students of universitas muhammadiyah yogyakarta. method: this study was a non-experimental study utilizing the quantitative method and descriptive survey design. the population of this study was active students of nursing study program at universitas muhammadiyah yogyakarta with a sample of 217 respondents. the sample was obtained using a proportional convenience sampling technique. the data were obtained through an instrument in the form of a valid and reliable earthquake preparedness questionnaire. the obtained data were then analyzed by using descriptive statistical analysis. results: the findings of this study indicated that the level of students' earthquake preparedness was still in the low category. the findings on the parameters supported it. students' knowledge and attitude towards an earthquake risk were in the high category while the emergency response plan parameter was included in the low category. the disaster warning system parameter was in the good category. at last, the resource mobilization parameter obtained was in a low category. conclusion: thus, it was concluded that the level of earthquake preparedness of nursing science students of universitas muhammadiyah yogyakarta was in a low category. these findings explained the urge for disaster preparedness for students in the nursing science study program. accordingly, routine training in earthquake disaster management is needed to improve students' disaster preparedness. keywords: earthquake; disaster preparedness; nursing students introduction yogyakarta is located in the area where the australian plate and eurasian plate have faults and basins, which makes it easy to experience plate shifts that can cause an earthquake (prasetyo, 2016). people, especially those in disaster-prone areas like yogyakarta, are required to prepare themselves to face disasters. one of the efforts is by increasing earthquake preparedness in the community. preparedness has four components used as parameters in evaluating earthquake preparedness. these components are knowledge and attitude about earthquake risks, emergency response plans, disaster warning systems, and resource mobilization (rahmawati, 2016). preparedness is an obligation for every community, including the school community. yogyakarta is known as the city of education. it is expected to be able to build awareness of disaster preparedness 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/5304 indonesian journal of nursing practices 68 starting from elementary school to university level through the world of education in yogyakarta. especially for nursing science students who are prospective nurses, they have an important role in disaster management, including disaster mitigation, disaster response, and post-disaster rehabilitation. therefore, researchers conducted a study to measure the level of disaster preparedness in nursing science students to create prospective nurses who are ready to face disasters. the results of a preliminary study conducted by researchers to ten students of the nursing study program at the universitas muhammadiyah yogyakarta showed that seven of them said they did not yet know about what preparations to take in the incident of an earthquake. based on this phenomenon, researchers were interested in investigating "the level of earthquake preparedness in students of nursing study program at universitas muhammadiyah yogyakarta.” method this study used a quantitative method with a descriptive survey research design. the study was conducted at the nursing study program of universitas muhammadiyah yogyakarta from february to june 2017. the subjects involved in this study were active students of nursing study program of universitas muhammadiyah yogyakarta, 2013-2016, with a total of 468 students. solvin's formula was used in sampling obtaining a sample of 216 respondents. the sampling technique used was the proportional convenience sampling technique. the data were collected by using an earthquake preparedness questionnaire which had been tested for its validity with r count of 0.395-0.851 and its reliability with r of 0.95. the questionnaire was then distributed to nursing science students. additionally, this study had been declared to have passed an ethical test by the research ethics committee of the faculty of medicine and health sciences, universitas muhammadiyah yogyakarta, with ethical number 195/ep-fkik-umy/iii/2017. the data were then analyzed using a descriptive statistical technique to calculate the preparedness index for each respondent, the preparedness index for each parameter, and the overall preparedness index for each student of nursing study program of universitas muhammadiyah yogyakarta. the earthquake preparedness index was calculated based on the weighted value of each parameter. data processing was done using a matrix of the number of questions of each earthquake preparedness parameters for students. results data on demographic characteristics of respondents in the table 1 serving the data from the class of 2013, the majority of respondents were 35 female students or 37.5% and 56 students or 100% of the total respondents had an age range of 21-23 years old (young adult 43 students or 76.8% of the total respondents did not join the disaster response organization and the majority of respondents which were 46 students or 92.1% of the total respondents had no experience of volunteering. meanwhile, the majority of respondents, 47 students or 83.9% of the total respondents, had experienced an earthquake. in table 1 presents the data from the class of 2014, most of the students, 33 students or 62.3% of the total respondents, were female and the majority of respondents, 50 students or 62.3% of the total respondents, had an age range of 21-23 years old (young adults). data on the activity of participating in the organization indicated that 35 students or 66% of the respondents from the class of 2014 did not join the disaster organization. additionally, the majority of respondents, 47 students or 88.7% of them, had no experience of volunteering even though 75.5% or 45 students had experienced an earthquake. table 1 showed the data from the class of 2015. most of the students, 45 students or 86.5% of the total respondents, were female, and the majority of respondents, 36 students or 69.2% of the total respondents, had an age range of 17-20 years old (late adolescence). in the data of joining an organization, it showed that students from the class of 2015, 36 students or 69.2% of the total respondents, did not join the organization, and most vol. 3 no. 2 december 2019 69 of them, 45 students or 86.5% had no experience of volunteering. moreover, most of the respondents, 42 students or 80.8% had experienced an earthquake. table 1 respondent characteristic data demographic data 2013 2014 2015 2016 f % f % f % f % gender male female 21 35 37,5 62,5 20 33 37,7 62,3 7 45 13,5 86,5 10 46 17,9 82,1 total 56 100 53 100 52 100 56 100 age late adolescence (17-20 y.o) young adult (21-23 y.o) 56 100 3 50 5,7 94,3 36 16 69,2 30,8 55 1 98,2 1,8 total 56 100 53 100 52 100 56 100 participating in a disaster response organization yes no 13 43 23,2 76,8 18 35 34,0 66,0 16 36 30,8 69,2 13 43 23,2 76,8 total 56 100 53 100 52 100 56 100 having the volunteering experience yes no 10 46 17,9 82,1 6 47 11,3 88,7 7 45 13,5 86,5 7 49 12,5 87,5 total 56 100 53 100 52 100 56 100 having an earthquake experience yes no 47 9 83,9 16,1 40 13 75,5 24,5 42 10 80,8 19,2 39 17 69,6 30,4 total 56 100 53 100 52 100 56 100 (source: primary data 2017) preparedness level for students from the class of 2013-2016 the results of data analysis using descriptive statistics indicated that the preparedness level of students from each class was as follows: tabel 2 preparedness level distribution among students class of indicators knowledge of earthquake emergency response plan disaster warning system resource mobilization overall preparedness f % f % f % f % f % 2013 high 39 69,6 9 16,1 22 39,3 35 62,5 7 12,5 fair 13 23,2 9 16,1 22 39,3 16 28,6 25 44,6 low 4 7,1 38 67,9 12 21,4 5 8,9 24 42,9 total 56 100 56 100 56 100 56 100 56 100 2014 high 41 77,4 9 17,0 23 43,4 18 34,0 8 15,1 fair 5 9,4 8 15,1 20 37,7 7 13,2 14 26,4 low 7 13,2 36 67,9 10 18,9 28 52,8 31 58,5 total 53 100 53 100 53 100 53 100 53 100 2015 high 25 48,1 8 15,4 14 26,9 8 15,4 5 9,6 fair 22 42,3 9 17,3 23 44,2 7 13,5 10 19,2 low 5 9,6 35 67,3 15 28,8 37 71,2 37 71,2 total 52 100 52 100 52 100 52 100 52 100 2016 high 28 50,0 7 12,5 11 19,6 12 21,4 4 7,1 fair 19 33,9 10 17,9 28 50,0 7 12,5 5 8,9 low 9 16,1 39 69,6 17 30,4 37 66,1 47 83,9 total 56 100 56 100 56 100 56 100 56 100 (source : primary data (2017) indonesian journal of nursing practices 70 table 1 showed the data from the class of 2016. most of the students, 46 students or 17.9% of the total respondents were female and the majority of respondents, 55 students or 98.2% of the total respondents, had an age range of 17-20 years old (late adolescence). as many as 43 students or 76.8% of the total respondents did not join the organization and the majority of respondents, 87.5% of the total respondents, had no experience of volunteering. furthermore, the majority of the respondents, 39 students or 69.4% of them, had experienced an earthquake. based on table 2, it can be seen that the parameters of knowledge and attitudes towards earthquake risk had a high-level of preparedness category. to be specific, the class of 2014 had the highest level of preparedness compared to other classes, as many as 41 students or 77.4% of the total respondents. emergency response plan parameters had a lowlevel preparedness category, especially from the class of 2016 with 39 students or 69.6% of the total respondents. the disaster warning system had a level of preparedness in the good category. the class of 2016 had the highest category in this parameter compared to other classes with 28 students or 50% of the total respondents. the resource mobilization parameter had a low level of preparedness. among the class of 2013-2015, the class of 2015 and 2016 had the lowest level of preparedness. there were 37 students or 71.2% of the total respondents in the class of 2015 and 37 students or 66.1% of the total respondents in the class of 2016 who obtained a low level of preparedness. according to the results of data analysis on each parameter using preparedness index formula, the results of earthquake preparedness for nursing science students at universitas muhammadiyah yogyakarta can be concluded to be in a low level of preparedness. the class of 2016 had the lowest preparedness level among others with 47 students or 83.9% of the total respondents. discussions a. knowledge and attitude towards disaster risk the analysis from table 2 indicates that the parameters of knowledge and attitude towards disaster risk were in high category, especially in the class of 2014 with 41 students or 77.4% of the total respondents. most of the students in the class of 2014 were activists of disaster response organizations. according to a study conducted by masyudi & rizki (2016), disaster organizations have training programs to deal with disasters. thus, individuals who are active in disaster response organizations have more opportunities to gain knowledge in dealing with disasters. table 1 showed that 75% of the total respondents in the class of 2014 had experienced an earthquake disaster. the more often a person is exposed to disasters, the more knowledge and attitudes he has towards a disaster. respondents who had experienced earthquakes had a high level of preparedness in knowledge and attitudes towards disaster risk. disasters experience or events that had been experienced by individuals can stimulate individuals to understand the process of dealing with disasters. therefore, it can affect the process of disaster preparedness, especially on knowledge and attitude to face disaster risk (becker et al., 2017). b. emergency response plan the emergency response plan in this study included organizing evacuations such as determining evacuation assembly points and communication related to disaster management institutions. based on table 2, the results of the emergency response plan preparedness level for the nursing science students of universitas muhammadiyah yogyakarta were in a low category. the class of 2016 had the lowest level of emergency preparedness plan among others where 69.6% of vol. 3 no. 2 december 2019 71 the total respondents in the class of 2016 had a low level of preparedness parameter. it indicates that organizing evacuations such as determining evacuation and communication assembly points relating to disaster management institutions had not been going well at the nursing study program of universitas muhammadiyah yogyakarta. a study by nakao, kawasaki & ohnisiaa (2019) concluded that the lack of community preparedness was due to the lack of available evacuation facilities such as evacuation sites or assembly points and inadequate collaboration between evacuation systems. based on the observations of the researchers at the nursing study program, lecture building did not have an assembly point location. meanwhile, according to a previous study by nuraini (2018), assembly point in public facilities such as schools are very important. the assembly point is useful for evacuating students and teachers to a safe place during an earthquake. c. disaster warning system disaster warning system parameters in this study had two indicators, namely knowing the source of disaster warning information in the learning environment and knowing both traditional and modern equipment that can be used for warning when a disaster occurs. table 2 showed that most nursing science students at universitas muhammadiyah yogyakarta had a good category of preparedness in the disaster warning system, especially in the class of 2015. among the other classes, the class of 2015 had the most students or 50% of the total respondents, who had a good category of preparedness level. it indicates that students have sufficient understanding of disaster warning and understand the equipment that can be used as a warning sign of disaster. the preparedness level in the disaster warning system can be influenced by culture or local wisdom of the surrounding community. the community around the research site has used clams and rang the bell/siren as a disaster warning system. indonesian have been implementing disaster warning systems using sirens, slit drums (kentongan), and other means of delivering information or warnings when an earthquake disaster occurs (hidayat & andi, 2017). the culture makes students understand or learn related to the existing disaster warning system in the environment around them. also, a study conducted by herminingrum & esti (2016) concluded that local wisdom has an important role in mitigation, especially for the disaster warning system. local wisdom can be applied as an effective instrument in disaster risk reduction in a community (zulfadrim et al., 2018). therefore, through the culture that exists in indonesian society, students can understand the existing disaster warning system in the surrounding environment. additionally, they also get to know the equipment that can be used as a disaster warning system. d. resource mobilization the parameter of resource mobilization capability used in this study was measured using indicators of participation in disaster-related training, seminars, or meetings. table 2 presented the finding of resource mobilization preparedness level for students of nursing science students at universitas muhammadiyah yogyakarta. the findings showed that the students were in a low category, especially in the class of 2016 and class of 2015. they had the lowest level of preparedness among others. it indicates the low participation of students in conducting disaster management training. this finding is in line with a study by wulansari, darumurti, & eldo (2017) which stated that people with low interest in participating in disaster management training have low disaster management skills causing low human resources in the community. disaster management training for communities is one of the significant ways to improve resilience and the quality of community human resources in dealing with a disaster (carone, 2019) indonesian journal of nursing practices 72 e. students’ preparedness level in facing an earthquake table 2 presented the analysis on the measurement of nursing science students’ level of earthquake disaster preparedness through four parameters, namely knowledge and attitude, emergency response plans, disaster warning system, and the ability to mobilize resources and the results of the preparedness level to face disasters. nursing science students of universitas muhammadiyah yogyakarta were categorized in the low level, especially those in the class of 2016, which had the lowest level of preparedness among others. in this study, students’ preparedness level was seen from a number factors such as training and simulation of disaster management for students to take part in, experiences of students volunteering in disasters, policies related to disaster to disaster preparedness programs, and infrastructure facilities that support the creation of a disaster preparedness community. the first factor was the training and simulation of disaster management participated by students. the resource mobilization parameter achieved a low category. it indicates that students were less active in participating in the training and simulation of disaster management. training and simulation are very important. even though students have a high level of knowledge and attitude towards disaster risk, they do not affect students' preparedness. this finding is in line with the research results of adenekan, balogun, & inem (2016) stating that even though knowledge and attitude towards disaster risk are included in the high category, they will not be influential in increasing the disaster preparedness if they are not followed by adequate training or disaster simulation. furthermore, previous studies by watkins et al. (2019) and tan et al. (2017) explain that training and simulations carried out routinely can improve one's skills as well as confidence in dealing with disasters. training can be optimal if it is followed by a simulation to test the community's readiness in dealing with disasters. previous studies by xia et al. (2016) and kaufman et al. (2017) explain that simulations can increase student preparedness because simulations can improve teamwork, problem-solving, and increase confidence in playing an active role in dealing with disasters. additionally, simulations can also improve skills in carrying out the incident command system (ics) on disasters. thus, individuals will get a better understanding of how to coordinate in a disaster and be ready to face a disaster. the second factor was the students' experience in disasters volunteering. it can be seen through the characteristics of respondent data in table 1. most of the students, 49 students or 87.5% of the total respondents in the class of 2016, did not have the experience of volunteering in a disaster. whereas, being a volunteer in a disaster can increase preparedness for students since volunteers are the first person to rescue a disaster victim. a study by pedersen et al. (2016) explained that individuals who have experience becoming volunteers (rescue team) tend to have a good level of preparedness and have a good coping mechanism in dealing with post-disaster trauma. hence, lack of experience in volunteering in a disaster can cause a low level of preparedness for students in facing an earthquake. students’ low preparedness level is the absence of policies or standard operating procedures (sop) in dealing with disasters. the absence of policies and sop can make students do not understand the procedures in dealing with disasters leading to a low level of students’ preparedness. besides, in his study, taufik (2016) also explained that school policy has an important role in a school located in a disaster-prone area. through the implementation of school policy, it can instill vol. 3 no. 2 december 2019 73 resilience or preparedness of students, teachers, and other stakeholders in dealing with disasters. the last factor was the available disaster management facilities and infrastructure. based on the observation, it was found that there was no evacuation route plan, evacuation assembly point, and disaster warning signs when a disaster occurs. meanwhile, the facilities and infrastructure for disaster management in a community is a supporting factor for the creation of a community prepared for disaster. the importance of facilities and infrastructures in a community is also explained in takahashi's research (2016), which stated that complete school facilities and infrastructures could support the creation of a disaster preparedness community. in addition to being access to education, schools also function as social security for the community. it means that the school has a function as a shelter or evacuation place for people affected by the disaster. thus, the availability of emergency management facilities and infrastructure is essential in a school. conclusions 1. most respondents have a high level of category preparedness for the parameters of knowledge and attitudes towards disaster risk. 2. most respondents have a low level of preparedness category for emergency response plan parameters. 3. most respondents have medium category preparedness for disaster warning system parameters. 4. most respondents have a low level of preparedness category for resource mobilization parameters. 5. most respondents have a low level of category preparedness in dealing with earthquake disasters. references adenekan, b. a., balogun, m. r., & inem, v. 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(2017). pengembangan sumber daya manusia dalam manjemen bencana. journal of governance and public policy, 4(3), 407-421. xia, s. s., yang, b. x., chen, x. l., petrini, m. a., schory, s. a., & liu, q. (2016). application and effects of a disaster nursing simulation training for chinese undergraduates. journal of nursing education and practice, 6(10), 8-15. zulfadrim, z., toyoda, y., & kanegae, h. (2018). the implementation of local wisdom in reducing natural disaster risk: a case study from west sumatera. in iop conference series: earth and environmental science, 106(1), 012008. iop publishing. jurnal mjn vol. 3 no. 1 juni 2016.indd 1 muhammadiyah journal of nursing yohanes andy rias1, elsye maria rosa2, falasifah ani yuniarti3 1) mahasiswa magister keperawatan universitas muhammadiyah yogyakarta 2) bagian fakultas kedokteran universitas muhammadiyah yogyakarta 3) bagian magister keperawatan universitas muhammadiayah yogyakarta pengembangan model konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer abstrak latar belakang: diabetic foot ulcer pada umumnya menyebabkan rendahnya self management behavior dan quality of life, yang memerlukan intervensi keperawatan untuk meningkatkan individual and family self management. intervensi ini merupakan proses perubahan perilaku pada penderita dan keluarga melalui pendidikan kesehatan. pendidikan kesehatan ini dilaksanakan melalui discharge planning dengan memberikan informasi, mengidentifi kasi kebutuhan dan merencanakan kepulangan serta mempersiapakan partisipan untuk meninggalkan pelayanan kesehatan dimulai saat masuk sampai pulang termasuk klien diabetic foot ulcer. tujuan penelitian: pengembangan model konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer. motode penelitian: penelitian ini menggunakan desain action research dengan pengumpulan data melalui the conceptual content cognitive map (3cm) dan triangulasi dilanjutkan dengan penyajian data secara deskriptif. jumlah partisipan sebanyak 4 pasien dan 4 keluarga untuk pre action research dengan accidental sampling, 6 perawat untuk action research dengan purposive sampling, 4 pakar untuk triangulasi dengan accidental sampling, dan 10 perawat dan praktisi dengan accidental sampling untuk validasi tools konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer. hasil: terdapat kategori kebutuhan partisipan dalam individual and family self management antara lain: (a) pengetahuan, (b) keyakinan, (c) regulasi diri, (d) fasilitas sosial, (e) self management behavior. hasil dari action research adalah tersusun tools konservasi discharge planning terstruktur dengan 4 siklus penelitian. kesimpulan dan saran: tersusun tools konservasi discharge planning terstruktur diharapkan dapat meningkatkan individual and family self management. perlu dilakukan penerapan dan validasi terhadap tools model konservasi discharge planning terstruktur. kata kunci: diabetic foot ulcer, tools, konservasi discharge planning terstruktur, individual and family self management. abstract background : diabetic foot ulcers generally causing low self management behaviors and quality of life, requiring of nursing intervention to improve individual and family selfmanagement. the intervention is the process of behavioral changes in patients and families through health education. health education for participants and families can be implemented through discharge planning to provide the information, to identify needs and to plan the return and to prepare participants to leave the health service, beginning at admission until discharge, including diabetic foot ulcers client. objective: to develop a model of the structured discharge planning conservation for individual and family self-management of diabetic foot ulcers. research methodology: this study using action research design by collecting data through the conceptual content cognitive map (3cm) and triangulation followed by presenting descriptive data. the number of participants in this study are 4 patient and 4 family for pre action research with accidental sampling, 6 nursing for action research with purposive sampling, 4 experts for triangulation with accidental sampling, and 10 nursing and practitioners with accidental sampling for validation of structured discharge planning conservation tools for individual and family selfmanagement of diabetic foot ulcers. results: there are categories of participants needs in the individual and family selfmanagement, which are: (a) knowledge, (b) beliefs, (c) self-regulation, (d) social facilities, (e) self management behaviors. the results of action research is the completion of discharge planning conservation tools that structured by four cycles of study. conclusion: the presence of structured discharge planning conservation tools expected to increase individual and family self management. necessary to implementation and validatin of tools model structured discharge planning conservation keywords: diabetic foot ulcers, tools, structured discharge planning conservation, individual and family self management. 2 muhammadiyah journal of nursing pendahuluan diabetes mellitus (dm) merupakan penyakit g a n g g u a n m e t a b o l i s m e k a r b o h i d r a t ya n g berlangsung kronis dengan komplikasi diabetic foot ulcer 1. diabetic foot ulcer (dfu) merupakan kerusakan jaringan akibat gangguan neurologis (neuropati) dan vaskuler pada tungkai yang pada akhirnya menjalani amputasi dan mempengaruhi quality of life penderita 2,3,4. quality of life (qol) dipengaruhi pengetahuan, dukungan sosial, regulasi diri dan self behavior 5,6,7,8. h a s i l k o n s e n s u s i n t e r n a s i o n a l t e n t a n g manajeman dan pencegahan dfu dari beberapa negara seperti di inggris insiden dfu sebesar 7,4%, di belanda 2,1%, swedia 3,6% dan 5,8% di amerika serikat dari partisipan dm 9,10. insiden dfu di negara berkembang mencapai 2-4% kenaikan lebih tinggi dibandingkan dengan negara maju 11. insiden dfu tahun 2005 mencapai 25% dengan rentang kenaikan 1,9%-2,6% setiap tahunnya 12. kenaikan jumlah partisipan dfu di indonesia belum tercatat dengan jelas, namun dapat terlihat dari kenaikan prevalensi dm. world health organization (who) menyebutkan penderita dm pada tahun 2000 berjumlah 8,4 juta jiwa dan diprediksi meningkat menjadi 21,3 juta jiwa pada tahun 2030. berdasarkan angka tersebut dapat diprediksi jumlah penderita dm yang mengalami dfu dengan tingkat resiko 25% mencapai 5,3 juta jiwa 13. berdasarkan profil dan informasi layanan rsud dr. moewardi surakarta tahun 2006 terdapat penderita dm sebesar 13.968 pada tahun 2005 dan meningkat tahun 2006 menjadi 15.365 penderita, diantaranya menderita dfu pada tahun 2005 sebesar 362 penderita dan meningkat pada tahun 2006 menjadi 487 penderita. data di bangsal dan poli bedah rsu dr. saiful anwar malang, menyebutkan bahwa dfu mengalami peningkatan sebanyak 11,8 % dari 118 kasus pada 6 bulan pertama menjadi 132 kasus pada 6 bulan kedua tahun 2011. data yang diperoleh di pku muhammadiyah unit ii terdapat 29 penderita dfu pada tahun 2012, 40 penderita dfu pada tahun 2013, dan pada tahun 2014 (januari-maret) terdapat 8 penderita dfu yang menjalani pengobatan rawat inap. pengobatan dfu berfungsi untuk mencegah dan meminimalisasi komplikasi akut maupun kronik yang berdampak pada self behavior dan qol 4, 6,7,8, 16. berdasarkan penelitian wijanarko (2012) dari 23 partisipan dfu sebanyak 15 partisipan (65,22%) dalam kategori pengetahuan kurang. penelitian souza (2013) menyatakan bahwa partisipan dfu memiliki keterbatasan aktifi tas dan kemauan yang rendah dalam melakukan kegiatan seharihari. pengetahuan dan kemauan yang rendah dapat digunakan sebagai tolak ukur dalam menilai self behavior. berdasarkan penelitian costa (2011) 10 partisipan dfu merasa kurang mendapatkan pendidikan tentang pengelolahan penyakitnya, presepsi negatif terhadap status kesehatan dan kesejahteraannya sehingga qol dalam kategori rendah. hasil penilaian qol partisipan dfu dari kategori dimensi fi sik sebesar 50%, dimensi sosial sebesar 25%, dimensi lingkungan sebesar 24%, dan dimensi psikologis sebesar 65% masing masing dalam kategori rendah. studi pendahuluan telah penulis lakukan pada 26 maret 2014, pukul 09.00 wib melaui wawancara 4 partisipan dfu beserta keluarga partisipan di ruang rawat jalan pku muhammadiyah unit ii yogyakarta, partisipan berusia rata-rata 56 tahun terdiri dari 2 pria dan 2 wanita yang menderita dm lebih dari 3 tahun dan mengalami dfu satu tahun terakhir. keluarga partisipan berumur rata-rata 33 tahun kesemuanya wanita. seluruh partisipan dalam pengobatan menggunakan obat oral, keseluruhan tidak pernah berolahraga, akan tetapi satu partisipan rajin memeriksakan kadar gula darah dan satu partisipan merasa terkadang bosan dalam pengobatan. ketiga partisipan mengalami masalah dalam pengaturan nutrisi dan merasa dibatasi untuk makan sesuai dengan keinginan. partisipan merasa menjadi beban keluarga dan rendah diri. partisipan dfu 3 muhammadiyah journal of nursing dan keluarga mengalami kebingungan tentang perawatan di rumah setelah keluar dari rumah sakit dan terkadang merasa letih serta bosan dalam pengelolahan dfu. hasil dari wawancara di atas bahwa partisipandfu mengalami masalah bosan dalam pelaksanaan pengobatan, merasa menjadi beban keluarga dan rendah diri, sedangkan keluarga terkadang merasa letih dan bosan dalam merawat partisipan serta kebingungan dalam melakukan perawatan di rumah. kesimpulan dari hasil wawancara adalah self management individu dan keluarga pada partisipan dfu dalam kategori rendah. menurut ryan & sawin (2009) individual and family self management merupakan proses perubahan perilaku pada penderita dan keluarga melalui pendidikan kesehatan meliputi proses self management (pengetahuan dan kepercayaan), hasil proksimal (self behavior) dan hasil distal (qol). pendidikan kesehatan bagi partisipan dan keluarga dapat dilaksanakan melalui discharge planning untuk memberikan informasi, mengidentifi kasi kebutuhan dan merencanakan kepulangan serta mempersiapakan partisipan untuk meninggalkan pelayanan kesehatan dimulai saat masuk sampai pulang dari rumah sakit 7,17, 18. layanan keperawatan di indonesia telah merancang format discharge planning, namun format dan pelaksanaanya hanya dalam bentuk pendokumentasian resume partisipan pulang, berupa informasi seperti intervensi medis dan non medis, jadwal kontrol, gizi yang harus dipenuhi setelah di rumah. cara tersebut merupakan pemberian informasi ke partisipan dan keluarga hanya untuk sekedar tahu dan mengingatkan, namun tidak menjamin partisipan dan keluarga mengetahui serta memahami faktor resiko yang dapat membuat penyakitnya kambuh, penanganan kegawatdaruratan terhadap kondisi penyakitnya, perawatan maintenance di rumah yang menyebabkan tingginya angka rehospitalisasi 19. terkait dengan individual and family self management serta pelaksanaan discharge planning di atas, maka peneliti memberikan solusi alternatif dengan mengembangkan konservasi discharge planning terstruktur. konservasi discharge planning terstruktur merupakan modifikasi discharge planning dengan konservasi myra e. levine yang meliputi 4 tahap yaitu knowledge analyse, discusion of needs, role play dan integrated evaluation. knowledge analyse yaitu item tools yang bertujuan bagaimana perawat mampu untuk mengetahui dan mampu menganalisis pengetahuan dan keyakinan partisipan dan k e l u a r g a t e n t a n g d f u s e p e r t i k o n s e r va s i integritas energi (pengunaan dan efek samping obat, penggunaan obat alternatif, program diet, dan istirahat), konservasi integritas struktural (rom, penilaian vaskularisasi, perawatan luka, personal hygine, dan manajemen nyeri), konservasi integritas personal (pengertian penyakit, tanda dan gejala, komplikasi, klasifikasi wagner, pengelolahan kecemasan dan spritual, fl eksibilitas diri serta autonomi), konservasi integritas sosial (peranan keluarga, hubungan sosial dan modifi kasi lingkungan). berdasarkan uraian di atas maka peneliti tertarik untuk melaksanakan pengembangan model konservasi discharge planning terstruktur yang merupakan strategi kombinasi kekuatan individu dan keluarga serta perawat sebagai educator diharapkan dapat memperbaiki self management individu dan keluarga meliputi proses self management (pengetahuan dan kepercayaan, kemampuan regulasi diri, dan fasilitas sosial), hasil proksimal (self behavior ) dan hasil distal (qol) pada partisipan dfu dan keluarga sebagai penelitian dengan action research. rumusan masalah b a g a i m a n a k a h p e n g e m b a n g a n m o d e l konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer di pku muhammadiyah unit ii yogyakarta. 4 muhammadiyah journal of nursing tujuan penelitian tujuan umum pengembangan model konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer di pku muhammadiyah unit ii yogyakarta. tujuan khusus 1) mengetahui kebutuhan partisipan dan keluarga terhadap individual and family self management diabetic foot ulcer di pku muhammadiyah unit ii yogyakarta. 2) mengetahui dan menyusun format tools discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer. 3) mengetahui tingkat pengetahuan praktisi dan perawat luka tentang konsep discharge planning dan individual and family self management diabetic foot ulcer. 4) mengetahui review format tools konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer kepada praktisi dan perawat luka. 5) mengetahui validasi kebutuhan partisipan dan keluarga terhadap individual and family self management diabetic foot ulcer yang telah dilengkapi dengan kebutuhan praktisi dan perawat. 6) mengetahui hasil triangulasi tools konservasi discharge planning terstruktur. 7) memberikan rekomendasi untuk meningkatkan self management individu dan keluarga pada partisipan diabetic foot ulcer di pku muhammadiyah unit ii yogyakarta. metode penelitian desain yang digunakan dalam penelitian ini terdiri dalam dua tahap, rancangan tahap pre action research menggunakan penelitian kualitatif dengan metode the conceptual content cognitive map (3cm) dilanjutkan dengan wawancara dan penyajian data secara deskriptif dan tahap kedua adalah action research dengan 4 tahapan siklus. lokasi dan waktu penelitian dilakukan di pku muhammadiyah unit ii gamping dan wilayah kabupaten bantul pada tanggal 05 juni 2014 sampai dengan 05 april 2015. variabel bebas dalam penelitian ini adalah konservasi discharge planning terstruktur, sedangkan variabel terikat adalah individul and family self management. adapun defi nisi operasional dalam penelitian ini antara lain: 1) konservasi discharge planning terstruktur adalah paket belajar mandiri yang meliputi materi pembelajaran yang dirancang dan dilaksanakan s e c a r a s i s t e m a t i s u n t u k m e m e n u h i s e l f management individu dan keluarga dalam mempersiapkan kepulangan melaui 4 tahap meliputi: knowledge analyse, needs of discusion, role play dan integrated evaluation pada klien diabetic foot ulcer (dfu) di ruang medikal bedah pku muhammadiyah unit ii gamping. 2) individual and family self management adalah informasi pengelolahan diri dan keluarga dalam membentuk perilaku self management penderita diabetic foot ulcer yang meliputi: a. p r o s e s s e l f m a n a g e m e n t , m e l i p u t i pengetahuan dan kepercayaan (selfeffi cacy, outcome expectancy, dan keselarasan tujuan); kemampuan regulasi diri (penetapan tujuan (goal sett ing), pengambilan keputusan dan kontrol emosi); fasilitasi sosial (pengaruh sosial, dukungan sosial, dan kolaborasi) b. hasil proksimal: self behaviour adalah aktivitas responden dalam perawatan mandiri penderita dfu dalam 7 hari terakhir meliputi penilaian meliputi : diet, aktivitas fi sik, pengobatan, kontrol gula darah dan perawatan dfu. c. h a s i l d i s t a l : q u a l i t y o f l i f e a d a l a h kemampuan responden untuk melakukan f u n g s i h i d u p n ya s e c a r a n o r m a l d i masyarakat menurut persepsi penderita dfu dengan penilaian berdasarkan who tahun 2003, meliputi: aspek fi sik (nyeri dan kenyamanan, kekuatan dan kelemahan, 5 muhammadiyah journal of nursing aktivitas seksual, istirahat dan tidur, fungsi sensoris); aspek psikologis (pikiran positif, pikiran, belajar, ingatan dan konsentrasi, harga diri, penampilan, perasaan negatif); h u b u n g a n s o s i a l ( h u b u n g a n s o s i a l , d u k u n g a n s o s i a l , a k t i v i t a s p e m b e r i pelayanan); lingkungan (kenyamanan fi sik, lingkungan rumah dan kondisi rumah, kepuasan kerja). instrumen dan metode yang digunakan dalam penelitian ini untuk menangkap kebutuhan partisipan dan keluarga dalam penatalaksanaan dfu adalah sebagai berikut: 1) wawancara dengan metode 3cm untuk mengklarifikasi dan menemukan secara mendalam isi dari persepsi kebutuhan partisipan. partisipan ditanya pertanyaan berdasarkan data respon mereka yang terdaftar pada metode 3cm. wawancara ini bertujuan untuk meningkatkan pemahaman peneliti tentang persepsi kebutuhan partisipan terhadap penatalaksanaan dfu. selama wawancara, peneliti mencatat temuan baru terkait dengan konten 3cm pada selembar kertas terpisah. pada akhir wawancara, lembar-lembar yang didapat ditempelkan ke peta 3cm. 2) perekam suara digunakan untuk merekam data dalam sesi wawancara tipe voice recorder 3gpp. 3) format konservasi discharge planning terstruktur yang akan dilakukan perbaikan format melalui action research a. knowledge analyse yaitu bagaimana seorang p e r a wa t m a m p u u n t u k m e n g e t a h u i dan mampu menganalisis pengetahuan partisipan dan keluarga tentang dfu seperti konservasi integritas energi (diet, aktivitas terkontrol, obat dan efek samping), konservasi integritas struktural (rom, perawatan luka, personal hygine, manajemen nyeri), konservasi integritas personal (goal congruence, outcome expectancy, self effi cacy, self regulation dan menjaga privasi partisipan), konservasi integritas sosial (sosial influence, sosial support, negotiated collaboration, rekreatif). b. discusion of needs yaitu melakukan diskusi antara perawat dengan partisipan dfu d a n k e l u a r g a m e n g e n a i k e b u t u h a n perawatan baik di rs maupun di rumah sesuai dengan penilaian dalam knowledge analyse karena juga merupakan kebutuhan yang dikehendaki sesuai konservasi energi, integritas struktural, integritas personal dan integritas sosial sesuai dengan knowledge analyse. c. role play dilakukan dengan melakukan demonstrasi dan skill pada partisipan dan keluarga dalam manajemen dfu seperti konservasi integritas energi (menu praktis dfu, pemaparan obat dan efek samping, jadwal kegiatan dan pengaturan istirahat), konservasi integritas struktural (rom ankle, perawatan luka, membalut luka, terapi suntik insulin, relaksasi nafas dalam, dzikir khafi , seterilisasi alat), konservasi integritas personal (goal congruence, outcome expectancy, self effi cacy, self regulation), dan konservasi integritas sosial (berkeluh kesah kepada orang terdekat yang dipercayai, keluarga mampu menfasilitasi emosional, dan instrumental, dan dapat melakukan kerjasama antara perawat, kelurga dan partisipan). d. integrated evaluation merupakan tahap terakhir yang berfungsi untuk mengevaluasi atau menilai tingkat kesiapan partisipan dan keluarga dalam manajemen perawatan dfu. dirumah yang dilihat dari nilai knowledge analyse, discusion of needs dan role play yang telah dilaksanakan selama perawatan serta skrining faktor resiko pasien pulang. 4) kuesioner a. pengetahuan dan kepercayaan k u e s i n e r a ya n g t e r d i r i d a r i 2 0 i t e m pertanyaan, yang terdiri dari 7 item pertanyaan 6 muhammadiyah journal of nursing tentang self effi cacy, 6 item pertanyaan tentang harapan hasil dan 7 item pertanyaan tentang keselarasan tujuan. pertanyaan tentang self effi cacy dan harapan hasil diadaptasi dari the multidimensional diabetes questionnaire section iii yang dirancang untuk menilai faktor sosial dan kognitif terkait diabetes. pertanyaan tentang self-efficacy yang telah dimodifikasi oleh peneliti terdiri dari tujuh item pengukuran kepercayaan pasien dalam kemampuan mereka untuk melakukan perilaku khusus untuk aktivitas perawatan diri diabetes (yaitu, diet, olahraga, obat-obatan, pemantauan glukosa darah, perawatan kaki dengan foot ulcer dan manajemen diabetes). tanggapan didasarkan pada skala 1 (tidak yakin) sampai 4 (sangat yakin). pertanyaan tentang outcome expectancy (harapan hasil) dari mdq yang telah dimodifikasi peneliti terdiri dari enam item penilaian persepsi pasien dari efek perilaku perawatan diri diabetes pada kontrol metabolik dan pencegahan komplikasi diabetes. tanggapan didasarkan pada skala 1 (tidak berharap sama sekali) sampai 4 (selalu berharap). pertanyaan tentang keselarasan tujuan dari the goal instability scale yang telah dimodifi kasi oleh peneliti terdiri dari 7 pertanyaan untuk menilai kemampuan seseorang dalam menyelesaikan kebingungan dan kecemasan terkait dengan tujuan kesehatan. jawaban didasarkan pada skala 1 (selalu) sampai 4 (tidak pernah) 21. 5) kuesioner b. kemampuan regulasi diri kuesioner kemampuan egulasi diri telah dimodifikasi dari the short self regulation questionnaire (ssrq) terdiri dari 25 item pertanyaan dengan skala likert 1-4 22. pertanyaan positif dengan nilai 1 : sangat tidak setuju; 2 : tidak setuju; 3 : setuju; dan 4 : sangat setuju. pertanyaan negatif dengan nilai 4 : sangat tidak setuju; 3 : tidak setuju; 2 : setuju; dan 1 : sangat setuju. 6) kuesioner c. fasilitasi sosial kuesioner fasilitasi sosial terdiri dari 26 item pertanyaan yang terdiri dari 5 item pertanyaan tentang pengaruh sosial, 14 pertanyaan tentang dukungan sosial keluarga dan 7 pertanyaan tentang kolaborasi pasien perawat. pertanyaan tentang pengaruh sosial dimodifi kasi dari social infl uence on health behaviors questionairre yang berisi tentang utilitarian influence dan informational infl uence. nilai 1 ; sangat tidak setuju, 2; tidak setuju, 3 : setuju, 4 : sangat setuju23. pertanyaan tentang dukungan sosial keluarga dimodifikasi dari diabetes family behaviour checklist 24. nilai 1 ; tidak pernah, 2; jarang, 3 : sangat sering, 4 : selalu. pertanyaan tentang kolaborasi dengan. nilai 1 ; tidak pernah, 2; jarang, 3 : sangat sering, 4 : selalu. 7) kuesioner d. self management behavior kuesioner sdsca digunakan untuk mengukur self care behavior atau perilaku perawatan mandiri pada penderita dm tipe 2 25. kuesioner ini terdiri dari 12 item pertanyaan dengan nilai tiap item 1-7. skor berada pada rentang 1284. kuesioner ini berisi tentang kemampuan perawatan mandiri pasien dm tipe 2 meliputi : diet (3 item), aktivitas fi sik (2 item), pengobatan (1 item), pengecekan gula darah (2 item) dan perawatan kaki (4 item). 8) kuesioner e. kualitas hidup (quality of life) kuesioner quality of life dari who yang dimodifi kasi terdiri dari 26 item pertanyaan dengan skala likert 1-4. nilai11; tidak yakin, 2; cukup yakin, 3 : yakin,4; sangat yakin. rentang skor adalah 26-104. kuesioner ini meliputi aspek fi sik (7 item), aspek psikologis (6 item), aspek hubungan sosial (5 item) dan aspek lingkungan (8 item) penderita diabetes melitus 26. berdasarkan hasil uji validitas oleh gitawati (2013) pada kuesioner a (pengetahuan dan kepercayaan) didapatkan nilai p < α (0,05) namun terdapat 5 item pertanyaan yang tidak valid, yaitu item pertanyaan 1, 4, 9, 10 7 muhammadiyah journal of nursing dan 16. hasil uji validitas pada kuesioner b (kemampuan regulasi diri) didapatkan nilai p < α (0,05) namun terdapat 7 item pertanyaan yang tidak valid, yaitu item pertanyaan 2, 9, 11, 14, 15, 17 dan 20. hasil uji validitas untuk kuesioner c (fasilitasi sosial) didapatkan nilai p < α (0,05) namun terdapat 5 item pertanyaan yang tidak valid yaitu pertanyaan 9, 12, 14, 23 dan 25. hasil uji validitas untuk kuesioner e (kualitas hidup) didapatkan nilai p < α (0,05) namun terdapat 5 item pertanyaan yang tidak valid yaitu pertanyaan 2, 5, 8, 10 dan 18. pertanyaan pada kuesioner yang tidak valid di keluarkan dari daftar pertanyaan pada kuesioner tersebut. uji reliabilitas kuesioner dalam penelitian ini adalah: tabel 1. hasil uji reliabilitas kuesioner kuesioner nilai peneliti uji cronbach reliabilitas alpha kuesioner a 0,900 kuesioner b 0,880 gitawati kuesioner c 0,923 (2013) kuesioner d 0,917 kuesioner e 0,917 pre action research the conceptual content cognitive map (3cm) draf tools i konservasi discharge planning terstruktur action research siklus i melalui tahapan x siklus (pelatihan dan diskusi konservasi dp terstruktur) siklus ii (review tools konservasi dp terstruktur) siklus iii (validasi kebutuhan partisipan terhadap ifmst) siklus iv draf tools ii (triangulasi) konservasi discharge planning terstruktur siklus v (uji coba tools ii a1 dan a2) siklus vi (uji coba tools ii b1 dan b2) siklus vii tools ii c (uji coba tools knowladge analyse) tools konservasi discharge siklus viii tools ii c planning terstruktur (uji coba tools discussion of needs) siklus ix tools ii c (uji coba tools role play) siklus x (uji coba tools ii d integreted evaluation) model konservasi discharge planning keterangan : batas penelitian terstruktur : penelitian selanjutnya gambar 1 : kerangka kerja action research: pengembangan model konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer. 8 muhammadiyah journal of nursing hasil dan pembahasan berdasarkan hasil penelitian tahap pre action research, maka dapat diketahui karateristik informan penderita dfu (p) dan keluarga (k) berdasarkan jenis kelamin, umur, tingkat pendidikan, pekerjaan dan lama menderita dfu dapat dilihat di tabel 4.1. tahap action research dibagi menjadi 3 kelompok informan yaitu : kelompok perawat sebagai analisis kebutuhan informan pre action research, kelompok triangulasi sebagai analisis dari pakar, dan kelompok perawat sebagai uji validitas dan rehabilitas tools yang di action researchkan. tabel 2. karateristik informan tahap pre action research no kode informan jenis karateristik jenis kelamin pendidikan usia pekerjaan lama dfu 1 p1 (l) slta 36 pegawai negeri 6 bulan k1 (p) sarjana 32 guru 2 p2 (p) slta 43 pedagang 6 bulan k2 (l) slta 23 pedagang 3 p3 (l) diploma 40 pensiunan 6 bulan k3 (p) slta 37 rumah tangga 4 p4 (p) slta 52 pedagang 6 bulan k4 (p) s-1 ekonomi 24 wiraswasta * sumber primer peneliti, 2014 tabel 3. karateristik informan tahap action research (perawat) no kode informan jenis karateristik jenis kelamin pendidikan usia lama jabatan pekerjaan 1 p1 (l) ners 26 3 tahun perawat luka 2 p2 (p) ners 26 3 tahun perawat luka 3 p3 (p) ners 32 3 tahun perawat luka 4 p4 (p) diploma 34 3 tahun kepala ruang 5 p5 (p) ners 41 8 tahun manager keperawatan 6 p6 (l) ners 39 6 tahun perawat luka sumber primer peneliti, 2014 tabel 4. karateristik informan tahap triangulasi no kode informan jenis karateristik jenis kelamin pendidikan usia lama jabatan pekerjaan 1 p1 (l) prof.spbp (k) 59 32 tahun praktisi 2 p2 (l) doktoral 46 19 tahun praktisi keperawatan 3 p3 (l) magister 40 18 tahun praktisi keperawatan 4 p4 (p) magister 39 16 tahun dosen keperawatan * sumber primer peneliti, 2014 9 muhammadiyah journal of nursing tabel 5. karateristik informan tahap validitas dan rehabilitas tools no kode informan jenis karateristik jenis kelamin pendidikan usia lama jabatan pekerjaan 1 p1 (l) ners 33 13 tahun kepala ruang 2 p2 (p) ners 41 25 tahun perawat luka 3 p3 (p) ners 37 11 tahun perawat luka 4 p4 (p) ners 29 3 tahun perawat luka 5 p5 (p) ners 27 2 tahun perawat luka 6 p6 (l) ners 39 6 tahun perawat luka 7 p7 (l) ners 35 3 tahun perawat luka 8 p8 (l) ners 26 2 ,5 tahun perawat luka 9 p9 (l) ners 33 4 tahun perawat luka 10 p10 (l) ners 35 7 tahun dosen dan perawat luka * sumber primer peneliti, 2015 setelah dilakukan penelitian kepada informan yaitu penderita dfu dan keluarga diperoleh hasil action research dengan 5 point kategori kebutuhan dengan 26 sub kategori dengan total 106 frekuensi peryataan kebutuhan individual and family self management diabetic foot ulcer dengan metode 3 cm (conceptual content cognitive map) 10 muhammadiyah journal of nursing kategori 1 : pengetahuan kategori kebutuhan individual and family self management diabetic foot ulcer ke 1 adalah pengetahuan antara lain konsep dasar penyakit, kegunaan obat yang dipakai, penggunaan obat alternatif dan komplementer, cara ganti balutan, cara suntik insulin, cara test gula darah dan tata cara tayamum dengan total frekuensi 11 peryataan. berikut quotasi informan mengenai kebutuhan pengetahuan konsep dasar penyakit yang di “ nggih bingung mas boten ngertos pencegahane kajenge boten parah” (p4) terdapat satu quotasi tentang menginginankan informasi kegunaan obat terhadap informan yaitu: “ beberapa obat yang saya terima dari perawat itu saya juga masih bingung” (p1) obat alternatif dan komplementer juga muncul dalam quotasi informan meskipun dengan frekuensi satu peryataan “ daun insulin niku digodhog dulu, dimasak, direbus njuk nanti diminum” (k3) “ ke ustadz-ustadz orang pintar gitu malah dikasih apa itu, pakai air minum gitu lah” (p1) berikut merupakan quotasi informan bahwa membutuhkan cara suntik insulin dengan quotasi sebagai berikut: “ ngenehi contohe nek disuntik ki ngene ki lho pak” (p1) cara menganti balutan juga menjadi salah satu kebutuhan dengan quotasi partisipan meskipun hanya terdapat 2 peryataan dengan 1 quotasi sebagai berikut: “ pengin ganti dhewe, penak teles apa...apa lukane bernanah, tur ganti lan ngobati dhewe” (p2) cara cek gula darah secara mandiri juga menjadi salah satu kebutuhan partisipan meskipun hanya terdapat 3 peryataan dengan 1 quotasi sebagai berikut: “ tahu darahnya naik turun, butuh diajari carane ngetes….” (p2) tata cara tayamum juga muncul dalam pernyataan informan meskipun dengan frekuensi satu peryataan dengan 1 quotasi sebagai berikut: “ tayamum, ngak ngerti carane ngono lho, lupa caranya” (p1) kategori 2 : keyakinan kategori kebutuhan individual and family self management diabetic foot ulcer ke 2 adalah keyakinan meliputi kepercayaan terhadap budaya dan orang lain, kemauan diri sendiri (niat), tawakal (pasrah dan berusaha), dan keyakinan untuk sembuh dengan total 7 frekuensi peryataan. percaya kepada orang lain dan budaya menjadi salah satu kebutuhan partisipan dengan total frekuensi 1 peryataan dengan 1 quotasi sebagai berikut: “ ana tangga sing omong coba alternatif ndhana aku ki yo ndhana saya juga ke sana, wis tak lakoni orang pintar” (p1) kemauan diri sendiri (niat) menjadi salah satu kebutuhan partisipan dengan total frekuensi 1 peryataan dengan 1 quotasi sebagai berikut: tawakal menjadi salah satu peryataan dalam kategori kepercayaan ini sebanyak 2 frekuensi dengan 1 quotasi sebagai berikut: “ …..yang penting saya berusaha aja, saya berusaha, pasrah itu tawakal gitu lah sampai sekarang ini” (p1) berikut merupakan peryataan informan bahwa menginginkan keyakinan untuk sembuh sebanyak 3 peryataan dengan 1 quotasi sebagai berikut: “ kalau punya penyakit itu kan harus optimis harus sembuh ya” (k4). kategori 3 : fasilitas sosial berikut merupakan peryataan informan bahwa membutuhkan dukungan sosial meliputi dukungan keluarga, kunjungan teman sebanyak 4 peryataan dengan quotasi sebagai berikut: “ butuh dikunjungi sama keluarga, sama temen dan itu kan napa nggih saged nambah semangat kula ngaten lho.” (p1) dukungan spritualitas juga muncul dalam peryataan informan tetapi 1 frekuensi saja berupa doa kesembuhan untuk partisipan baik dari keluarga maupun dari pemuka agama dengan quotasi, yaitu: 11 muhammadiyah journal of nursing “ doa dari keluarga, lah kemaren itu juga apa saya sampai ke kyai-kyai, ke ustadz-ustadz” (p1) dukungan perawat juga menjadi salah satu kebutuhan partisipan meskipun hanya terdapat 4 peryataan “ perawate niku, sing mbake niku mbok sing sumeh, terus nek apa ngenehi penjelasan, napa-napa ngaten niku sing sumeh lah, seng alus” (k1) “ nggih penjelasan dokter napa perawat kajenge boten tambah parah “ (p4) dukungan dokter juga menjadi salah satu kebutuhan partisipan meskipun hanya terdapat 3 peryataan “ ...kalih dijak omong-omong, bapake keluhannya apa gitu, penyakitnya gimana ho o” (k3) b e r i k u t p e r ya t a a n i n f o r m a n m e n g e n a i kebutuhan negoisasi kolaboratif 2 terdiri dari intimasi intelektual dan konfl ik peryataan dengan 1 quotasi sebagai berikut: “ obat wae kayak gitu. saya pengennya kaya gitu. lah sapa ngerti nek aku seneng diombe ngono kan malah cepet mari, nek disuntik ngono kan yo rung karuan juga to, wong aku wis wedi dhisik. lha karepku ki doktere terbuka gitu lho, sama dokternya terbuka” (p1) b e r i k u t p e r ya t a a n i n f o r m a n m e n g e n a i kebutuhan akan alas kaki yang sesuai dengan kondisi kaki sebanyak 2 peryataan dengan 1 quotasi sebagai berikut: “…..sandal biasa tu ndhak muat gitu, kalau ada sandal yang lebih besar” (k3) glukometer pribadi juga menjadi salah satu kebutuhan partisipan meskipun hanya terdapat 2 peryataan dengan 1 quotasi sebagai berikut: “ lebih enak gadhah alat piyambak, kangge cek priksa gula darahe” (p4) pelindung perban anti air menjadi salah satu kebutuhan partisipan namun hanya terdapat 1 pernyataan dengan 1 quotasi “ mau perban seng ndak tembus air, anti air, ada gak ya…” (p1) berikut merupakan peryataan informan bahwa menginginkan perkembangan luka melalui foto sebanyak 1 peryataan dengan 1 quotasi sebagai berikut: “ … diweruhke lah fotone napa kan enten buktine wis marine sepira” (k1) akses pelayanan kesehatan dan home care juga menjadi kebutuhan dari partispan yang mempunyai 4 peryataan dengan 1 quotasi sebagai berikut: “ ke puskesmas jauh, daripada jauh-jauh repot, perawat suruh dateng ke rumah ngerawat di rumah” (k2) standart kegiatan yang terdiri dari 1 peryataan dengan quotasi sebagai berikut “ …dadi mbok ada, apa jenenge kuwi aturan sing padha ki apa jenenge, dadine ki le mengerjakan pekerjaan ki bisa sama” (k1) catatan tes darah merupakan peryataan partisipan sebanyak pemantauan gula darah, kolesterol, asam urat dan tekanan darah diperoleh sejumlah 7 peryataan, berikut salah satu quotasi informan: “ kepengin ngertos mas perkembangan gula darah, terus kalih tensi, terus kalih kolesterol” (p4) pemantauan asam urat diperoleh sejumlah 2 peryataan, berikut adalah salah satu quotasi informan: “ pengennya tau asam uratnya, biar kakinya tidak kesemutan dan cekot-cekot” (p3). kategori 4 : regulasi diri kategori kebutuhan individual and family self management diabetic foot ulcer ke 5 adalah regulasi diri yang terdiri dari penetapan tujuan, fl eksibilitas diri, autonomi, salutogenesis (mengenali masalah, mencari solusi, dan mengambil keputusan) dan kontrol pikiran (percaya diri, pikiran positif, pengelolahan stress: melihat tv, pergi berlibur, keliling rumah sakit). penetapan tujuan dan fleksibilitas menjadi salah satu kebutuhan partisipan dengan gabungan quotasi sebagai berikut: “ pengen mari, kepengin sembuh. dadi aku ki yo golek obat ki yo kepiye carane saya di rumah sakit sana kok nggak sembuh saya pindah” (p1). salutogenesis meliputi mengenali masalah, mencari soslusi, dan menetapan solusi menjadi 12 muhammadiyah journal of nursing salah satu kebutuhan partisipan dengan gabungan quotasi sebagai berikut: “ dadi aku ki yo golek obat ki yo kepiye carane saya di rumah sakit sana kok nggak sembuh saya pindah, saya di rumah sakit ngendi to kae, ning pku terus ning kono rada mendhing ning kok yo nggak kelong-kelong. ana tangga sing omong coba alternative ndhana aku ki yo ndhana saya juga ke sana. pernah tak coba kon mangan godhong kon mangan apa yo wis tak lakoni. yo intine ki ngene lho apa eee kita pandai-pandai, pandai-pandai mencari obat, mencari tempat pengobatan yang bagus, yo istilahe apa yo nek diomongke ki, nah berusaha, berusaha mencari tempat pengobatan yang bagus yang baik (p1) autonomi menjadi salah satu kebutuhan partisipan yaitu sebagai berikut: “ mbok pendapatku itu yo dihargailah karo doktere apa kepiye dihormatilah” (p1) berpikir positif dan percaya diri juga menjadi salah satu kebutuhan partisipan meskipun hanya terdapat 2 peryataan dengan gabungan 1 quotasi yaitu: “ banyak pikiran bikin gula darah naik juga, jadi gini lho pikirannya tu nggak optimis” (k4) “ isa tak suntik dhewe apa bojoku sing nyuntik ngono kuwi ki aku isa tambah pede” (p1) pengelolahan stres juga menjadi salah satu kebutuhan partisipan meskipun hanya terdapat 1 peryataan melalui 1 quotasi berikut ini: “ pengin keluar, main itu apa jalan-jalan, makan malam bersama ndhak stres” (p2). kategori 5 : self management behavior kategori kebutuhan individual and family self management diabetic foot ulcer ke 5 adalah self management behavior yang terdiri dari olahraga, seks, istirahat, jadwal minum obat, rawat luka seperti manajemen balutan (membuang jaringan mati, kontrol bau, dan kontrol eksudat) serta pola makan meliputi jadwal makan dan menu makanan (tinggi protein, pengganti nasi/rendah karbohidrat dan rendah gula). kategori kebutuhan individual and family self management diabetic foot ulcer salah satunya adalah olahraga yang terdiri dari 1 quotasi “ kaki nak untuk tiduran bengkak ta malahan, enake ta jalan-jalan” (p2) kebutuhan seks dengan total frekuensi 1 peryataan menjadi salah satu kebutuhan partisipan dalam individual and family self management diabetic foot ulcer dengan quotasi sebagai berikut: “ ya intinya saya pengen berhubungan kaya gitu, hubungan suami istri ngono lho.” (p1) kategori kebutuhan individual and family self management diabetic foot ulcer adalah istirahat yang terdiri dari 1 peryataan saja. berikut peryataan informan mengenai kebutuhan akan istirahat sebanyak 1 quotasi “ soale kalau terlalu banyak jalan lukanya nganu lagi buka lagi” (k4). kebutuhan akan adanya jadwal obat juga diperlukan oleh para informan, salah satunya adalah berikut merupakan quotasi: “ perawat ngasih ngertos mas, nggih minum obat sami jam pinten kajenge teratur” (p4). rawat luka dalam manajemen balutan meliputi membuang jaringan mati, kontrol bau dan eksudat didapatkan sejumlah 1 quotasi, berikut ini peryataan informan: “ buang item-item sama itu perawatnya sama mas febinya ya buang yang hitamhitam biar bau dan yang iku apa kering item itu jadi putih, ho o meskipun disisakke yang sehat, ho o, sama itu yang ada lendirnya, lendir kuning ta itu dibuang, ho o itu biar bersih dan cepet kering nggak bau ” (p2). penanganan nyeri didapatkan 4 peryataan, berikut salah satu quotasi informan: “ langsung cekot-cekot tak kasih minum asam mefamat, antalgin itu bisa tho mas ” (p2). pola makan menjadi kebutuhan partisipan meliputi dua sub tema yaitu jadwal makan dan menu makanan. berikut merupakan peryataan informan bahwa membutuhkan jadwal makanan dengan quotasi sebagai berikut: “ jam segini udah nggak boleh makan juga harus tau kan kalau dm itu” (k4). 13 muhammadiyah journal of nursing menu makanan berdasarkan kebutuhan partisipan meliputi pengganti nasi atau rendah karbohidrat, tinggi protein, rendah gula dan resep makanan dm dengan total frekuensi sebanyak 9 peryataan. terdapat 2 peryataan tentang pengganti nasi didapatkan 1 quotasi dari informan yaitu: “ nasinya cuma terbatas, cuma berapa...berapa kali berapa sendok gitu ya” (k4). terdapat 1 peryataan akan kebutuhan akan protein yang tinggi dengan 1 quotasi: “ kan harusnya itu lho kayak, tuna, udang, cumi itu kan disaranin malahan” (k4). rendah gula juga muncul dalam peryataan informan dengan quotasi , yaitu: “ gula putih nggak. ho o.buah yang tidak terlalu manis ” (k4). resep makanan juga muncul dalam peryataan informan dengan 3 frekuensi berikut quotasi dari partisipan, yaitu: “ disuda napa boten dingge dhaharan ngaten mawon... oo niku resepe makanan sik boleh dimakan” (k3). draf tools konservasi discharge planning terstruktur tools mengacu pada teori konservasi myra e levine yang dikombinasikan dengan teori individual & family self management. draf ini belum dilakukan tahapan action research, hanya disusun berdasarkan telaah literatur dan hasil kualitatif (pre action). tools konservasi discharge planning terstruktur terdiri dari 3 bagian yaitu skrinning awal, implementasi dan evaluasi yang akan dipaparkan dalam paragraf-paragraf berikutnya. berdasarkan hasil wawancara dan literatur dalam formulir a (skrining konservasi discharge planning terstruktur) yang meliputi skrining, tinggi resiko perawatan, resiko jatuh, resiko dekubitus, dan pic. skrining awal diperlukan orientasi oleh anggota tim medis yang menangani, hak dan kewajiban klien serta penjelasan terhadap tindakan medis. skrining digunakan menentukan tindak lanjut lebih dini dalam penyusunan program pencegahan dan pembatasan yang dapat diimplikasikan pada discharge planning. discharge planning bertujuan mengidentifi kasi kebutuhan dalam mempertahankan fungsi maksimal setelah pulang melalui proses pengkajian berkelanjutan 19, 27. m e m p e r k e n a l k a n t i m m e d i s d e n g a n mengorientasi, menjelaskan hak dan kewajiban klien merupakan langkah awal dari perawatan prosedur discharge planning, kemudian dilakukan pengkajian terhadap keluhan utama yang dirasakan klien. hal tersebut difungsikan untuk menentukan tindakan umum yang akan dilakukan sebagai dasar pelaksanaan spesifi k dalam mereduksi keluhan utama. sistem pendukung sosial diperlukan dalam skrining awal yaitu mengenai kondisi tempat tinggal, pelayanan home care, dan akses pelayanan kesehatan. resiko tinggi perawatan untuk mengetahui intervensi yang akan dilakukan. resiko tinggi perawatan merupakan hambatan dalam pelaksanaan discharge planning 28. resiko tinggi perawatan dalam klien dfu seperti keadaan psikologis, fi sik, dan psikososial. resiko jatuh dan resiko dekubitus akan mempengaruhi kondisi pada klien dfu dalam perawatan dan proses persiapan dp. hal ini sesuai dengan penelitian rahmi (2011) bahwa dalam melakukan discharge planning perlu diperhatikan kondisi sosial dan keluarga dalam penangganan di rumah atau hal-hal yang mempengaruhi hambatan dan keberhasilan perawatan di rumah, sehingga dalam skrining awal diperlukan langkah-langkah pengkajian umum yang berhubungan dengan kesiapan klien dan keluarga terhadap kesiapan pulang. pencatatan tools implementasi konservasi discharge planning terstruktur dilakukan perbaikan format melalui action research dalam sub kategori knowledge analyse. knowledge analyse merupakan item untuk mengetahuai seorang perawat mampu mengetahui dan menganalisis pengetahuan 14 muhammadiyah journal of nursing partisipan serta keluarga tentang dfu seperti konservasi integritas energi (diet, aktivitas terkontrol, obat dan efek samping), konservasi integritas struktural (rom, perawatan luka, personal hygine, manajemen nyeri), konservasi integritas personal (goal congruence, outcome expectancy, self effi cacy, self regulation dan menjaga privasi partisipan), dan konservasi integritas sosial (sosial infl uence, sosial support, negotiated collaboration, rekreatif). berdasarkan hasil pre action research di atas disesuaikan dengan pembahasan sebelumnya mengenai kategori pengetahuan. pengetahuan yang baik merupakan kunci keberhasilan dari manajemen dfu secara mandiri didapatkan dengan knowledge analyse. knowledge analyse digunakan untuk meningkatkan pengetahuan dengan menganalisis pengetahuan dasar dari perubahan perilaku individu dan keluarga, serta menentukan tingkat kemampuan individu dalam melakukan perawatan secara mandiri. peningkatan pengetahuan pasien dan keluarga diketahui berkaitan dengan perbaikan perilaku, peningkatan kemampuan, serta kontrol yang lebih baik terhadap penyakit. discusion of needs merupakan panduan melakukan diskusi antara perawat dengan partisipan dfu dan keluarga mengenai kebutuhan perawatan baik di rs maupun di rumah. item knowledge analyse merupakan kebutuhan yang dikehendaki sesuai konservasi energi, integritas struktural, integritas personal dan integritas sosial. integritas personal meliputi keyakinan, harapan hasil, keselarasan tujuan, penetapan tujuan, self monitoring & pemikiran refl ektif, pengambilan keputusan, perencanaan, evalusi diri, kegiatan spritual, management of responses and behavior dan kualitas hidup. integritas energi meliputi jadwal dan resep menu, obat yang dikonsumsi, jadwal istirahat, cara mempermudah melakukan istirahat (tidur) dan integritas struktural meliputi penentuan manajemen nyeri baik farmakologis d a n o n f a r m a k o l o g i s , s e r t a m e n e n t u k a n kegiatan rom yang tepat. integritas sosial meliputi peran keluarga, hubungan sosial, serta penetapan modifi kasi lingkungan. berdasarkan penelitian muplihun (2013) bahwa diskusi dapat meningkatkan prestasi belajar dan motivasi. data di atas diperlukan diskusi untuk memudahkan klien dalam manajemen dfu yang terbagi dalam 4 pokok yaitu integritas struktural, energi, personal dan sosial. role play merupakan pelaksanaan demonstrasi dan skill dalam manajemen dfu seperti konservasi integritas energi (menu praktis dfu, pemaparan obat dan efek samping, jadwal kegiatan dan pengaturan istirahat), konservasi integritas struktural (rom ankle, perawatan luka, membalut luka, terapi suntik insulin, relaksasi nafas dalam, dzikir khafi , seterilisasi alat), konservasi integritas personal (goal congruence, outcome expectancy, self effi cacy, self regulation), dan konservasi integritas sosial (berkeluh kesah kepada orang terdekat yang dipercayai, keluarga mampu menfasilitasi emosional, dan instrumental, dan dapat melakukan kerjasama antara perawat, kelurga dan partisipan). integrated evaluation merupakan tahap terakhir dari item tools implementasi yang berfungsi untuk mengevaluasi atau menilai tingkat kesiapan partisipan dan keluarga dalam manajemen perawatan dfu di rumah yang dilihat dari nilai knowledge analyse, discusion of needs dan role play yang telah dilaksanakan selama perawatan serta skrining faktor resiko pasien pulang. berdasarkan analisis di atas dapat diperoleh bahwa penyusunan tools konservasi discharge planning terstruktur dapat digunakan sebagai langkah-langkah persiapan pulang klien dfu yang dimulai saat klien masuk sampai pulang dari rumah sakit. tools konservasi discharge planning terstruktur pada tahap ini bersumber dari kebutuhan partisipan dfu dengan penambahan dari literatur-literatur yang disesuaikan dengan kondisi partisipan, oleh karena itu diharapkan perawat melaksanakan persiapan pulang secara komperhensif dengan langkah-langkah yang tepat dan terstruktur. 15 muhammadiyah journal of nursing tahap action research a. tahap 1 (pertama) tahap pertama ini dilakukan diskusi konservasi discharge planning terstruktur dan konsep ifsmt dengan partisipan adalah 6 orang perawat rs pku ii muhammadiyah yogyakarta. hasil menunjukkan bahwa seluruh partisipan aktif dalam proses diskusi, memperhatikan, antusias, dan melakukan evaluasi serta memvalidasi hasil diskusi. partisipan mampu menerangkan kembali tentang konsep dasar konservasi discharge planning terstruktur dan konsep ifsmt dengan tujuan, serta tahapan proses. berdasarkan penelitian sukardjo (2007) menunjukkan hasil bahwa dengan diskusi dan memecahkan problem solving efektif meningkatkan pengetahuan sekaligus dapat memecahkan suatu masalah. diskusi suatu pengelihatan dua atau lebih individu yang berinteraksi secara verbal atau sasaran yang sudah ditentukan melalui cara tukar-menukar informasi mempertahankan pendapat atau pemecahan masalah 29. diskusi pada umumnya bertujuan memberikan informasi dan terjalin komunikasi interaksi dengan saling menukar informasi dan pada akhirnya memberikan kesimpulan dalam proses akhir diskusi. awal proses diskusi beberapa partisipan mengungkapkan bahwa discharge planning merupakan persiapan pasien pulang dengan memberikan informasi kepada pasien berupa obat, jadwal kontrol dan yang harus dihindari sebelum pasien pulang dan biasanya dilaksanakan selama kurang lebih 5 menit sampai 10 menit sesaat sebelum pulang. hasil action research menyimpulkan bahwa konservasi discharge planning terstruktur merupakan paket belajar mandiri dari awal sampai sebelum klien pulang meliputi materi pembelajaran yang dirancang dan dilaksanakan secara sistematis untuk memenuhi self management individu dan keluarga dalam mempersiapkan kepulangan melalui 4 tahap meliputi: knowledge analyse, needs of discusion, role play dan integrated evaluation pada klien diabetic foot ulcer (dfu). b. tahap ii (kedua) tahap ini dilakukan review dengan mengkaji dan mengevaluasi dengan memberikan masukan. hasil tahap ini partisipan menjelaskan perlu ditambahkan penilaian diantaranya skrinning nutrisi, keluhan utama dengan format pilihan, foto perkembangan luka minimal 3 kali, serta menghilangkan role play yoga. penambahan dan pengurangan item-item tersebut sesuai hasil review, bisa dilakukan atau tidak, dikaji perlu atau tidaknya penambahan yang harus dilakukan sesuai dengan literatur manajemen dfu. masukkan yang diberikan oleh partisipan mulai dari tata bahasa serta urutan item yang ada pada skrining awal dan partisipan melakukan evaluasi kebutuhan yang partisipan harus lakukan dalam pelaksanaan konservasi discharge planning terstruktur. menurut witt en, et al (2004) bahwa review adalah mentelaah dan memberikan masukkan terhadap sesuatu berdasarkan pengalaman dan literatur yang diketahui pereview. fungsi dari tahap dua ini adalah perawat sebagai partisipan dalam mereview tools konservasi discharge planning terstruktur mampu untuk memperbaiki dan menganalisis kebutuhan yang harus dipenuhi dalam pelaksanaan tools. c. tahap iii (ketiga) tahap ketiga dilakukan validasi kebutuhan partisipan individual and family self management dfu (pre action research). berdasarkan pemaparan hasil, maka dapat diketahui bahwa dengan validasi untuk meyakini kebenaran dan ketepatan data dalam kebutuhan individual and family self management. va l i d a s i p e n t i n g d a l a m p e l a k s a n a a n d f u sehingga mampu sebagai acuan dan bahan utama penyusunan tools. tools ini mampu dipertanggung jawabkan hasil luaran dari penelitian ini. tahap ini dilakukan validasi dengan teknik statistik deskriptif sederhana dalam penelitian kuantitatif meliputi kuesioner pengetahuan dan kepercayaan, kemampuan regulasi diri, fasilitas sosial, self management behavior, dan quality of life yang akan 16 muhammadiyah journal of nursing dipaparkan pada paragraf-paragraf selanjutnya. te r d a p a t 3 r e s p o n d e n d a l a m k a t e g o r i pengetahuan dan kepercayaan cukup dan 1 partisipan dalam kategori baik. pengetahuan dan kepercayaan dalam self managemen individu dan keluarga memiliki tiga subvariabel yaitu self effi cacy, outcome expectancy dan goal congruence. penderita dfu sebagian besar memiliki self effi cacy, outcome expectancy dan goal congruence pada kategori cukup dan kurang. self effi cacy menentukan bagaimana seseorang merasa, berpikir dan memotivasi dirinya sendiri untuk bertindak dan berperilaku. outcome expectancy memberikan keyakinan bahwa keterlibatan dalam perilaku tertentu akan menghasilkan hasil yang diinginkan dan goal congruence membantu seseorang menyelesaikan kebingungan dan kecemasan terkait dengan tujuan kesehatan (ryan & sawin, 2009). self effi cacy yang tinggi mendorong pembentukan pola pikir untuk mencapai outcome expectancy dan pemikiran untuk mencapai outcome expectancy akan memunculkan outcome expectancy yang nyata, namun hal ini harus didukung dengan goal congruence yang baik. pengetahuan dan kepercayaan merupakan komponen yang mendasari pelaksanaan self management individu dan keluarga, karena pengetahuan dan kepercayaan memberikan dampak pada perilaku yang lebih spesifik yaitu self efficacy, outcome expectancy dan goal congruence namun pengetahuan tidak mengarah secara langsung kepada perubahan perilaku self management, peningkatan pengetahuan terkait dengan peningkatan perilaku self regulation dan fasilitasi sosial 5. penelitian sebelumnya menyebutkan bahwa meningkatkan pengetahuan melalui edukasi dapat meningkatkan self effi cacy dan self management behavior pada penderita dm tipe 2 7. lorig (2001) menyebutkan pengetahuan dan kepercayaan sebagai bagian terpenting dari keberhasilan seseorang untuk melakukan self management. pengetahuan merupakan domain yang penting dalam membentuk perilaku seseorang. self effi cacy, outcome expectancy dan goal congruence yang kurang optimal pada partisipan dikarenakan penderita memiliki pengetahuan dan kepercayaan yang belum optimal. hal ini dibuktikan dalam hasil 3 cm sebagian partisipan meyatakan bahwa akses mendapatkan informasi untuk meningkatkan pengetahuan masih terbatas, belum ada penyuluhan secara terstruktur. pendidikan mempengaruhi proses belajar, makin tinggi pendidikan seeorang makin mudah orang tersebut untuk menerima informasi. seseorang dengan pendidikan tinggi, maka cenderung mendapatkan informasi dari orang lain maupun dari media massa. semakin banyak informasi yang masuk semakin banyak pula pengetahuan yang didapat tentang kesehatan. sebagian besar responden memiliki tingkat pendidikan slta. pengetahuan sangat erat kaitannya dengan pendidikan dimana diharapkan seseorang dengan pendidikan tinggi, maka akan semakin luas pengetahuannya. perlu ditekankan bahwa seorang yang berpendidikan rendah tidak berarti mutlak berpengetahuan rendah pula, tetapi peningkatan pengetahuan tidak mutlak diperoleh di pendidikan formal, tetapi juga non formal. responden dalam penelitian ini sebagian besar memiliki status ekonomi yang cukup. status ekonomi seseorang juga akan menentukan tersedianya suatu fasilitas yang diperlukan untuk kegiatan tertentu, sehingga status sosial ekonomi ini akan mempengaruhi pengetahuan seseorang. lingkungan berpengaruh terhadap proses masuknya pengetahuan ke dalam individu yang berada dalam lingkungan tersebut. hal ini terjadi karena adanya interaksi timbal balik sebagai pengetahuan oleh setiap individu. pengalaman memberikan pengetahuan, mengembangkan k e m a m p u a n d a n m e n g a m b i l k e p u t u s a n . berdasarkan data-data diatas maka pengetahuan dan kepercayaan merupakan hal yang penting dalam pelaksanaan konservasi discharge planning terstruktur untuk meningkatkan individual and family self management dfu. k e m a m p u a n r e g u l a s i d i r i d a l a m s e l f 17 muhammadiyah journal of nursing management individu dan keluarga memiliki enam subvariabel yaitu menetapkan tujuan, monitoring diri, pengambilan keputusan, perencanaan tindakan, evaluasi diri dan kontrol emosi. kemampuan regulasi diri dari partisipan belum optimal. enam sub variabel dalam kemampuan regulasi diri sebagian besar berada pada kategori cukup dan kurang. kemampuan self regulation seseorang dapat mengubah respon seseorang, seperti mengendalikan impuls perilaku (dorongan perilaku), menahan hasrat, mengontrol pikiran dan mengubah emosi 7. kemampuan self regulation meliputi menetapkan tujuan, monitoring diri, pengambilan keputusan, perencanaan tindakan, evaluasi diri dan kontrol emosi berhubungan dengan perubahan perilaku kesehatan. regulasi diri merupakan penggunaan suatu proses yang mengaktivasi pemikiran, perilaku dan perasaan yang terus menerus dalam upaya untuk mencapai tujuan yang telah ditetapkan 5. penelitian sebelumnya yang dilakukan oleh rubin (1999) diperoleh kesimpulan bahwa diabetes education efektif untuk meningkatkan kemampuan self regulation pada penderita dm tipe 2 karena melakukan self regulation dengan edukasi memungkinkan seseorang memperoleh penguatan secara langsung, mengetahui perubahan kondisi kesehatan dengan segera dan dapat merasakan efek atau manfaat dari pengobatan dengan cepat. pada penelitian ini sebagian besar partisipan jarang dan belum melaksanakan perencanaan target dan strategi pencapaian serta evaluasi diri dan kontrol emosi. hal ini dikarenakan partisipan belum mengenal proses self regulation. kemampuan regulasi diri yang belum optimal pada responden menyebutkan bahwa masalah pribadi terkadang mempengaruhi pencapaian target yang telah ditetapkan salah satunya adalah masalah ekonomi. penjelasan yang diberikan oleh petugas kesehatan (dokter, perawat atau bidan) terkadang juga masih membingungkan sehingga keluarga dan responden merasa kesulitan untuk membuat target dan menyusun strategi serta enggan untuk bertanya kembali meskipun belum jelas. kemampuan regulasi diri menurut bandura (1997) dipengaruhi oleh faktor eksternal dan faktor internal. faktor eksternal terdiri dari standar dan penguatan, sedangkan faktor internal terdiri dari observasi diri, proses penilaian, dan reaksi diri. seseorang dapat mencapai standar tingkah laku tertentu, maka perlu penguatan agar tingkah laku semacam itu menjadi pilihan untuk dilakukan lagi. kemampuan regulasi diri yang kurang optimal pada responden memerlukan contoh standar perilaku kesehatan yang dapat disosialisasikan oleh para petugas kesehatan melalui media-media pembelajaran seperti melalui penyuluhan. fasilitas sosial dari partisipan belum optimal. tiga subvariabel dalam fasilitasi sosial sebagian besar berada pada kategori cukup dan kurang. teori individual and family self management menyebutkan bahwa self management yang baik memerlukan pengetahuan dan kepercayaan, kemampuan regulasi diri dan fasilitasi sosial yang baik pula. interaksi dari ketiganya dapat membentuk self management behavior yang baik pula 7. social infl uence berisi pesan yang menyarankan dan mendorong individu dan keluarga untuk terlibat dalam perilaku kesehatan tertentu. social support berisi dukungan emosional, instrumental, atau informasi yang diberikan kepada seseorang dengan tujuan eksplisit membantu atau memfasilitasi keterlibatan seseorang dalam perilaku kesehatan. kolaborasi merupakan kerjasama, interaksi, kompromi beberapa elemen yang terkait baik individu, atau pihak-pihak yang terlibat secara langsung dan tidak langsung yang menerima akibat dan manfaat 7. nilai-nilai yang mendasari sebuah kolaborasi adalah tujuan yang sama, kesamaan persepsi, kemauan untuk berproses, saling memberikan manfaat, kejujuran, dan kasih sayang 31. fasilitasi sosial dapat diartikan sebagai dampak dari kinerja yang berasal dari orang lain. dampak yang dihasilkan bisa positif (meningkatkan kinerja) maupun negatif (menurunkan kinerja). dampak yang dihasilkan dari fasilitasi sosial dipengaruhi 18 muhammadiyah journal of nursing oleh ketiga elemen dari fasilitasi sosial yaitu social infl uence, social support dan collaboration. seseorang yang telah memperoleh influence, support dan kolaborasi yang efektif akan dihasilkan fasilitasi sosial yang baik pula. penelitian sebelumnya oleh zajonc 1996 dalam gitawati, 2013 menyebutkan bahwa kerjasama dan interaksi dengan orang lain dapat meningkatkan fasilitasi sosial seseorang. hal ini dikarenakan kehadiran orang lain dapat meningkatkan reaksi tubuh akan meningkatkan kecenderungan untuk menampilkan respon yang sesuai dengan situasi sosial. fasilitasi sosial pada responden belum optimal dikarenakan social infl uence, social support dan collaboration yang belum optimal pula. aspek social support yang belum optimal dibuktikan pada 3cm dimana responden sering salah paham apabila keluarga bermaksud untuk mengatur m e n u d i e t r e s p o n d e n a t a u m e n g i n g a t k a n responden, sehingga keluarga sering mengalah pada keinginan responden. aspek collaboration pada responden masih ada rasa segan, malu dan takut ketika berhadapan dengan petugas kesehatan sehingga sulit terbentuk keterbukaan dan kerjasama, selain itu belum terlaksananya kegiatan home visit sebagai salah satu sarana untuk mendekatkan petugas kesehatan dengan responden serta keluarga. dukungan dari keluarga dapat meningkatkan fasilitasi sosial dan dapat diperkuat dengan k o l a b o r a s i o l e h t e n a g a k e s e h a t a n k a r e n a keduanya dapat meningkatkan kecenderungan untuk menampilkan perilaku yang sesuai dengan perilaku kesehatan yang seharusnya. berdasarkan hasil 3cm dan kuesioner diketahui bahwa self management pada respoden belum optimal karena pengetahuan yang kurang, kemampuan regulasi diri yang belum optimal dan kurangnya fasilitasi sosial. atas dasar itu disusun pembelajaran yang terstruktur yang berusaha merangkum ketiga aspek dalam proses self management agar dapat diaplikasikan kepada responden sehingga dapat meningkatkan self management behavior. edukasi dengan knowledge analyse, diskusi, role play dan integrasi evaluasi dilakukan dengan tujuan lebih mempererat kolaborasi antara penderita, keluarga dan petugas kesehatan. quality of life (qol) adalah persepsi individu terhadap posisi mereka dalam kehidupan dalam konteks budaya dan nilai dimana mereka hidup dan dalam hubungannya dengan hidup, harapan, standart dan perhatian. hal ini merupakan konsep yang sangat luas yang mempengaruhi kesehatan fisik seseorang, keadaan psikologis, hubungan sosial dan hubungannya dengan keinginan dimasa yang akan datang terhadap lingkungan mereka 33. hal ini karena dfu adalah penyakit kronis yang tidak dapat diobati secara tuntas, namun apabila terkontrol dengan baik dapat menghambat atau mencegah keluhan fi sik akibat komplikasi akut maupun kronisnya. penderita dfu dengan kualitas hidup yang rendah dapat memperburuk gangguan metabolik baik secara langsung melalui stres hormonal maupun tidak langsung melalui compliance yang buruk. pengelolaan dfu melalui berperilaku positif dalam menjalani penyakitnya, maka penderita mampu mempertahankan dietnya, dan mampu melakukan pola hidup yang sehat sesuai dengan diet. penderita bisa mengontrol kadar gulanya dengan baik, secara tidak langsung kualitas hidup penderita akan meningkat karena dengan keinginan yang konsisten untuk tetap mempertahankan kadar gula darah dalam rentang normal maka quality of life nya juga akan meningkat. d. tahap iv (keempat) ta h a p k e e m p a t m e n g g u n a k a n m e t o d e triangulasi untuk mengurangi bias dengan triangulasi sumber dan metode. triangulasi sumber dilakukan cross check data dengan fakta dari partisipan dan hasil dari penelitian lain. metode dilakukan dengan wawancara dan observasi pada partisipan-partisipan. tahap triangulasi penelitian ini menggunakan 4 pakar sesuai dengan keahliannya masing-masing untuk 19 muhammadiyah journal of nursing memberikan masukkan dan kemudian dilakukan revisi tools kembali sesuai masukkan pakar serta disesuaikan dengan literatur baik buku maupun jurnal penelitian dan di refleksikan dengan mengkonfi rmasi kembali ke pakar. tahap ini setelah dilakukan triangulasi awal maka banyak perubahan yang terjadi dalam draf tools konservasi discharge planning terstruktur meliputi formulir a1 (formulir skrinning awal), a2 (formulir skrinning fokus), b1 (pengkajian singted), b2 (treatmen plan), c (pencatatan intervensi konservasi discharge planning terstruktur) dan d (integrated evaluation konservasi discharge planning terstruktur). formulir a berisi tentang screening awal yang meliputi kesiapan partisipan untuk pulang, terdapat item resiko tinggi perawatan, pengkajian resiko jatuh, pengkajian dekubitus, penilaian tingkat nyeri, penilaian nutrisi (formulir mna), penilaian individual and family self management, hasil kultur bakteri, hasil laboratorium dengan format pilihan (√). formulir a2 berisi tentang formulir skrinning focus yang meliputi identitas dengan alergi obat, situation, foot screnning tool, masalah keperawatan, dan rencana keperawatan. pada formulir a1 dan a2 merupakan tools yang digunakan untuk melakukan deteksi awal pada klien dalam persiapan pulang dan tidakan yang akan dilakukan kedepannya. hal di atas sesuai dengan penelitian siahaan (2008) bahwa diperlukan untuk mendeteksi kesiapan pulang perlu dilakukan pengkajian untuk mengetahui sejak awal kesiapan klien pulang. formulir a diharapkan dapat mengetahui kesiapan klien dalam mempersipan tingkat kemandirian setelah dirumah sedini mungkin. formulir b1 merupakan pengkajian singted yang dikembangkan oleh dr. suriadi., bsn, mns, rn, awcs terdiri dari item size, inflammation, granulation, necrotic, tunneling, wound edge dan depth. singted lebih mudah diaplikasikan oleh perawat klinik kitamura dari pada penggunaan pengkajian design dan bwat dengan reliabelitas 0,978. berdasarkan penelitian fachrurrozi (2014) bahwa reliabelitas design 0,759 sedangkan reliabelitas bwat 0,978, namun dalam penggunaan tools ini hendaknya disesuaikan dengan kondisi tempat kerja dan harus dilakukan penelitian lebih lanjut untuk membandingan ketiga tools tersebut, sehingga dapat digunakan oleh perawat setempat. f o r m u l i r b 2 m e r u p a k a n t r e a t m e n t p l a n digunakan untuk mencatat intervensi perawatan luka berdasarkan time manajemen dan digunakan sebagai perhitungan biaya yang akan dikeluarkan terhadap barang habis pakai dalam pemilihan balutan, terdapat frekkuensi ganti balut serta prosentase luka secara umum. fungsi catatan digunakan sebagai catatan kendala waktu perawatan seperti adanya bledding, jaringan mati yang sulit diangkat, nyeri yang berlebihan waktu pengangkatan serta ketidakoperatifan dari klien. formulir c pada dasarnya ini masih sama dengan draf tools (hal 154) namun ada bebarapa penambahan sesuai dengan hasil evaluasi triangulasi seperti salutogenese dan pengahapusan dari yoga sebagai proses penurunan kecemasan dan nyeri. formulir d memiliki banyak perubahan dengan beberapa pengurangan item dikarena itemitem yang di hapus sudah tercantum dalam formulir item a dan b, namun dengan pengurangan tersebut juga terdapat penambahan item obat yang dibawa pulang dengan rekap nilai singted dari awal sampai akhir pengkajian. lembar evaluasi ini dapat dibawa pulang oleh klien dan digunakan sebagai data untuk pasien kontrol di poli luka. tahap keempat didapatkan bahwa dari semua partisipan mampu untuk memahami tools yang disusun akan tetapi ada beberapa kata yang kurang dipahami. hal ini dikarenakan masih awam tentang kelainankelainan medis pada anatomi kaki, namun hal ini akan bisa mudah dipahami dengan mengatahui kelainan anatomi kaki melalui gambar dan terdapat petunjuk dalam pelaksanaan tools yang disusun. beradasarkan hasil evaluasi dan refl eksi triangulasi didapatkan bahwa tools yang dibuat sudah sesuai dengan teori dan literatur yang ada dengan berbagai tahapan dalam penyusunan. 20 muhammadiyah journal of nursing implikasi bagi keperawatan hasil penelitian ini memberikan gambaran kebutuhan partisipan terhadap individual and family self management dfu. penelitian ini memberikan informasi masalah-masalah dan kebutuhan yang dihadapi partisipan dfu hasil penelitian ini dapat menjadi dasar peneliti selanjutnya untuk menerapkan konservasi discharge planning terstruktur degan penelitian kuantitatif sebagai valiadasi analitik. konservasi discharge planning t e r s t r u k t u r m e r u p a k a n wa d a h ya n g t e p a t untuk mengembangkan program pendidikan kesehatan baik individu maupun keluarga untuk meningkatkan kemampuan diri, dan belajar koping atau regulasi diri, fasilitas sosial, pengetahuan dan kepercayaan yang baru dalam mengatasi masalah, menemukan strategi dalam menejemen behavior dimana untuk peningkatan kualitas hidup. peneliti berharap hasil akhir penelitian ini tersusun model pengembangan konservasi discharge planning terstruktur. model konservasi discharge planning terstruktur yang peneliti susun diharapkan dapat dilakukan kajian ulang melalui penelitian grounded theory. berikut ini merupakan gambar model konservasi discharge planning terstruktur keterangan gambar contens level quadrant integreted pattern of needs 1 : knowing analyse p: personal kb : knowledge & believe 2 : discussion of needs e : energy sc : social facilies 3 : role play st : structure sr : self regulation 4 : integreted evaluation so : social mb : management behaviors gambar 3 model konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer 21 muhammadiyah journal of nursing tabel 6. definisi konsep model konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer content component i : core conservation structured discharge planning paket belajar mandiri meliputi materi pembelajaran yang dirancang dan dilaksanakan secara sistematis untuk memenuhi self management individu dan keluarga dalam mempersiapkan kepulangan melaui 4 tahap meliputi: knowledge analyse, discussion of needs, role play dan integrated evaluation pada klien. content component 2 : metaparadigma of nursing theory nurse profesi yang autonomi secara profesional keperawatan. fungsi profesional yaitu membantu mengenali, menemukan dan membantu kebutuhan klien dan keluarga berkaitan dengan proses keperawatan dengan dukungan informasi, emosioanal, intelektual, dan pengahargaan. diperhatikan tentang disiplin proses keperawatan mengandung elemen dasar, yaitu pengetahuan dan kepercayaan klien dan keluarga, fasilitas sosial, regulasi diri, dan self management behavior serta reaksi perawat dan tindakan perawatan yang dirancang untuk kebaikan klien dan keluarga berdasarkan spritual dan budaya. health terpenuhinya kebutuhan individual and family self management, sehingga bebas dari ketidaknyamanan fisik dan mental dan merasa adekuat. sehat dipengaruhi oleh karakteristik individu dan keluarga dalam peningkatan atau pengurangan manajemen diri. person seseorang yang bertindak atau berperilaku secara verbal dan nonverbal, terkadang dalam situasi tertentu manusia dalam memenuhi kebutuhannya membutuhkan pertolongan, dan mengalami distress jika mereka tidak dapat melakukannya serta memerlukan pengelolahan diri atau dengan kata lain individual and family self management. manusia dipengaruhi oleh kondisi spesifik. society situasi keperawatan yang terjadi ketika perawat dan klien berinteraksi, dan keduanya mempersepsikan, berfikit, dan merasakan dan bertindak dalam situasi yang bersifat segera. klien dapat mengalami distress terhadap lingkungan therapeutik dalam mencapai tujuannya, perawat perlu mengobservasi perilaku kline dikarenakan kondisi lingkungan untuk mengetahui tanda-tanda distress lingkungan. 22 muhammadiyah journal of nursing content component 3 : pattern of needs knowladge & belief 1. pengetahuan merupakan informasi factual dan persepsi tentang kondisi atau perilaku kesehatan 2. keyakinan adalah suatu kepercayaan terhadap segala informasi baik yang bersifat factual maupun non faktual yang dipengaruhi oleh spiritualitas dan kebudayaan dalam perilaku kesehatan social facilities merupakan dukungan baik instrumen, penghargaan, emosional, informasi dan spiritual untuk membantu atau memfasilitasi keterlibatan klien dan keluarga dalam perilaku kesehatan yang terdiri dari dukungan sosial, pengaruh sosial, negosiasi kolaboratif dan laporan perkembangan self regulation merupakan proses individu untuk mencapai perubahan dalam perilaku kesehatan dengan keterampilan dan kemampuan yang dimiliki antara lain penetapan tujuan, fleksibelitas diri, autonomi, salutogenese, dan kontrol pikiran self management perilaku perawatan mandiri yang harus dilaksanakan oleh behaviors individu dan keluarga meliputi aktivitas fisik, seks, istirahat, jadwal minum obat, rawat luka (management balutan & penanganan nyeri) dan pola makan (jadwal makan dan menu makanan) content component 4 :contextual factors individual and karakteristik individu dan keluarga yang meningkatkan atau family mengurangi manajemen diri, misalnya, status kognitif individu, perspektif, pengolahan informasi, tahap perkembangan, kemampuan dan kohesi individu dan keluarga, spesific conditions dan akal fisiologis, struktural, kondisi karakteristik fungsional, pengobatan, atau pencegahan yang mempengaruhi jumlah, jenis, dan sifat kritis perilaku yang diperlukan untuk mengelola kondisi pada saat stabilitas atau transisi. physical and faktor fisik atau sosial termasuk akses ke pelayanan kesehatan, environment transisi dalam penyedia atau seting layanan kesehatan, transportasi, lingkungan, sekolah, pekerjaan, budaya, dan modal sosial yang meningkatkan atau menghambat individu dan keluarga untuk melaksanakan manajemen diri adaptive pattern proses dimana individu mempertahankan integritas dalam menghadapi realitas lingkungan internal dan eksternal meliputi riwayat masa lalu, stimulus, pilihan akan keadaan. 23 muhammadiyah journal of nursing content component 5 : levels knowledge analyse bagaimana seorang perawat mampu untuk mengetahui dan mampu menganalisis pengetahuan partisipan dan keluarga tentang dfu seperti konservasi integritas energi (diet, aktivitas terkontrol, obat dan efek samping), konservasi integritas struktural (rom, perawatan luka, personal hygine, manajemen nyeri), konservasi integritas personal (goal congruence, outcome expectancy, self efficacy, self regulation dan menjaga privasi partisipan), konservasi integritas sosial (sosial discusion of needs influence, sosial support, negotiated collaboration, rekreatif). melakukan diskusi antara perawat dengan partisipan dfu dan keluarga mengenai kebutuhan perawatan baik di rs maupun di rumah sesuai dengan penilaian dalam knowledge analyse karena juga merupakan kebutuhan yang dikehendaki sesuai konservasi energi, integritas struktural, integritas personal dan role play integritas sosial sesuai dengan knowledge analyse. melakukan demonstrasi dan skill pada partisipan dan keluarga dalam manajemen dfu seperti konservasi integritas energi (menu praktis dfu, pemaparan obat dan efek samping, jadwal kegiatan dan pengaturan istirahat), konservasi integritas struktural (rom ankle, perawatan luka, membalut luka, terapi suntik insulin, relaksasi nafas dalam, dzikir khafi, seterilisasi alat), konservasi integritas personal (goal congruence, outcome expectancy, self efficacy, self regulation), dan konservasi integritas sosial (berkeluh kesah kepada orang terdekat yang dipercayai, keluarga mampu menfasilitasi emosional, dan instrumental, dan dapat melakukan kerjasama antara perawat, integrated evaluation kelurga dan partisipan). tahap terakhir yang berfungsi untuk mengevaluasi atau menilai tingkat kesiapan partisipan dan keluarga dalam manajemen perawatan dfu dirumah yang dilihat dari nilai knowledge analyse, discusion of needs dan role play yang telah dilaksanakan selama perawatan serta skrining faktor resiko pasien pulang. 24 muhammadiyah journal of nursing content component 6 : quadrants integrated energy 1. individu membutuhkan keseimbangan energi dan pembaharuan konstan dari energi untuk mempertahankan aktivitas hidup. konservasi energi bertujuan untuk menjaga keseimbangan energi sehingga input dan output sesuai atau seimbang untuk menghindari kelelahan yang berlebihan. 2. setiap orang membutuhkan keseimbangan energi tetapi ada faktor-faktor dalam pribadi dan lingkungan eksternal yang dapat menyebabkan menipisnya energi. mengacu pada masukan menyeimbangkan energi dan output untuk menghindari kelelahan berlebihan dan termasuk istirahat, gizi dan olahraga jantung. contoh: istirahat dan pemeliharaan gizi yang cukup. structure 1. perawat dapat membatasi jumlah jaringan yang terlibat dalam penyakit dengan deteksi dini terhadap perubahan 2. fungsi dan dengan intervensi keperawatan konservasi integritas struktur bertujuan untuk mempertahankan atau memulihkan struktur tubuh sehingga mencegah terjadinya kerusakan fisik dan meningkatakan proses penyembuhan. contoh: membantu pasien dalam latihan rom dan pemeliharaan kebersihan diri. personal konservasi integritas personal bertujuan untuk mengenali individu sebagai manusia yang mendapatkan pengakuan, rasa hormat, kesadaran diri, dan dapat menentukan nasibnya sendiri. setiap orang memiliki rasa sendiri senilai identitas dan diri. contoh: regulasi diri. social 1. seorang individu diakui sebagai anggota keluarga, anggota komunitas atau masyarakat, kelompok keagamaan, 2. kelompok etnis, dan sistem politik suatu bangsa melibatkan keberadaan dan pengakuan dari interaksi manusia, khususnya dengan orang lain yang signifikan dengan klien sebagai sistem dukungannya. contoh: posisi pasien di tempat tidur, mempromosikan penggunaan pasien dari surat kabar, majalah, dan sosial media. kesimpulan berdasarkan hasil penelitian dapat disimpulkan pengembangan konservasi discharge planning terstruktur sebagai berikut: 1. kebutuhan individual and family self management dfu terdiri dari pengetahuan dan keyakinan, regulasi diri, fasilitas sosial dan self management behavior. 2. tersusun draf tools konsevasi discharge planning terdiri dari 3 bagian yaitu skrinning awal, implementasi dan evaluasi. 3. peningkatan pengetahuan praktisi dan perawat luka tentang konsep discharge planning dan individual and family self management diabetic foot ulcer 4. terdapat hasil review format tools konservasi discharge planning terstruktur terhadap individual and family self management diabetic foot ulcer kepada praktisi dan perawat luka. 5. tervalidasi kebutuhan partisipan dan keluarga terhadap individual and family self management diabetic foot ulcer yang telah dilengkapi dengan 25 muhammadiyah journal of nursing kebutuhan praktisi dan perawat. 6. triangulasi tools konservasi discharge planning terstruktur oleh 4 pakar. 7. adanyarekomendasi untuk meningkatkan self management individu dan keluarga pada partisipan diabetic foot ulcer di pku muhammadiyah unit ii yogyakarta melalui format tools dan rancangan model konservasi discharge planning terstruktur. saran 1. berbagai bentuk model intervensi perlu diteliti dan dikembangkan guna meningkatkan individual and self management diabetic foot ulcer. diperlukan studi lanjutan yang mengkaji secara lebih mendalam pengalaman-pengalaman partisipan yang telah teridentifikasi dari penelitian ini, misalkan pengalaman keluarga dalam merawat anggota keluarga, pengalaman menghadapi kondisi hambatan-hambatan pada klien diabetic foot ulcer. 2. hasil penelitian ini menekankan pentingnya asuhan keperawatan yang berkesinambungan bagi penderita dfu. oleh karenanya institusi penyedia pelayanan keperawatan perlu menyusun suatu model yang mengintegrasikan perawatan di rumah sakit dan perawatan lanjut pasca hospitalisasi. hal ini dapat dicapai melalui beberapa cara, misalnya membentuk unit follow up care, atau bekerja sama dengan penyedia jasa pelayanan keperawatan yang berdekatan dengan tempat tinggal pasien sehingga memudahkan akses. 3. peneliti selanjutnya bisa menerapkan tools konservasi dan mengembangankan model discharge planning terstruktur untuk mengetahui p e n g a r u h n ya t e r h a d a p k u a l i t a s h i d u p baik melalui penelitian kualitatif maupun kuantitatif. daftar pustaka agustin, r. 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(2014). laporan tahunan diagnosa pasien. pku muhammadiyah yogyakarta. rondhianto. (2011). pengaruh diabetes self management education dalam discharge planning terhadap self efficacy dan self behaviour pasien diabetes mellitus tipe 2, tesis fkp universitas airlangga, surabaya. rosyad, y.s (2014). persepsi gay terhadap stigmatisasi gay oleh petugas kesehatan. skripsi stikes a.yani yogjakarta. ryan, polly & sawin, kathlen j. (2009). the individual and family selfmanagement theory: background and perspectives on context, process, and outcomes’, nurs outlook, vol. 57, no. 4, p. 217–225, retrieved september 12, 2013, from http://www. ncbi.nlm.nih.pdf. sarwono & meinarno (2009). psikologi sosial: individu dan teori-teori psikologi sosial, balai pustaka: jakarta. skarbek, edyta anna. 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(2013). flow chart perencanaan pulang. tesis universitas indonesia, jakarta. world health organization. (2012). health topics: diabetes. retrieved september 12, 2013. from http://www.who.int/topics/ diabetes_mellitus. wu, sf. (2007). effectiveness of self management for persons with type 2 diabetes following the implementation of a self efficacy enhancing intervention program in taiwan’, quensland university of technology schooll of nursing, retrieved september 12, 2013. from http://eprints.qut.edu.au/. 109 muhammadiyah journal of nursing abstract diabetes mellitus is a condition characterized by chronic hyperglycemia associated with insulin defi ciency. regular and measurable physical exercise can lower blood glucose levels and increase the endogenous antioxidant defenses, thereby the levels of lipid peroxidation (mda) can also decrease. the objective of this study was to determine the relation between blood glucose levels and kidney malondialdehyde levels in streptozotocin(stz)-induced rats which were given physical exercise. this study was purely experimental with group post-test only design. the subjects were 10 stz-induced male rats of sprague dawley strain. physical exercise was given for 9 weeks using a treadmill. the results of independent t-tests showed that the fasting blood sugar level of the rats was 0.048 and the kidney mda level was 0.767. pearson correlation test result of stz-induced rat group was only 0,799 and that of stz-induced rats with physical exercise was 0.35. in conclusion, there was no signifi cant correlation between fasting blood glucose levels and kidney mda levels after treatment. keywords: diabetes mellitus (dm), physical exercise, blood sugar, malondialdehyde, kidney. diyah candra anita k. stikes aisyiyah yogyakarta email: diyah.candra@yahoo.com kadar glukosa darah dan malondialdehid ginjal tikus diabetes yang diberi latihan fisik pendahuluan diabetes mellitus ditandai dengan kondisi hiperglikemia kronis yang disertai abnormalitas metabolisme karbohidrat, lipid, protein dan berkaitan dengan defi siensi insulin (adji, 2008; kumawat et al., 2011). kondisi hiperglikemia kronis akan mengakibatkan meningkatnya produksi radikal bebas sehingga terjadilah stres oksidatif (kumawat et al., 2011). stres oksidatif adalah peristiwa dimana radikal bebas yang berupa molekul reaktif, yang muncul melalui suatu reaksi biokimiawi dari sel normal merusak membran sel dan menyebabkan berbagai gangguan fungsi tubuh (adji, 2008). radikal bebas dalam tubuh akan menyebabkan kerusakan dna, karbohidrat, protein dan lipid (hanachi et al., 2009). stres oksidatif merupakan salah satu komponen pada mekanisme kerusakan jaringan pada manusia. stres oksidatif dapat ditunjukkan dengan meningkatnya malondialdehid (mda) serum maupun jaringan. malondialdehid terbentuk dari peroksidasi lipid (lipid peroxidation) pada membran sel yaitu reaksi radikal bebas (radikal hidroksil) dengan poly unsaturated fatt y acid (pufa). peningkatan mda ini menandakan adanya proses peroksidasi lemak yang berpotensi besar terjadinya komplikasi baik mikro maupun makrovaskular (marjani, 2010). salah satu upaya untuk mengontrol kadar gula darah adalah latihan fi sik yang teratur. latihan fi sik yang teratur dapat meningkatkan homeostasis glukosa, mengurangi rasio glukosa/insulin, dan meningkatkan sensitivitas insulin (angelis et al., 2000). otot yang aktif bergerak 110 muhammadiyah journal of nursing tidak memerlukan insulin untuk memasukan glukosa kedalam sel, selain itu latihan fi sik akan menyebabkan ambilan glukosa meningkat 7-20 kali lipat (indriyani et al., 2007). latihan fi sik mampu menyebabkan kerusakan oksidatif. kondisi paradoksal akan terjadi jika latihan fi sik tersebut dilakukan secara teratur dan terukur. hal ini dikarenakan adanya peningkatan pertahanan antioksidan endogen yang disertai penurunan kadar lipid peroksidase, selain itu dengan adanya penurunan jumlah produk akhir glikasi, maka suplai radikal bebas pada tubuh akan berkurang (atalay & laaksonen, 2002). latihan fi sik yang teratur diduga mampu menurunkan kadar glukosa darah dan kadar lipid peroksidase di serum maupun jaringan. oleh karena itu, pada kesempatan kali ini, penulis ingin meneliti tentang hubungan kadar glukosa darah dengan kadar malondialdehid (mda) ginjal pada tikus jantan sprague dawley induksi diabetes yang diberi latihan fi sik. metode penelitian penelitian ini merupakan eksperimental murni dengan rancangan post-test control group design. subjek penelitian ini adalah tikus putih jantan, galur spraque dawley (sd), usia 1112 minggu dengan berat badan 200-250 gram diinduksi streptozotocin dosis rendah yaitu 35 mg/kg bb serta memiliki glukosa plasma >200 mg/dl atau glukosa puasa >140 mg/dl. subjek dibagi menjadi dua kelompok, yaitu kelompok tikus yang diinduksi stz tanpa diberikan latihan fi sik teratur dan terukur dan kelompok tikus yang diinduksi stz dengan diberikan latihan fi sik teratur dan terukur. program latihan fi sik terukur dan teratur dilakukan 5 hari/minggu selama 9 minggu dengan treadmill. perlakuan latihan fi sik tersebut diawali adaptasi treadmill selama satu minggu dengan kecepatan 5 m/menit selama 10 menit, dilanjutkan 8 minggu dengan kecepatan bertingkat mulai 5 menit hingga 20 m/menit selama 1 jam dengan derajat kemiringan 0º (souza et al., 2007). minggu pertama adaptasi treadmill, tikus berlari dengan kecepatan 5 m/menit selama 10 menit. fase latihan rutin dimulai pada minggu kedua dengan kecepatan 5 m/menit selama 30 menit, minggu ketiga kecepatan 11 m/menit selama 30 menit, minggu keempat 14 m/menit selama 45 menit. minggu keenam hingga kesembilan, kecepatan treadmill 20 m/menit selama 1 jam. kadar gula darah puasa diukur sebanyak empat kali yaitu hari ke-3 (gdp1), hari ke-17 (gdp2), hari ke-47 (gdp3) dan hari ke-87 (gdp4) setelah induksi stz. pemeriksaan kadar mda ginjal diukur dengan pembuatan homogenat ginjal dan dibaca dengan spektofotometri. hasil dan pembahasan kadar gula darah puasa diukur 4 kali, yaitu hari ketiga sesudah induksi streptozotocin intra peritoneal (gdp1), hari ke-17 sesudah induksi (gdp2), hari ke-47 sesudah induksi (gdp3) dan hari ke-87 sesudah induksi (gdp4). sebelum pengambilan darah, tikus dipuasakan selama 8 jam. pengambilan darah dilakukan melalui pleksus retroorbitalis tikus sebanyak 1-1,5 cc. rerata gdp1 tikus setelah tiga hari diinduksi stz adalah 336,77±37,30 mg/dl dengan rerata berat badan 225,50±8,09 gram. rerata gdp2 tikus setelah diinduksi stz dan dikroniskan selama dua minggu adalah 307,70±35,66 mg/dl dengan rerata berat badan 241,60±10,74 gram. hasil pemeriksaan tersebut menunjukkan bahwa kadar gdp1 lebih tinggi daripada kadar gdp2. rerata gdp pada pemeriksaan pertama dan kedua peneliti sajikan dalam tabel 1. tabel 1. rerata kadar gula darah puasa sebelum randomisasi gula darah puasa mean±sem (mg/dl) hari ketiga setelah induksi stz (gdp1) 336,77±37,30 hari ketujuh belas setelah induksi stz (gdp2) 307,70±35,66 111 muhammadiyah journal of nursing gambar 1. rerata kadar gula darah puasa setelah randomisasi rerata gdp3 menunjukkan kadar yang lebih tinggi pada kelompok kontrol (329,46±76,99 mg/ dl) daripada kelompok perlakuan (256,36±50,68 mg/dl). rerata gdp4 menunjukkan kadar yang lebih tinggi pada kelompok kontrol (327,84±70,35 mg/dl) daripada kelompok perlakuan (167,94±31,44 mg/dl). tabel 2. uji beda prosentase gdp4 antara kelompok kontrol (stz) dan kelompok perlakuan (stz+latihan fi sik) kelompok mean±sem p value keterangan kelompok kontrol 327,84±70,35 0,048 ada beda bermaknakelompok perlakuan 167,94±31,44 hasil uji statistik yang diperoleh dengan menggunakan uji independent t-test tidak menunjukkan perbedaan yang bermakna rerata gdp setelah perlakuan pada kedua kelompok (p=0,048; p£0,05). hal ini disebabkan rerata perbedaan antara kedua kelompok yang besar, yaitu 159,90. nilai gdp4 pada kelompok perlakuan pun hampir mendekati batas normal yaitu 167,94 mg/dl; sedangkan nilai gdp4 pada kelompok kontrol masih menunjukkan angka yang tinggi dan menjauhi gdp normal (327,84 mg/dl), meskipun gdp pada kelompok kontrol tersebut masih dalam rentang mild hiperglikemia. hasil yang menunjukkan adanya perbedaan bermakna antara kedua kelompok diduga disebabkan nilai gdp pada kelompok kontrol yang tidak terlalu melonjak naik sementara kelompok perlakuan mengalami penurunan yang cukup signifi kan. kadar gdp pada kelompok kontrol tidak melonjak naik dikarenakan adanya mekanisme pankreas dalam mengkompensasi hiperglikemia (alsahli & gerich, 2010) akibat degenerasi reversibel pada sel β pankreas pada induksi stz dosis rendah (akbarzadeh et al., 2007). penurunan rerata gdp pada kelompok perlakuan setelah akhir perlakuan cukup tinggi yaitu 167,94 mg/dl, hal ini disebabkan karena perlakuan latihan fi sik teratur dan terukur akan menginduksi permintaan energi lebih tinggi (boor et al., 2009) sehingga ambilan glukosa meningkat 30-40 kali lipat (giriwijoyo, 2008). peningkatan permintaan energi di otot skelet disebabkan meningkatnya ambilan glukosa melalui glukosa transporter terutama glut 4 (goodwin, 2010). latihan fi sik teratur dan terukur juga dapat melindungi kerusakan sel beta pankreas pada tikus yang diinduksi stz sehingga dapat mencegah penurunan antoksidan endogen, seperti sod, gshpx dan katalase (coskun et al., 2004). tabel 3. uji beda independent t-test kadar mda ginjal kelompok mean±sem p value kelompok kontrol 9,03±1,01 0,767 kelompok perlakuan 9,40±0,64 hasil penelitian mda pada ginjal tikus kelompok kontrol (9,03 nmol/gr) maupun kelompok perlakuan (9,40 nmol/gr) menunjukkan rerata yang hampir sama, sehingga hasil uji signifi kansi antara kedua kelompok tidak ada beda yang bermakna (p=0,767; p³0,05). hasil penelitian tersebut menunjukkan bahwa latihan fi sik kurang berpengaruh terhadap penurunan mda pada ginjal tikus diabetes. terdapat beberapa dugaan yang mampu menjawab mengapa mda ginjal kelompok tikus yang diberi latihan fi sik justru 112 muhammadiyah journal of nursing lebih tinggi dibandingkan kelompok tikus yang hanya diinduksi stz saja. dugaan pertama adalah latihan fi sik yang dilakukan kurang berpengaruh terhadap kadar mda pada tikus disebabkan tikus tersebut sudah menderita diabetes kronis, sehingga kadar mda di ginjal sudah cukup tinggi. penelitian ini menggunakan tikus yang diinduksi stz (35 mg/ kgbb) dan setelah itu tikus tersebut dikroniskan selama 14 hari. menurut rungby et al. (1992) dan kakkar et al. (1998), peningkatan lipid peroksida di ginjal maupun hati sudah terjadi setelah satu minggu induksi stz dosis rendah tanpa disertai perubahan histopatologis ginjal. induksi stz dosis rendah mampu menciptakan kondisi diabetes dengan kerusakan minimal baik di ginjal maupun hati (koulmanda et al., 2003). dugaan yang kedua adalah kurangnya pembatasan makanan pada subyek penelitian. penelitian yang dilakukan lemos et al. (2012) menunjukkan adanya penurunan kadar mda plasma setelah 12 minggu, pada subyek diabetes yang diberi perlakuan latihan fi sik serta pembatasan makanan. sedangkan pada subyek dengan latihan fi sik saja tidak menunjukkan penurunan kadar mda setelah 12 minggu dan baru menunjukkan adanya penurunan mda setelah 6 bulan (24 minggu) latihan fi sik. penelitian yang dilakukan gordon et al. (2008) juga menunjukkan adanya penurunan kadar mda plasma sebesar 1,8% setelah subyek diberikan latihan fi sik selama 6 bulan (24 minggu), dan tidak menunjukkan penurunan signifi kan ketika latihan fi sik dilakukan selama 3 bulan (12 minggu). salah satu kelemahan dalam penelitian ini adalah peneliti hanya memberikan perlakuan berupa latihan fi sik teratur dan terukur tanpa memperhatikan dietnya. malondialdehid merupakan produk akhir dari pufa (purboyo, 2009) yang meningkat kadarnya akibat adanya peningkatan aktivitas acyl-coa (evans et al., 2002). dugaan ketiga adalah perlakuan latihan fi sik yang dilakukan pada penelitian ini masih kurang lama. latihan fi sik treadmill dalam penelitian ini hanya diberikan selama 9 minggu dengan kecepatan dan durasi yang ditingkatkan secara bertahap. penelitian yang dilakukan oleh leeuwenburgh & heinecke (2001) berhasil membuktikan bahwa latihan fi sik pada tikus yang bertujuan untuk endurance akan meningkatkan antioksidan dan enzim antioksidan di otot skelet maupun otot jantung setelah pemberian latihan fi sik selama 10 minggu. setelah 10 minggu latihan fi sik, kadar glutathion di otot yang aktif terbukti meningkat 33%, aktivitas glutathion peroksidase meningkat 62% dan kadar superoksid dismutase meningkat sebesar 27%. peningkatan aktivitas antioksidan tersebut akan mampu menurunkan kadar malondialdehid dalam tubuh. penelitian yang dilakukan oleh lemos et al. (2011) menyebutkan bahwa penurunan mda plasma mulai terjadi pada minggu ke-14 dengan pemberian latihan fi sik teratur dan terukur pada subyek dm. penelitian yang dilakukan oleh coskun et al. (2004) juga menyebutkan bahwa penurunan mda baik di eritrosit maupun jaringan tikus terjadi setelah pemberian latihan fi sik (renang) selama 12 minggu dalam berbagai intensitas. penelitian yang dilakukan oleh liu et al. (2000) menyebutkan bahwa, latihan fi sik yang dilakukan secara kronis selama 8 minggu akan mengakibatkan efek samping perubahan oksidan dan stres oksidatif. hal tersebut akan memiliki konsekuensi terinduksinya enzim antioksidan dan sintesis antioksidan untuk meminimalkan efek dari oksidan-oksidan tersebut. kelemahan lain dalam penelitian ini adalah peneliti tidak mengukur aktivitas antioksidan endogen guna memperkuat dugaan latihan fi sik yang diberikan masih kurang lama. dugaan keempat adalah stres yang dialami oleh tikus selama perlakuan latihan fi sik teratur dan terukur. kregel et al. (2006) menyebutkan bahwa exercise pada hewan coba sangat rentan dengan stres. ada beberapa cara yang dapat dilakukan guna mengurangi stres pada hewan 113 muhammadiyah journal of nursing coba yang diberi perlakuan berupa latihan fi sik. cara pertama adalah dengan melakukan perlakuan exercise sesuai dengan fase aktif alaminya berdasarkan ritme sirkadian. hal yang juga perlu diperhatikan adalah waktu yang digunakan untuk latihan adalah waktu yang sama pada setiap harinya. paparan yang berulang dalam waktu yang sama pada jam yang sama terbukti dapat menurunkan tingkat stres pada tikus (kregel et al., 2006). cara kedua adalah subyek pemberi perlakuan seharusnya adalah orang yang sama (kregel et al., 2006). cara ketiga adalah memastikan bahwa tikus yang akan diberi perlakuan latihan fi sik telah cukup makan dan minum. exercise membutuhkan kalori yang cukup sebagai bahan bakar energi yang digunakan. jika latihan fi sik dilakukan tanpa kalori yang cukup, maka akan terjadi penumpukan benda-benda keton akibat pembakaran lemah berlebih dan penumpukan asam laktat (giriwijoyo, 2008). faktor stres lain yang mempengaruhi adalah latihan fi sik yang dilakukan cukup melelahkan pada beberapa tikus kelompok perlakuan. menurut kregel et al. (2006), salah satu cara mengetahui kelelahan yang dialami oleh hewan coba adalah, performance yang buruk seperti tikus tidak mau berlari; tikus mengenai alat kejut listrik sebanyak 4 kali dalam 1 menit; peningkatan suhu; peningkatan asam laktat dan peningkatan nadi. semakin sering tikus mengenai alat kejut listrik pada treadmill, maka hal tersebut menandakan tikus mengalami kelelahan. menurut cooper et al. (2002), latihan fi sik yang melelahkan akan terkait dengan peningkatan pembentukan radikal bebas, terutama akibat konsumsi o2 yang meningkat di jaringan yang aktif. sebagian o2 yang dikonsumsi akan digunakan untuk fosforilasi oksidatif dalam mitokondria, yang kemudian dikurangi melalui perubahan bentuk menjadi air. sebagian kecil o2 tersebut (2-5%) dapat meninggalkan rantai transport elektron dan dikonversi menjadi radikal bebas sehingga menghasilkan ros. kondisi tersebut akan mengakibatkan ketidakseimbangan antara radikal bebas dengan antioksidan yang disebabkan adanya peningkatan konsumsi oksigen saat respirasi. oksigen yang berlebihan tersebut akan menghasilkan ros, terutama melalui kebocoran elektron yang berasal dari rangkaian transport elektron pada mitokondria dan oksidasi xanthine oleh xo (lemos et al., 2011). dugaan kelima adalah tingginya mda sebagai biomarker oksidatif stres pada dm tidak hanya disebabkan oleh hiperglikemia dan rage. sumber utama oksidatif stres pada dm adalah : (1) auto-oksidasi glukosa; (2) produksi ros yang berlebih pada mitokondria; (3) glikasi nonenzimatik dan; (4) jalur poliol (lemos et al., 2012). tabel 4. uji korelasi antara gdp dan mda ginjal tikus jantan yang diinduksi stz dan diberi latihan fi sik variabel signifi kansi r keterangan gdp terhadap mda ginjal tikus jantan induksi stz + latihan fi sik 0,351 0,537 tidak ada hubungan bermakna, kekuatan korelasi sedang tabel 5. uji korelasi antara gdp dan mda ginjal tikus jantan yang diinduksi stz saja variabel signifi kansi r keterangan gdp terhadap mda ginjal tikus jantan induksi stz saja 0,799 0,158 tidak ada hubungan bermakna, kekuatan korelasi sangat lemah hasil uji korelasi antara gdp dan mda ginjal menunjukkan hasil yang tidak signifi kan (p=0,351; p³0,05) dengan kekuatan korelasi sedang (r=0,537); demikian juga pada kelompok tikus yang diinduksi stz saja, hasil uji korelasi pearson juga menunjukkan tidak terdapat hubungan bermakna antara kadar gula darah puasa (gdp) setelah perlakuan terhadap kadar 114 muhammadiyah journal of nursing mda ginjal pada tikus jantan yang diinduksi stz saja (p=0,799; p³0,05) dengan kekuatan korelasi sangat lemah (r=-0,158). mda meningkat dikarenakan ketidakseimbangan antara produksi ros dan antioksidan dalam tubuh suatu organisme. meningkatnya produksi ros pada tikus yang diinduksi stz tidak hanya disebabkan oleh hiperglikemia, namun juga disebabkan oleh faktor yang lain. sumber utama ros pada dm adalah : (1) autooksidasi glukosa; (2) produksi ros yang berlebih pada mitokondria; (3) glikasi non-enzimatik dan; (4) jalur poliol (lemos et al., 2012). pada kondisi dm, terdapat peningkatan konsumsi nadph oleh enzim aldose reduktase pada jalur poliol. nadph diperlukan untuk membentuk antioksidan endogen glutathione (gsh). berkurangnya nadph akan mengakibatkan berkurangnya gsh dan semakin meningkatkan stres oksidatif. peningkatan ros pada mitokondria disebabkan oleh beberapa alasan, yaitu: (1) komponen-komponen mitokondria, seperti dna, membran protein dan lemak; (2) terbukanya mitochondrial permiability transition pore (mptp); (3) pelepasan protein proapoptosis dari mitokondria, seperti sitokrom c yang mampu menstimulasi kematian sel. terbentuknya ros di rantai respirasi mitokondria sebagai second messengers untuk aktivasi nfkb melalui tnf-a dan il-1. peningkatan produksi superoksid dikatalisis melalui nadph oksidasi, insulin dan xo. lipooksigenase juga merupakan produsen dari radikal bebas pada saat reaksi enzimatik. produk lipooksigenase terutama 12(s)-hete dan 15(s)-hete akan memberikan efek proatherogenik dan mampu memediasi aksi dari faktor pertumbuhan dan sitokin proinfl amasi. sumber ros yang berasal bukan dari mitokondria juga termasuk enzim cyclooxygenase (cox), yang mengkatalisis sintesis dari berbagai prostaglandin. sitokin proinfl amasi mampu menginduksi ekspresi cox2 melalui stimulasi nadph oksidase dan produksi ros. sumber ros yang lain adalah sitokrom p-450 monooksigenase, yang akan meningkatkan ekspresi cyp2e1. dalam kondisi yang tidak biasa cyp2e1 akan memproduksi radikal bebas. reactive oxygen species (ros) akan mengaktivasi sejumlah stress-sensitive kinase dan mampu memediasi resistensi insulin. aktivasi dari berbagai kinase akan meningkatkan dan mengaktivasi nfkb dan activator-protein-1(ap-1) yang kemudian akan: (1) mengaktivasi c-jun-n terminal kinase (jnk) dan menghambat nfkb kinase-β (ikk); (2) meningkatkan transkripsi gen sitokin-sitokin proinfl amasi dan; (3) meningkatkan sintesis dari reaksi fase akut (lemos et al., 2012). latihan fi sik yang dilakukan secara teratur mampu meningkatkan pembentukan antioksidan, namun jika latihan fi sik tersebut dilakukan secara berlebihan, justru akan menimbulkan efek negatif yaitu meningkatkan oksidan. latihan fi sik yang diberikan, pada beberapa tikus yang diinduksi stz tersebut mungkin dirasa cukup berlebihan. hal tersebut ditunjukkan melalui kondisi tikus yang semakin sering terkena alat kejut listrik bahkan kemudian tidak mau berlari dan meloncat keluar treadmill. cara mengetahui kelelahan yang dialami oleh hewan coba adalah performance yang buruk seperti tikus tidak mau berlari; tikus mengenai alat kejut listrik sebanyak 4 kali dalam 1 menit; peningkatan suhu; peningkatan asam laktat dan peningkatan nadi. semakin sering tikus mengenai alat kejut listrik pada treadmill, maka hal tersebut menandakan tikus mengalami kelelahan (kregel et al., 2006). simpulan dan saran tidak ditemukan hubungan yang bermakna antara kadar glukosa plasma berhubungan dengan kadar mda ginjal pada kelompok tikus jantan yang diinduksi stz baik yang diberikan latihan fi sik teratur dan terukur maupun yang tidak. 115 muhammadiyah journal of nursing daftar pustaka adji, d. 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(2010). lipid peroxidation alterations in type 2 diabetic patients. pak j biol sci. 13(15):723-730. purboyo, a. 2009. efek antioksidan ekstrak etanol daun jambu biji (psidium guajava l) pada kelinci yang dibebani glukosa. tesis. tidak dipublikasikan rungby, j., flyvbjery, a., andersen, h.b., nyborg, k. (1992). lipid peroxidation in early experimental diabetes in rats: eff ects of diabetes and insulin. acta endocrinol. 126:378-380. souza, s.b.c., flues, k., paulini, j., mostarda, c., rodrigues, b., souza, l.e., irigoyen m-c., angelis kd. (2007). role of exercise training in cardiovascular autonomic dysfunction and mortality in diabetic ovariectomized rats. am heart j. 50:786791. blank page 93 muhammadiyah journal of nursing ferika indarwati, rahmah, bayu panggita, syarif indrawan. universitas muhammadiyah yogyakarta e-mail: ferika.sonumy@gmail.com perspektif perawat tentang manejemen terpadu balita sakit di puskesmas wilayah kabupaten bantul yogyakarta abstract integrated management of childhood illness (imci) is an integrated approach to the treatment of sick children in primary helath care services which include promotive, preventive and curative programs. the role of nurses in providing nursing care must be in accordance with the system of the health care centers. the purpose of this study was to determine nurses perspective on integrated management of childhood illness (imci) in primary health care centres, bantul, yogyakarta. the method used in this research is descriptive qualitative. the sampling was recruited by purposive sampling, 6 respondents was involved in this research. data analysis was done by thematic analysis. the results of this study found that 5 out of 6 respondents can explain imci defi nition, objectives and actions of nurses that had been taken in imci. respondents said that the biggest obstacle in implementing imci at health centers is the time, facilities and infrastructures. sources like fi nancial support and the support of the leadership is very important to support the implementation of imci in health centers. based on this research can be concluded that the implementation of imci in phc requires the commitment of all parties, not only nurses but also doctors, health center leaders and other health workers. advice can be given to primary health care centres associated with imci is conducting training for nurses, repair facilities and infrastructure so that implementation of imci in health centers could have better. keywords: nurse, knowledge level, imci, health center pendahuluan angka kematian balita diseluruh negara pada tahun 2011 mencapai 6,9 juta jiwa, tercatat 1900 kematian balita dalam sehari dan 800 kematian balita setiap jam. sekitar 80% kematian balita terjadi dinegara-negara berkembang (who, 2012). indonesia sebagai salah satu negara yang berkembang mempunyai masalah yang serius secara global tentang angka kematian bayi dan balita. angka kematian bayi (akb) di indonesia mencapai 34/1.000 kelahiran hidup, angka kematian balita (akba) 44/1.000 kelahiran hidup dan angka kematian anak umur satu sampai lima tahun mencapai 10/1.000 kelahiran hidup (sdki, 2007). di daerah istimewa yogyakarta (diy) angka kematian balita pada tahun 2002 mencapai mencapai 43/1.000 kelahiran hidup dan pada tahun 2003 turun menjadi 23/1.000 kelahiran hidup (depkes ri, 2010). kasus angka kematian balita pada kabupaten bantul pada tahun 2011 tercatat ada 136 balita/mil. kasus kematian balita ini terjadi disemua wilayah kecamatan kabupaten bantul (dinkes kabupaten bantul, 2012). sebagian besar kematian tersebut atau hampir 12 juta anak meninggal sebelum usia lima tahun dan (70%) diantaranya disebabkan karena penyakit infeksi, infeksi saluran pernafasan (ispa), diare, malaria, kekurangan gizi dan campak dengan komplikasinya atau gabungan dari penyakit itu (sdki, 2003). penyakit infeksi bakteri, penyakit infeksi saluran pernafasan (ispa) dan pneumonia pada balita tahun 2008 pada daerah istimewa yogyakarta (diy) sebanyak 97.621 kasus. meliputi pneumonia sebesar 1.388 balita 94 muhammadiyah journal of nursing dan non pneumonia 970.233 balita (depkes ri, 2008). pada tahun 2010 penyakit pneumonia dikabupaten bantul mencapai 434 kasus dan pada tahun 2011 penyakit pneumonia pada balita meningkat menjadi 606 kasus (dinkes kabupaten bantul, 2012). upaya world health organization (who) dan departemen kesehatan republik indonesia (dep.kes ri) untuk menurunkan angka kematian dan kesakitan secara global adalah dengan mengenalkan sick child initiative (sci) atau intergrted management of childhood illness (imci) yaitu langkah-langkah pengambilan keputusan dalam mengelola anak balita sakit. dalam usaha meningkatkan cakupan penemuan dan meningkatkan tatalaksana penyakit yang mengancam kehidupan pada anak balita, dep. kes telah menerapkan manajemen terpadu balita sakit (mtbs) di unit pelayanan kesehatan dasar/ puskesmas (depkes ri, 2008). perawat sebagai salah satu tenaga kesehatan di puskesmas memiliki peranan yang sangat penting dalam kesuksesan program mtbs tersebut. kemampuan mengenali tanda dan gejala atau mendeteksi dini masalah secara cepat dan tepat dapat mengetahui penyakit dan intervensi yang tepat (pott er dan perry, 2005). berdasarkan uraian diatas peneliti ingin mengetahui perspektif perawat tentang penerapan manajemen terpadu balita sakit (mtbs) di puskesmas wilayah kabupaten bantul yogyakarta. metode penelitian rancangan penelitian ini merupakan jenis penelitian deskriptif dengan pendekatan deskriptif kualitatif untuk mengetahui perspektif perawat tentang manajemen terpadu balita sakit (mtbs) di puskesmas wilayah kabupaten bantul yogyakarta. populasi dalam penelitian ini perawat puskesmas di kabupaten bantul. tehnik pengambilan responden dalam penelitian ini menggunakan teknik purposive sampling responden pada penelitian ini diambil berdasarkan kriteria inklusi dan eksklusi. kriteria inklusi yaitu perawat yang bersedia menjadi responden, telah bekerja minimal 1 tahun di puskesmas dan telah mengikuti pelatihan mtbs. kriteria ekslusi perawat yang tidak bersedia menjadi responden. responden penelitian ini berjumlah 6 orang perawat puskesmas yang berada di kabupaten bantul. indeep interview dilakukan untuk mengambil data responden. panduan wawancara digunakan untuk memandu jalannya wawancara sedangkan tape recorder digunakan untuk merekam hasil wawancara dengan responden. metode analisis data menggunakan thematic analysis. hasil dan pembahasan 1. karateristik responden karakteristik responden dalam penelitian ini adalah perawat puskesmas sekabupaten bantul. gambaran umum karakteristik responden berdasarkan umur, jenis kelamin, tingkat pendidikan dan lama bekerja. karakteristik responden dapat dilihat pada tabel berikut. tabel 1. distribusi frekuensi perawat puskesmas sekabupaten bantul berdasarkan umur, jenis kelamin, tingkat pendidikan dan lama bekerja no karakteristik frekuensi (f) presentase (%) 1 umur 20-40 tahun 40-60 tahun 3 3 50 % 50% 2 jenis kelamin laki-laki perempuan 0 6 0% 100% 3 tingkat pendidikan diii s1 4 2 75% 25% 4 lama kerja 6-10 tahun 11-15 tahun 4 2 75% 25% sumber: data primer 95 muhammadiyah journal of nursing berdasarkan tabel 1 dapat diketahui bahwa pada karakteristik responden berdasarkan umur, responden berumur 20-60 tahun). semua responden berjenis kelamin perempuan. mayoritas responden berpendidikan d iii keperawatan, dan rata – rata lama bekerja 6 – 10 tahun. 2. perspektif perawat tentang mtbs tema yang muncul dalam penelitian ini adalah pengetahuan perawat tentang mtbs, pengetahuan perawat tentang pelaksanaan mtbs di puskesmas, sumber dukungan dalam pelaksanaan mtbs dan hambatan dalam pelaksanaan mtbs. a. pengetahuan perawat tentang mtbs responden pada penelitian ini mampu menyebutkan defi nisi dari mtbs dengan tepat. mtbs menurut sebagian besar responden merupakan suatu program manajemen kasus balita sakit yang merupakan integrasi pelayan kesehatan pada tingkat dasar. penegtahuan ini mereka dapatkan dari training mtbs yg diberikan oleh pihak puskesmas. mtbs juga diangap sebagai bentuk pelayanan paling komprehensif bagi anak anak. “mtbs merupakan salah satu bentuk pelayan kesehatan terintegrasi di tingakt pelayan dasar, ada form nya dan ada panduannya.” (r2) “mtbs sebetulnya sangat membantu, mtbs memberikan panduan terutama perawat bila dokter tidak ada.” (r1) b. pelaksanaan mtbs di puskesmas pelaksanaan mtbs secara konsisten dijelaskan oleh responden sebagai memakan waktu, tetapi ini juga dilihat sebagai bermanfaat dalam meningkatkan hubungan dengan ibu, dan keyakinan responden meningkat bila menggunakan pendekatan mtbs menyebabkan ibu melihat mereka dengan rasa hormat yang lebih karena menunjukkan keprofesionalan perawat dalam bekerja. “ dengan mtbs kita harus memeriksa anak dari kepala sampai kaki, jadi waktu yang dibutuhkan sangat lama.” (r 3) selain hal di atas, responden juga menyebutkan bahwa tidak semua puskesmas menerapkan mtbs sebagai bagian dari pelayanan. satu dari responden mengatakan bahwa puskesmas yang memiliki klinik mtbs saat ini di bantul hanya ada 1 puskesmas, puskesmas lain belum memilikinya. responden mengatakan bahwa apabila pasien banyak maka perawat harus bekerja cepat oleh karena itu jarang memakai mtbs. “kalau pasennya banyak, perlu cepat ditangani, tidak sempat pakai mtbs” (r 4). “pasien sudah antri dari pagi, kalau pakai mtbs tidak selesai selesai” (r 2). c. sumber dukungan dalam pelaksanaan mtbs responden menyebutkan faktor-faktor yang memfasilitasi pelaksanaan mtbs adalah dukungan dari rekan-rekan, terutama mereka yang sudah terlatih, dukungan dari pimpinan dan obat yang direkomendasikan oleh mtbs tersedia di klinik. “kami memiliki motivasi dari orang-orang yang dilatih sebelum anda, dukungan dari rekan-rekan kami” (fgd3). “satu hal yang bisa saya katakan adalah pengobatan, karena kita punya itu di klinik, jadi jika buklet grafi k mengatakan ‘ memberikan ini untuk itu anda tahu bahwa anda [telah] mendapatkannya” (r4). d. hambatan pelaksanaan mtbs di puskesmas hambatan terbesar untuk pelaksanaan mtbs, yang secara konsisten disebutkan, adalah bahwa konsultasi mtbs memakan waktu lebih lama, yang merupakan masalah khusus yang diberikan kekurangan staf di puskesmas. 96 muhammadiyah journal of nursing “saya satu-satunya orang yang dilatih mtbs, sehingga tidak mudah untuk melakukannya dengan cara yang benar karena saya tidak akan mampu menyelesaikan anak-anak ini sampai dengan jam 4 sore” (r4). kurangnya dukungan dari rekan-rekan di klinik, khususnya mereka yang tidak terlatih dalam mtbs, diidentifi kasi sebagai penghalang utama . mendorong anggota lain dari tim kesehatan, termasuk layanan ambulans dan dokter di rumah sakit rujukan, untuk mendukung mtbs dinyatakan sebagai sebuah tantangan . “orang-orang yang tidak [mtbs] dilatih, mereka tampaknya memiliki sikap negatif terhadap orangorang yang dilatih mtbs, karena orang itu tidak akan mengerti mengapa anda terlalu lama untuk mengobati/melayani klien anda” (r4). ‘jika pimpinan/perawat bertanggung jawab atas klinik tidak menjalani pelatihan ini dia tidak akan mengerti bahasa mtbs dan jika saya ingin menerapkan mtbs itu akan menjadi masalah” (fgd2). waktu yang dibutuhkan untuk konsultasi mtbs itu menyebabkan waktu tunggu lebih lama. responden mengatakan kadang mtbs hanya diimplementasikan secara parsial. “untuk [mengurangi antrian], kita harus cpat jadi kadang pakai mtbs tidak selesai..langsung dilanjutkan klien berikutnya” (r 1). “kadang juga pasien tidak sabar, mereka ingin cpat di atasi dan diberi obat, mau yang praktis dan cepat saja” (r5). responden juga mengatakan bahwa dukungan pimpinan sangat penting karena hal ini berhubungan dengan dukungan fi nancial seperti pengadaan booklet mtbs, form mtbs termasuk gaji perawat ketika melaksanakan mtbs. “pimpinan harus tahu, kalau tidak uang tidak cair, tidak ada dukungan” (r 2). “sarana dan prasaran juga harus memadai, sekarang ini puskesmas sangat penuh, antrian saja panjang. tidak ada tempat khusu seperti klinik mtbs” (r6). pembahasan perspektif perawat tentang mtbs dibagi kedalam 4 tema yaitu: pengetahuan perawat tentang mtbs, pelaksanaan mtbs di puskesmas, sumber dukungan pelaksanaan mtbs di puskesmas dan hambatan pelaksanaan mtbs di puskesmas. berdasarkan hasil wawancara tentang pengetahuan perawat tentang mtbs diketahui bahwa sebagian besar perawat mampu menyebutkan tentang defi nisi mtbs. seluruh responden mampu menjelaskan apa itu mtbs dan bagaimana melaksanakan dan menggunakan form form nya. menurut notoatmodjo pengetahuan adalah hasil dari tahu, yang terjadi setelah seseorang melakukan penginderaan terhadap suatu objek tertentu, penginderaan ini berasal dari penglihatan, pendengaran, penciuman, rasa dan raba, tetapi sebagian besar pengetahuan manusia diperoleh melalui mata dan telinga (notoatmodjo, 2011). pengetahuan perawat yang baik dapat di mungkinkan karena tingkat pendidikan dari responden berasal dari tingkat pendidikan diploma sampai dengan sarjana yang merupakan jenjang pendidikan tinggi. hal ini sesuai dengan penelitian lehrer (2004) yang menyatakan bahwa pengetahuan umumnya berasal dari pendidikan, perjalanan individu, informasi yang di proleh dari guru, orang tua, buku, surat kabar dan lainnya (hanafi ah, 2008). faktor pendidikan sangat berpengaruh terhadap perbedaan prilaku individu (hanafi ah 2008 dan sudarmayanti, 2001). semakin tinggi tingkat pendidikan seseorang, maka akan semakin tinggi 97 muhammadiyah journal of nursing pengetahuan seseorang (hanafi ah, 2008). responden mengatakan bahwa pelaksanaan program mtbs di puskesmas belum konsisten, hal tersebut sangat terkait dengan sumber dukungan dan hambatan yang ada. responden menuturkan bahwa pelaksanaan mtbs juga bervariasi di kabupaten bantul. ada yang melaksanakan secara baik dan konsisten namum juga ada yang melaksanakan secara parsial atau bahkan tidak melaksanakannya. hal hal yang dilihat dari gambaran proses ini yaitu proses berjalannya program mtbs. dalam proses manajemen kasus mtbs setelah menilai dan mengklasifi kasikan penyakit anak, langkah selanjutnya adalah menentukan tindakan dan memberi pengobatan yang dibutuhkan. pengobatan anak sakit dapat dimulai di klinik dan diteruskan dengan pengobatan lanjutan di rumah. pada beberapa keadaan, anak yang sakit berat perlu dirujuk ke rumah sakit untuk perawatan lebih lanjut. dalam hal ini perlu dilakukan tindakan pra rujukan sebelumanak di rujuk (depkes ri, 2008). sebagian besar puskesmas dalam menangani balita sakit masih menggunakan metode konvensional sehingga semua pasien yang datang ditangani secara umum tanpa melihat jenjang umurnya. petugas mengungkapkan bahwa tidak ada waktu untuk menggunakan formulir mtbs karena banyak pasien dan kegiatan yang harus ditangani. jika menggunakan formulir mtbs, waktu yang digunakan untuk melayani pasien tidak akan cukup, karena 1 pasien memerlukan waktu sekitar 10-15 menit. dengan demikian sebagian besar petugas tidak mematuhi prosedur dalam mtbs. dalam pelaksanaannya, penggunaan mtbs belum berjalan secara efektif. kondisi tersebut dialami oleh sebagian besar puskesmas di kabupaten bantul, karena berbagai kendala antara lain terbatasnya jumlah tenaga yang dilatih mtbs, perpindahan tenaga yang sudah dilatih, kurang lengkapnya sarana dan prasarana pendukung serta peran pimpinan. pratono 2012, mengungkapkan bahwa peran dari seorang pemimpin dalam pelaksanaan mtbs sangat penting. pemimpin yang tegas dan konsisten menjaga terlaksananya program mtbs dapat menggantikan peran dinas ksehatan yang juga kurang dapat dirasakan untuk program mtbs ini (pratono, 2012). penelitian boymau dkk, 2009 sejalan dengan hasil penelitain ini, boymau dkk mengatakan bahwa prosentase tenaga kesehatan yang dilatih program mtbs dapat mempengaruhi terlaksananya program mtbs tersebut atau tidak. lebih lanjut lagi boymau dkk menjelaskan bahwa kelengkapan sarana prasana serta komunikasi antara puskesmas dengan dinas kesehatan perlu ditingkatkan (boymau et al, 2009). hal tersebut sesuai dengan temuan penelitian ini bahwa sarana dan prasarana yang kurang memadai dapat mengganggu kelancaran penerapan program mtbs di puskesmas. pada pelaksanaan proses manajemen kasus mtbs penggunaan sarana seperti formulir dan pengisian secara lengkap sangat menentukan keberhasilan penerapan proses manajemen kasus dalam rangka menangani balita sakit dan bayi muda secara komprehensif di fasilitas pelayanan kesehatan dasar (depkes ri, 2008). kesimpulan dan saran berdasarkan hasil penelitian dan pembahasan yang telah dilakukan, maka dapat diambil kesimpulan bahwa perawat menganggap pelaksanaan mtbs di puskesmas kabupaten bantul belum terlaksanan dengan baik. pengetahuan perawat tentang mtbs itu sendiri berada dalam kategori baik akan tetapi dalam melaksanakan mtbs tidak hanya dari sisi pengetahuan saja yang harus baik melainkan juga dari sisi yang lain, sebaggai contoh sisi kecukupan sumber daya, sarana prasarana dan dukungan dari pimpinan atau pengelola puskesmas itu sendiri. 98 muhammadiyah journal of nursing daftar pustaka boymau, a; kendjam, y; sinaga, m., 2009, evaluasi program manajemen terpadu balita sakit (mtbs) pneumonia pada puskesmas di kota kupang tahun 2008. jurnal gizi & kesehatan masyarakat .universitas nusa cendana. jurusan gizi kesehatan masyarakat depkes ri, 2008, buku modul manajemen terpadu balita sakit (mtbs). jakarta. depkes ri, 2010, pemerintah berkomitmen mempercepat upaya pencapaian mdgs. http://depkes.go.id/index.php/berita/ p r e s s r e l e a s e / 1 1 1 5 p e m e r i n t a h b e r k o m i t m e n m e m p e r c e p a t u p a ya pencapaian-mdgs.html. diunduh tanggal 12 november 2012. dinkes kabupaten bantul. (2012). profi l kesehatan bantul tahun 2012. dinas kesehatan kabupaten bantul. hanafi ah,said, 2008, pengaruh karakteristik individu dan sistem imbalan terhadap aktivitas. supervisi pada pelaksanaan manajemen terpadu balita sakit (mtbs) di dinas kesehatan kabupaten aceh timur. usu jurnal e-repository. notoatmodjo, 2011, kesehatan masyarakat: ilmu dan seni. jakarta: rineka cipta pott er & perry, 2005, buku ajar fundamental keperawatan konsep, proses dan praktik edisi iv. jakarta: egc pratono, 2012, pelaksanaan manajemen terpadu balita sakit (mtbs) di puskesmas di kabupaten tanah laut propinsi kalimantan selatan. skripsi. tidak dipublikasikan sdki, 2003, survei kesehatan rumah tangga tahun 2002-2003. jakarta sdki, 2007, indonesia demographic and healthy survey 2007. jakarta sudarmayanti, 2001, sumber daya manusia dan produktivitas kerja. bandung : madar maju who, 2012, health service. htt p://www.who. int/topics/health_services/en/. diunduh tanggal 12 november 2012 blank page indonesian journal of nursing practices 58 ijnp (indonesian journal of nursing practices) vol 3 no 2 december 2019 : 58-66 arni nur rahmawati1, meidiana dwidiyanti2, muhammad mu'in2 1universitas harapan bangsa 2universitas diponegoro corresponding author: arni nur rahmawati email: arninr@uhb.ac.id the effect of mindfulness on the family well-being in mother who works as a nurse article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.3294 abstract background: mothers who work as nurses are one of the vulnerable groups and are at risk of imbalance of roles in work and family due to multiple roles. the dual role requires working mothers to carry out their duties as mothers and wives at home, while at work can carry out duties as nurses. this is a stressor for mothers who work as nurses in adapting to their roles. this condition can reduce family well-being by decreasing the relationship of family structure, the ability of the role and function of the mother in the family, and the ability to prevent family vulnerability. interventions that can be carried out to improve the family well-being are mindfulness stop (stop, take a breath, observed, proceed). objective: this study aimed to determine the effect of mindfulness on family well-being in mothers who work as nurses at x hospital semarang. method: the design of this study was a quasi-experiment pre-post test with a control group, involving 52 respondents obtained by purposive sampling technique based on the results of inclusion criteria screening, consisting of 26 respondents in the intervention group (given mindfulness exercises) and 26 respondents in the control group (without treatment). mindfulness stop is given for 4 sessions totaling 4 meetings in 1 month. data analysis used wilcoxon and mann-whitney tests. results: the results of this study are mindfulness effect on improving family well-being in the intervention group of mothers who work as nurses with a p-value of 0.000. conclusion: the conclusion of this research is mindfulness can improve family well-being in mothers who work as nurses. mindfulness is recommended as an intervention to improve employee well-being, especially in carrying out roles in the family and as a basis for further research keywords: working mother; nurse; family well-being; mindfulness introduction the number of female workers is currently increasing. bureau of labor statistics u.s. in 2011 reported in 1975, there were 39% of women who have children under six years old in the us employed and in 2010, this figure increased to 64% (buehler & brien, 2011). similarly, the number of the labor in indonesia force in august 2013 was 120.17 million people increased to 125.44 million people in august 2016 (ministry of health (ministry of health of the republic of indonesia), 2016). while the number of female workers in central java in 2015 amounted to 6,709,835 people, increasing in 2016 to 6,808,569 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/5430 vol. 3 no. 2 december 2019 59 people (national labor force survey (sakernas), 2016). an increasing number of female workers or working mothers is due to financial needs, relational social needs, and self-actualization needs (badan pusat statistik, 2016). the most female occupation is a nurse where women constitute 80% of the total workforce in the world (sharma, dhar, & tyagi, 2015). working mothers are vulnerable groups and at risk for occupational hazards, one of which is a psychosocial hazard (nies & mcewen, 2014; oakley, 2008). the psychosocial hazard that is often experienced by mothers who work as nurses is an imbalance between work and family due to multiple roles. the results of a review by gonnelli and raffagnino in 2017 showed that work-family conflict is a stressor in nursing and is the most analyzed risk factor in the workplace (gonnelli, 2017). conflicts that occur in nursing staff are supported by the results of a study by agustian in 2015 which showed that there were 83.6% of nursing staff having high intrapersonal conflicts, these conflicts could come from patients, families or coworkers. the results of a preliminary study of 12 female nurses who were married showed 58.3% experienced high dual role conflicts such as childcare left to others, feeling exhausted after work, did not have quality time with family, and they were not satisfied with marriage. while 33.3% experienced moderate dual role conflicts such as feeling calm with the division of tasks as a mother, sometimes feeling tired with excessive responsibilities but still able to focus on work, and can perform the role of parents according to family expectations. rice found the results that working women tend to experience higher stress compared to men due to dual role conflict (widyasrini, 2016). stress on working mothers will affect the ability of mothers to function in parenting. the higher the stress due to multiple roles, the function of parenting in working mothers will decrease (gani, 2016). high workfamily conflict can also cause low marital satisfaction along with low levels of family wellbeing (fischer, zvonkovic, juergens, engler, & frederick, 2015). imbalance of work and family roles due to dual role conflict and psychological pressure will affect family well-being of mothers who work as nurses (westrupp, martin, & zubrick, 2016), which arises psychological problems and conflicts that are often associated with stressful events (erdilek, akyüz, & elçi, 2016; lucas et al., 2011; ruppanner, 2011). based on the results of a preliminary study of 12 female nurses, data obtained 75% of mothers who work as nurses were less prosperous (less able to develop themselves and carry out their role in the family in setting life goals) and some 25% of mothers who work as nurses were prosperous enough (capable of carrying out roles as mothers and nurses enough and desires to develop themselves in achieving life goals). family well-being for mothers who work as nurses is a mental health condition that describes maternal adaptive coping with stress in carrying out roles and functions in the family and maintaining the strength of relationships between family members (ora l. strickland, 2001). interventions that can be done to improve family well-being include positive psychology intervention: gratitude intervention, three good things, and best possible selves, wellbeing therapy, and mindfulness (kaplan, afra, anderson, & hargrove, 2013; malinowski peter, 2015; seear & vella-brodrick, 2012). mindfulness was chosen as an effort to improve well-being because the ability of mindfulness can strengthen an individual's adaptive coping with stressors, easily done independently and consciously, anytime and anywhere (malmberg-ceder, haanpää, korhonen, & kautiainen, 2017). coping strategies and adaptive behaviors will increase one's ability to prosper (zheng, kashi, fan, molineux, & ee, 2016). mindfulness has been proven to reduce stress, depression, sleep disorders, fatigue, increase happiness, nurturing children, relationships with partners, increase calmness, empathy, selfconfidence, work involvement, morale, and wellbeing (atanes et al., 2015; o 'leary & dockray, 2015; perez-blasco, viguer, & rodrigo, 2013), both the health professionals well-being (atanes et al., 2015), and the nurse employees well-being in the company area (bazarko, dawn; cate, rebecca a; azocar , francisca; kreitzer, 2013). mindfulness is a nursing training or therapy done by someone with awareness, full acceptance, carried out with high self-efficacy (confidence) and independently (self-care) to achieve the desired indonesian journal of nursing practices 60 goal dwidiyanti, pamungkas, & ningsih, 2017) mindfulness exercises are carried out through group processes (kar, shian-ling, & chong, 2014), to provide support for mothers who work as nurses in improving the ability to adapt to multiple role stressors. this group process can also foster selfefficacy in working mothers to be able to solve problems independently (self-care). the results of the study stated that self-efficacy can affect one's psychological well-being. high self-efficacy will result in high psychological well-being (salimirad, srimathi, 2016). thus, the nurse's role as a facilitator is needed in mindfulness training. mindfulness interventions to improve the wellbeing of nurses that have been tested only focus on the well-being of workers in the workplace, both psychological well-being and subjective well-being (atanes et al., 2015; bazarko, cate, azocar, & kreitzer, 2013; weare, 2014). the well-being of mothers who work as nurses in the family is needed to be able to achieve family well-being. mindfulness was chosen as an effort to improve family well-being in mothers who work as nurses because it can strengthen the individual's adaptive coping with stressors. this ability is complemented by the selfregulation of direct experience, being open, and accepting current experiences (dwidiyanti, pamungkas, & ningsih, 2017)). based on the description, the researcher wants to know the effect of mindfulness on family well-being in mothers who work as nurses. method this research design is a quasi-experiment pre-post test with a control group (sugiyono, 2011). the intervention group received mindfulness exercise intervention, while the control group did not get intervention from the researchers and data collection was carried out in both groups (sugiyono, 2013). the population in this study involved 155 female nurses in the inpatient room b rs x. large sample of this population was obtained by the lameshow formula of 52 female nurses divided into 2 groups, the intervention group consisted of 26 female nurses and the control group consisted of 26 nurses woman. the sampling technique used was purposive sampling with inclusion criteria, namely female nurses who were married, aged 20-40 years, worked more than 1 year, and lived with children and husband; exclusion criteria were divorced female nurses. this research was conducted at x hospital in february-may 2018. the instrument used in this study was the family well-being assessment (fwa) questionnaire developed by shirley m. caldwell which consisted of questionnaires for parental wellbeing and child well-being. this study only used the parents' well-being questionnaire. the indonesian translation fwa questionnaire used by previous researchers has tested its validity and reliability values. of the 57 statements tested, 42 valid items with r count> 0.297 and 15 invalid items were not used in this study. while the reliability test results of 42 valid items show an alpha value of 0.943 (alpha cronbach> 0.600) so that this instrument is reliable and can be used. in addition to the fwa questionnaire, the mindfulness exercise operational procedure standard (spo) is also completed with a training procedure checklist sheet and self-efficacy assessment using a self-efficacy scale developed from the 1-10 pain scale (dwidiyanti, pamungkas, & ningsih, 2017)). the study began with the selection of facilitators (field officers) who served as research assistants in collecting respondent data. there were two facilitators involved with the following criteria: 1) female nurses who were married 2) had work experience of more than 5 years 3) served as head of the room 4) had attended mindfulness training. after that, the researcher screened respondents according to inclusion and exclusion criteria, then explained the aims and procedures of the study and gave written informed consent to the respondent. the study began with the mindfulness stop training for the facilitator in week 0, with 60 minutes of four sessions. the training of the facilitators is conducted in a soundproof room, equipped with a mattress, and sound for the accompanying music training. after that, the researcher explained the mindfulness stop exercise procedure, goals and benefits, mindfulness exercise observation sheet and selfefficacy assessment sheet using a modified selfefficacy scale from the pain scale 1-10 (dwidiyanti, pamungkas, & ningsih, 2017). after facilitator training, the researcher divided the respondents who had agreed to informed consent into 2 groups, vol. 3 no. 2 december 2019 61 the intervention group (26 female nurses) and the control group (26 female nurses). the researcher then conducted a mindfulness exercise on the intervention group using the spo mindfulness stop which consisted of four sessions. the mindfulness group members meet every week, one meeting lasts for 60-90 minutes, and takes place within 2 weeks. the control group was not treated when the intervention group was given mindfulness training. pre-test and post-test respondents in both groups were assessed by the fwa questionnaire. all respondents in the intervention group successfully followed the mindfulness training procedure from the beginning to the end of the meeting. none of the respondents dropped out during the research activities. results univariate analysis was performed on the characteristics of respondents (age, income, length of work) and the well-being of mothers who worked as nurses. variants on the characteristics of respondents identified equality with the homogeneity of variance test. homogeneity test results showed that the variance of the age variable between the intervention group and the control group was significantly homogeneous with p = 0.912 (p value> 0.05). the work duration variable between the intervention group and the control group was also homogeneous with a p-value of 0.700 (p-value> 0.05). whereas the income variant is a constant value with the same income as rp.2,125,000, which means it is also homogeneous. bivariate analysis in this study is an analysis to find out the interaction between mindfulness variables with family well-being in mothers who work as nurses. data on family well-being of mothers who worked as nurses in the intervention and control groups before and after each intervention was tested for normality using the shapiro wilk test in which the number of study samples was less than 50. the results of the normality test showed the family well-being of mothers who worked as nurses in the group intervention and control is not normally distributed (p-value <0.05) so using the nonparametric test wilcoxon test. while the family well-being data for mothers who worked as nurses of the two groups (before and after the intervention) were tested for normality using the kolmogorov smirnov test with a p-value <0.05 which means the data before and after the intervention were not normally distributed so that the differences in the two groups were tested with nonparametric test mann-whitney test. table 1. differences in pre-test and post-test family well-being meaning for mothers working as nurses in the intervention and control groups at hospital x in april-may 2018 (n1 = 26 and n2 = 26) group pre/post test mean sd p-value intervention pre test 125.62 7.03 0,000* post test 141.35 10.04 control pre test 121.04 20,13 0,102* post test 121.69 19.21 *uji wilcoxon table 1 shows the average value of family well-being for mothers who worked as nurses before the intervention in the intervention group was 125.62 and the control group was 121.04. while the average value of family well-being for mothers who work as nurses after the intervention in the intervention group was 141.36 and the control group was 121.69. based on table 1 it is also obtained data that in the intervention group there are differences in well-being between pre-test and post-test where the p-value is smaller than the alpha value (p-value = 0,000 <α = 0.05). the difference in the pre-post intervention group can be seen from the increase in the mean value of 15.73. the difference in well-being values in the intervention group shows that providing mindfulness training can improve family well-being for mothers who work as nurses compared to the control group who did not get the intervention. while in the control group can be seen from the value of p-value = 0.102 (p> α) which means there is no significant change seen from the mean pre-post test which only increased by 0.65, this can occur because it is influenced by several factors. table 2. effects of mindfulness on family well-being of mothers working as nurses in the intervention and control groups after mindfulness training in hospital x april-may 2018 (n1 = 26 and n2 = 26) group mean mean differences 95% ci (upperlower) pvalue intervention 141.35 19.66 137.29129.45 0.000* control 121.69 * uji mann-whitney indonesian journal of nursing practices 62 table 2 shows that in the intervention group and the control group before and after the intervention there were significant differences in well-being values (mean differences = 19.66) where the p-value was smaller than the alpha value (0.000 <0.005). therefore, it can be concluded that the provision of mindfulness training in the intervention group effects on improving family well-being for mothers who work as nurses. discussions a. family well-being of a mother who works as a nurse in the intervention and control groups before providing mindfulness exercises the results of this study indicate that the average value of family well-being in mothers who work as nurses before mindfulness training in the intervention group is 125.62 and the control group is 121.04. the results of this study are in line with the results of a study by sahusilawane, lourista, et al in 2017 which showed that the well-being of nurses was in the moderate or well-being category with a mean well-being score of 123.62. family wellbeing for working mothers is the well-being of parents who describe mental health conditions in adapting to stressors to shape family health. the well-being of working mothers in both the intervention and control groups in this study, both of them were dominated by an excess role component of 82.45% due to the multiple roles experienced by working mothers as workers and mothers. the several factors that can affect the well-being conditions of working mothers in the family include age, work, income, attention, acceptance, adaptation, and health (across, center, & center, 2014; huppert, 2014; social policy evaluation and research unit, 2015 ; ryff, 2014). a mother has an important role in the family that is in her husband and child, as well as working mothers. a working mother is a mother who can combine work and family responsibilities. the role of mothers working at home, among others, as a wife, housekeeper, caregivers and educators of their children, as members of the community, as well as additional breadwinners for the family (kaakinen, coehlo, steele, & robinson, 2018 ). this role can be done well if a working mother has adaptive coping with multiple role problems experienced (davison, neale, & king, 2010). by following the results of pratiwi's research, p.y 2018 which showed that coping can mediate dual role conflict and significantly influence the conditions of the subjective well-being of nurses. mothers working in families, in this case working as nurses, can use positive coping so that psychological aspects can function properly and can carry out daily activities to improve well-being (davison, neale, & king, 2010; dwidiyanti, pamungkas, & ningsih, 2017). b. effects of mindfulness exercises on increasing family well-being for mothers who work as nurses in the intervention group the results showed that there were significant differences in the value of well-being in the intervention group and the control group after giving mindfulness exercises with a significance of 0,000 (p-value <0.05). based on this analysis it can be concluded that mindfulness training is proven to affect improving family well-being in mothers who work as nurses. this is indicated by the change in well-being values in the intervention group after the mindfulness exercise treatment, which initially an average well-being value of 125.62 increased to 141.32. mindfulness training is an exercise for someone to be aware of the conditions experienced by the body, mind, and feelings now, and consciously make goals and focus on solving problems that are faced in order to calm down (dwidiyanti, pamungkas, & ningsih, 2017; perez-blasco, viguer, & rodrigo, 2013). mindfulness training in this study is complemented by the stop technique (stop, take a breath, observed, proceed) which is a four-step approach to being able to enter and process mindfulness easily anytime and anywhere (kar, shian-ling, & chong, 2014). the stop method can help respondents in growing awareness, attention, and acceptance easily because it can be done anytime and anywhere. focusing the mind is done by stopping, pausing from whatever activities are being done and calming down. take a breath is done by taking a deep breath and feel the flow of air in and out of the body. this stage teaches to be able to respect oneself, love vol. 3 no. 2 december 2019 63 oneself, and compassion. observed is the stage of observing what is happening to yourself at this time, what is being thought, what is being felt and what emotions are being experienced. this stage can open awareness and allow focus on thoughts and feelings so that they can accept the condition of oneself and feel confident (cell efficacy) of one's own ability to solve problems. proceed is carried out by carrying out daily activities that are felt to support the creation of mindfulness. this session was conducted to always raise awareness, attention, and acceptance in everyday life (dwidiyanti, pamungkas, & ningsih, 2017; fiocco & mallya, 2014; kar, shian-ling, & chong, 2014; tang, hölzel, & posner, 2015). mindfulness stop exercises reshape neural pathways, increase the density and complexity of connections in areas related to cognitive abilities such as attention, awareness, introspection, areas related to kindness, compassion, and rationality, and decrease in areas involved in anxiety (brown, creswell, & ryan, 2015). the study results show that mindfulness meditation can change the structure and function of the brain to improve the quality of thoughts and feelings (tang, hölzel, & posner, 2015). this mindfulness stop exercise improves the family well-being of mothers who work as nurses through focusing on the mind, feelings, and sensations of the body so that respondents can feel and interpret their current condition and here. thus, respondents who initially experience role tension due to stress due to multiple roles will have calmness and happiness towards adjusting their roles. previous studies have shown that mindfulness is associated with health, can reduce stress, improve well-being in the health workforce, improve childcare abilities, relationships with partners, work spirit, and psychological well-being (atanes et al., 2015; bazarko, cate, azocar, & kreitzer, 2013 ; o'leary & dockray, 2015). mindfulness was chosen as an effort to help the working mother to improve well-being because the ability of mindfulness can strengthen individual adaptive coping with stressors (frank, reibel, broderick, cantrell, & metz, 2015; gu, strauss, bond, & cavanagh, 2015; khoury et al., 2013). this ability is complemented by self-regulation of direct experience, being open, and accepting current experience independently consciously, anytime, and anywhere (dwidiyanti, pamungkas, & ningsih, 2017; ivtzan, niemiec, & briscoe, 2016; white, 2014). this awareness will help loosen your thoughts and feelings more rationally than blaming others. the exercises conducted in this study were four formal meetings and informal exercises that were assessed for their abilities with a checklist of mindfulness exercises and self-efficacy assessments. mindfulness exercises that are done routinely can change positive behavioral habits such as calmness, self-acceptance, affection, and happiness (dwidiyanti, pamungkas, & ningsih, 2017; ivtzan, niemiec, & briscoe, 2016). this study also showed that the value of well-being in the control group tended to remain even increased without intervention. changes in conditions in the control group can occur due to internal and external factors that are difficult to control individuals. huppert in 2009 stated that the personality of a person with extraversion and neuroticism, supportive, warm, and trustworthy interpersonal relationships will influence the condition of psychological well-being (huppert, 2014). the time for self-efficacy assessment and homework review done by the facilitator is a limitation in this study. assessment and implementation of informal exercises (homework review) between one respondent and other respondents do at a different time because of differences work shifts. therefore, it is recommended 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(2016). impact of individual coping strategies and organisational work–life balance programmes on australian employee wellbeing. the international journal of human resource management, 27(5), 501-526. https://doi.org/10.1080/09585192.2015.1020 447 169 muhammadiyah journal of nursing abstract background : hypertension is the third cause of death after stroke and tuberculosis, reached 6,7% of the population mortality at all ages in indonesia. murattal is sound of al–qur’an recording which is chanted by qari’ or al – qur’an reader which contain verses of al – qur’an. murattal is used as a media to reduce an active guanylate cyclase which causes vasodilatation and relaxation so that it can fl ow the blood and lower the blood pressure. purpose: to know the diff erent of blood pressure before and after given murattal. to know the diff erent of blood pressure reducting between the intervention group (listen murattal twice a day and three times a day) primarily to the control group (pharmacology drugs). method: this research was a quasi experimental study with less form of non – equivalent group design control. the total of respondents was 86 people, 43 people for the intervention group and 43 for the control group and the analysis used was wilcoxon test, mann whitney test, kruskal willis and friedman test. result: the result of wilcoxon for intervention group and control group was 0,000. the result of mann whitney test for systolic blood pressure was 0,038 and diastolic blood pressure was 0,000. the result of kruskal willis for systolic blood pressure was 0,025 and diastolic blood pressure was 0,00. the result of friedman test for intervention group was 0,000. conclusion: both of the intervention group and the control group could lower high blood pressure in elderly. murattal could be used as alternative therapy non-pharmacological management to reduce hypertension. keywords: murattal, hipertension, elderly pengaruh murattal terhadap penurunan tekanan darah tinggi di posyandu lansia kabupaten lampung tengah novika andora universitas muhammadiyah yogyakarta email: mohafandi2003@yahoo.com latar belakang penyakit hipertensi merupakan salah satu faktor paling berpengaruh sebagai penyebab penyakit jantung. penderita penyakit jantung kini mencapai 800 juta orang diseluruh dunia. lebih dari 10-30% penduduk dewasa dihampir semua negara mengalami penyakit hipertensi, dan sekitar 50-60% penduduk dewasa dapat dikatagorikan sebagai mayoritas utama yang status kesehatannya akan menjadi lebih baik bila dapat mengkontrol tekanan darahnya (adib muhammad, 2009). salah satu penatalaksanaan non farmakologi adalah menenangkan diri dan menghindari stress. stres emosional, stres sosiokultural dan stres okupasinal memiliki pengaruh terhadap hipertensi. emosional stres dapat ditimbulkan melalui interaksi seseorang dengan lingkungan, perilaku, yang dapat menyebabkan menjadi suatu beban mental, semua tekanan muncul dari pertentangan mengenai kepuasan yang diperoleh dari kemampuan seseorang dalam menghadapi hambatan lingkungan maupun fi sik serta hambatan psikologis yang muncul dari dalam diri individu tersebut (mustacchi, 1990). untuk mengetahui pengaruh mendengarkan muratt al terhadap tekanan darah tinggi lansia maka diadakan penelitian tentang pengaruh muratt al terhadap penurunan tekanan darah tinggi pada lansia di kabupaten lampung tengah. 170 muhammadiyah journal of nursing rumusan masalah 1. apakah mendengarkan muratt al surat al – fatihaah dan al – baqarah 2x sehari dan 3x sehari dapat menurunkan tekanan darah tinggi pada lansia di posyandu lansia desa tanjung harapan kecamatan seputih banyak lampung tengah? 2. apakah ada penurunan tekanan darah pada lansia kelompok kontrol di posyandu lansia desa tanjung harapan kecamatan seputih banyak lampung tengah? 3. kelompok manakah yang hasilnya dapat menurunkan tekanan darah pada lansia di posyandu lansia desa tanjung harapan kecamatan seputih banyak lampung tengah? tujuan untuk membuktikan muratt al surat al – fatihaah dan al – baqarah menurunkan hipertensi pada lansia di posyandu lansia desa tanjung harapan kecamatan seputih banyak lampung. manfaat 1. muratt al sebagai salah satu terapi keperawatan non farmakologis yang dapat digunakan sebagai penatalaksanaan untuk menurunkan tekanan darah tinggi pada lansia 2. penelitian ini sebagai evidence based dalam mengembangkan muratt al dalam hal menurunkan tekanan darah tinggi. 3. menambah wawasan dan pengetahuan peneliti dalam hal penatalaksanaan non farmakologis menurunkan tekanan darah dengan cara menerapkan muratt al. tinjauan teori penyakit darah tinggi atau hipertensi (hypertension) adalah suatu keadaan dimana seseorang mengalami peningkatan tekanan darah di atas normal yang ditunjukkan oleh angka bagian atas (sistolik) dan angka bawah (diastolic) pada pemeriksaan tensi darah menggunakan alat pengukur tekanan darah baik yang berupa cuff air raksa (sphygmomanometer) ataupun alat digital lainnya (wahdah, 2012). hipertensi dapat didefi nisikan sebagai tekanan persisten dimana tekanan sistoliknya di atas 140 mmhg dan tekanan diastolik di atas 90 mmhg. pada populasi manula hipertensi didefi nisikan sebagai tekanan sistoliknya 160 mmhg dan tekanan diastolik 90 mmhg. menurut who, penyakit hipertensi merupakan peningkatan tekanan sistolik lebih besar atau sama dengan 160 mmhg dan atau tekanan diastolic sama atau lebih besar 95 mmhg (suddarth, 2008). al-qur’an merupakan obat yang komplit untuk segala jenis penyakit, baik penyakit hati maupun penyakit fi sik, baik penyakit dunia maupun penyakit akhirat (ad-dihami, 2005). al-qur’an yang berisi tartil yang berupa doadoa yang lembut berefek memberikan vibrasi yang kuat kepada perubahan mental dan mengandung kekuatan penyembuhan dapat menghibur perasaan sedih, menenangkan jiwa yang gelisah dan membersihkan serta melunakkan hati yang keras serta mendatangkan petunjuk. ketenangan dan kebahagiaan jiwa merupakan hal yang prinsipil dalam kesehatan mental dan manfaat tersebut menjadi landasan dalam psikoterapi (sangkan, 2004). membaca al-qur’an mempengaruhi proses kimiawi yang terjadi dalam tubuh manusia sehingga dapat berfungsi aktif dan sempurna. persenyawaan kimia gen yang melibatkan adn (asam deoksiribo nukleat) dan arn (asam ribo nukleat) mengatur kode-kode, kemudian diterjemahkan dalam bentuk hormon-hormon dan enzim-enzim. semuanya dapat dipengaruhi sekaligus menurunkan emosi (temperamental) pada diri manusia secara kimiawi (cambell d, 2002). ketika diperdengarkan muratt al, maka harmonisasi dalam muratt al yang indah akan masuk telinga dalam bentuk suara (audio), menggetarkan genderang telinga, mengguncangkan cairan 171 muhammadiyah journal of nursing ditelinga dalam serta menggetarkan sel-sel rambut di dalam koklea untuk selanjutnya melalui saraf koklearis menuju otak dan menciptakan imajinasi keindahan di otak kanandan otak kiri. hal ini akan memberikan dampak berupa kenyamanan dan perubahan perasaan. perubahan perasaan ini diakibatkan karena muratt al dapat menjangkau wilayah kiri kortek cerebri (purna, 2006). metode penelitian 1. desain penelitian penelitian ini merupakan penelitian quasieksperiment dengan bentuk non equivalent control group design yaitu dengan cara menambahkan kelompok control sebagai pembanding dari sebuah kelompok perlakuan, dimana pada kelompok perlakuan 1 diberikan perlakuan 1 mendengarkan muratt al surat al – fatihaah dan al – baqarah sebanyak 2x sehari, kelompok perlakuan 2 diberi perlakuan mendengarkan muratt al surat al – fatihaah dan al – baqarah sebanyak 3x sehari dan kelompok kontrol tidak diberikan intervensi hanya mengikuti perlakuan dari pelayanan kesehatan diwilayah tersebut, kemudian membandingkan hasil pengukuran ketiga kelompok. 2. populasi dan sampel. a. populasi populasi dalam penelitian ini adalah keseluruhan objek yang diteliti sehingga populasi dalam penelitian adalah semua lansia yang mengalami hipertensi di posyandu lansia desa tanjung harapan kecamatan seputih banyak kabupaten lampung tengah yaitu 86 lansia b. jumlah sampel pada penelitian adalah sebanyak 86 responden dengan cara purposive sampling yaitu yang dibedakan antara 43 kelompok perlakuan dan 43 kelompok kontrol. 3. pengumpulan dan analisa data a. data primer yang didapat dari pengukuran tekanan darah tinggi lansia b. data sekunder berasal dari data rekam medik dari posyandu lansis c. analisis yang digunakan wilcoxon test, mann whitney, fridman test dan kruskal willis. hasil penelitian dan pembahasan 1. hasil penelitian adapun hasil univariat bivariat secara lengkap dapat dilihat pada tabel berikut ini : tabel 1 distribusi karaktristik responden variable 3x sehari 2x sehari kontrol umur 50-60 tahun 61-70 tahun >70 tahun 14 6 1 11 8 3 23 18 2 jenis kelamin laki-laki perempuan 5 16 9 13 15 28 pekerjaan irt petani dagang swasta pns 7 7 5 2 0 6 4 4 1 7 11 12 10 3 7 pendidikan sd smp sma diploma sarjana 8 6 4 3 0 5 0 3 5 9 15 4 7 8 9 1. hasil univariat didapatkan bahwa umur terbanyak (50-60th) untuk kelompok mendengarkan muratt al 3x sehari sebanyak 14 orang, mendengarkan muratt al 2x sehari sebanyak 11, dan kontrol 23 orang. 2. hasil untuk jenis kelamin perempuan kelompok mendengarkan muratt al 3x sehari sebanyak 16 orang, mendengarkan muratt al 2x sehari sebanyak 13, dan kontrol 28 orang. 172 muhammadiyah journal of nursing 3. hasil pekerjaan irt muratt al 3x sehari sebanyak 7 orang, mendengarkan muratt al 2x sehari sebanyak 6, dan kontrol 11 orang. 4. hasil pendidikan sd muratt al 3x sehari sebanyak 8 orang, pendidikan sarjana untuk kelompok mendengarkan muratt al 2x sehari sebanyak 9 orang, dan sd untuk kontrol 23 orang. adapun hasil analisis bivariat secara lengkap dapat dilihat pada tabel berikut ini: tabel 2 hasil pretest dan postets uji wilcoxon var wilcoxon kelompok sig 3x sehari 0,000 2x sehari 0,000 kontrol 0,000 hasil wilcoxon menunjukan baik kelompok 3x sehari, 2x sehari dan kelompok kontrol menunjukan p-value 0,000(< 0,05). tabel 3 mann whitney kelompok intervensi (2x sehari dan 3x sehari dijadikan satu) dan kontrol. variable tekanan darah sig kelompok intervensi dengan kontrol tekanan darah sistolik 0,038 kelompok intervensi dengan kontrol tekanan darah diastolik 0,000 1. hasil mann whitney kelompok intervensi dan kontrol untuk tekanan darah sistolik menunjukan p-value 0,038 (< 0,05) 2. hasil mann whitney kelompok intervensi dan kontrol untuk tekanan darah diastolik menunjukan p-value 0,000 (< 0,05). adapun hasil multivariat secara lengkap dapat dilihat pada tabel berikut : tabel 3 hasil uji kruskal willis variable sig postt est tekanan darah sistolik kelompok 3x sehari,2x sehari,dan kontrol 0,025 postt est tekanan darah diastolik kelompok 3x sehari,2x sehari,dan kontrol 0,000 1. hasil kruskal willis untuk postt est tekanan darah sistolik kelompok 3x sehari,2x sehari,dan kontrol menunjukan p-value 0,025 (< 0,05) 2. hasil kruskal willis untuk postt est tekanan darah diastolik kelompok 3x sehari,2x sehari,dan kontrol menunjukan p-value 0,000 (< 0,05) adapun grafi k penurunan tekanan darah sistolik 3x sehari, 2x sehari dan kontrol dapat dilihat di grafi k berikut : grafi k 1 gambaran penurunan tekanan darah sistolik 3x sehari, 2x sehari dan kontrol keterangan : series 1/ warna biru menunjukan penurunan tekanan darah kelompok sistolik 3x sehari series 2/ warna biru menunjukan penurunan tekanan darah sistolik kelompok 2x sehari series 3/ warna hijau menunjukan penurunan tekanan darah sistolik kelompok kontrol 173 muhammadiyah journal of nursing dari grafi k 1 terlihat bahwa kelompok 3x sehari / warna biru lebih menurunkan tekanan darah sistolik dibanding kelompok lain nya. grafi k 2 gambaran penurunan tekanan darah diastolik 3x sehari, 2x sehari dan kontrol dari grafi k 2 terlihat bahwa kelompok 3x sehari / warna biru lebih menurunkan tekanan darah diastolik dibanding kelompok lain nya. pembahasan muratt al adalah rekaman suara alquran yang dilagukan oleh seseorang qori’. lantunan al-quran secara fi sik mengandung unsur manusia sedangkan unsur manusia merupakan instrument penyembuhan yang menakjubkan dan alat yang paling mudah dijangkau sehingga dapat diberikan untuk semua umur baik tua maupun muda (makhdlori, 2007). ayat – ayat dalam surat al – qur’an dapat menurunkan hormone stress, mengaktifk an hormone endofrin alami, meningkatkan perasaan releks dan mengalihkan perhatian dan rasa takut, cemas dan tegang, memperbaiki system kimia tubuh sehingga menurunkan tekanan darah serta memperlambat pernapasan, detak jantung, denyut nadi,tekanan darah dan aktifi tas gelombang otak. laju pernapasan lebih dalam atau lebih lambat tersebut sangat baik menimbulkan ketenangan kendali emosi pemikiran lebih dalam dan metabolisme yang lebih baik (abdel-khalek, 2007). proses mendengarkan muratt al surat al-fatihaah dan al-baqarah menurunkan tekanan darah adalah muratt al dalam bentuk audio menggetarkan genderang telinga dan mengguncangkan cairan telinga. diperantarai molekul nitric oxide yang terlibat dalam perkembangan system audiotorik dan secara spesifi k dalam perkembangan koklea menggetarkan sel-sel rambut dikoklea. dari saraf koklearis menuju otak dan berada disepanjang thalamus hingga ke korteks audiotorik, disepanjang jalur inilah pusat emosi dalam system limbic diaktifk an. dari korteks limbic dilanjutkan ke hipokampus meneruskan sinyal music ke amigdala yang merupakan area perilaku kesadaran yang bekerja pada tingkat bawah sadar. diteruskan ke hipotalamus yang merupakan area pengaturan sebagian fungsi vegetative dan fungsi endofrin tubuh seperti hal nya perilaku emosional. jaras pendengaran diteruskan ke ormatio retikularis sebagai penyalur implus menuju serat otonom yang dibagi menjadi saraf simpatis dan saraf parasimpatis. mempengaruhi relaksasi organ – organ yang diperantarai nitric oxide yang bertindak sebagai transmitt er dan sebagai hormone yang memiliki kerja local dengan mengaktifk an guanilate cyclase yang menyebabkan vasodilatasi dan relaksasi. merangsang pusat rasa ganjaran menimbulkan ketenangan. menurunkan hormone stress, mengaktifk an hormone endofrin alami, meningkatkan perasaan rileks dan mengalihkan perhatian dari rasa takut cemas dan tegang. memperbaiki system kimia tubuh neuropeptide yang merangsang reseptor – reseptor yang ada dalam tubuh dan akan memberikan umpan balik berupa kenikmatan dan kenyamanan sehingga menurunkan tekanan darah tinggi, memperlambat pernapasan, detak jantung, denyut nadi dan aktivitas gelombang otak (al-atsari, 2011). proses obat farmakologi dapat menurunkan tekanan darah adalah sebagai berikut obat farmakologi dibagi menjadi dua yaitu diuretic 174 muhammadiyah journal of nursing dan inhibitor ace. diuretic untuk menangani efek peningkatan volume natrium karena menurunya fungsi ginjal. menyebabkan cairan dan natrium terakumulasi. untuk menangani efek peningkatan volume natrium karena menurunya fungsi ginjal lalu diuretic bekerja dengan cara mendepelsi natrim tubuh. menurunkan volume darah dan menurunkan tekanan darah. inhibitor ace menghambat konversi angiotensi i menjadi angiotensin ii. meningkatkan output jantung dan cardiac index resistensi renovaskuler lebih rendah meningkatkan kapasitas vena. menyebabkan peningkatan ekskresi natrium dalam urin menggunakan inhibitor ace efek dari angiotensin ii dapat dicegah menurunkan tekanan darah (primadita, 2012). pengobatan alternatif terdiri dari 4 jenis yaitu pengobatan dengan ramuan obat, pengobatan alternatif spiritual/kebathinan, pengobatan alternatif dengan memakai peralatan/perangsangan, pengobatan alternatif yang telah mendapatkan pengarahan dan pengaturan pemerintah. muratt al adalah salah satu pengobatan alternatif spiritual/kebatinan (cambell, 2002). kesimpulan dan saran 1. kelompok 2x sehari, 3x sehari dan kontrol menurunkan tekanan darah tinggi. 2. kelompok 3x sehari lebih menurunkan tekanan darah dibanding kelompok lain nya. 3. diharapkan perlu penelitian lebih lanjut mengenai pengaruh mendengakan muratt al terhadap 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cardiopulmonary resucitation (cpr) in critical and emergency care unit info artikel online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.3193 abstract background: knowing the important relation between knowledge and skill is important because it reflexes the action that nurses do to save people life. objective: this research aimed to determine the relationship between the nurse's knowledge level and their performan ce on cardiopulmonary resuscitation in critical and emergency care unit. method: the study was quantitative descriptive with the crosssectional design used sequential sampling with 30 nurses in critical and emergency care unit. the data were analyzed using the fisher exact test. data was taken from questioner and observational assessment using a standard operating procedure which was developed by a hospital. results: the results of this study found that there were 63.3% respondents which all of them had poor knowledge also poor performance on doing cardiopulmonary resuscitation. conclusion: there is a relation between nurse’s knowledge level and the nurse’s performance on undertaking cardiopulmonary resuscitation. the more knowledge they have the better performance they have on cardiopulmonary resuscitation. routine training and evaluation may be useful to increase nurses’ knowledge and skills. keywords: nurse, knowledge, skills, cardiopulmonary resuscitation (cpr), emergency introduction there is some common problem that was facing health care services in indonesia. one of them is giving high-quality health services with reachable cost. the availability and quality of health care services depend on the values and response from the client itself. it is because of the quality of services and satisfaction of client are used as a measurement about how is the quality of health care services itself in the hospital they visited (wardani, 2013). therefore, all health care providers are involved to determine how good health services that they give in a hospital. health care providers that involve are including doctors, nurses, nutritionist, pharmacist, and other professional health care provider. however, the quantity of nurses is the hi ghest than in other professions. nurses are the one who works with the patient for 24 hours divided into 3 working shifts are morning, afternoon, and night shift (indonesian health minister, 2017). from this condition, can be assumed that nurses contribution hold hope in raising the quality of health services in a hospital. it can be said that nurses services are one of the main concern of a hospital based on their skill and knowledge that appropriate with the development of science and technology. 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/6646 vol. 3 no. 1 juni 2019 53 between skill and knowledge, knowledge is holding more dominant role rather than skill. however, even though knowledge is more dominant than skill, but still both of them are related to each other. it is because, someone performance is a reflection of the knowl edge they have through education, training or experience during their working time. one of the basic knowledge and skil l that must be mastered by nurses is performing emergency nursing care, for example, is cardiopulmonary resuscitation (hanafi, 2007). it is important because the emergency case can happen to anyone anywhere regardless of whoever and wherever they are. so that the quality of nurs e s i n emergency care is one of the factors that determine either someone can still alive or not (hazinki, 2015). cardiopulmonary resuscitation (cpr) is an emergency procedure that helps to support and maintain breathing and circulation in a client with has cardiac arrest (sudden heart stop) (mayo clinic). in a hospital, especially in emergency and critical care unit, cardiopulmonary resuscitation i s very important because, in both rooms, the number of morbidity and mortality are high. according to the american heart association (aha) (2010), too few victims of cardiac arrest receiving standard cpr. as known, cpr quality must b e h i gh and that victims require excellent post-cardiac arrest care by organized teams with members wh o function well together. education and frequent refresher training are likely the keys to improving resuscitation performance. the aha has established that initiation of cpr during cardiac arrest will increase the short and long term outcomes for patient survival (aha, 2005c). unfortunately, the quality of cpr performed by the public and health care providers alike is deficient resulting in a low (10%) survival rate after cpr (alspach, 2005). a person with cardio-pulmonary resuscitation (cpr) training can sustain an ailing person's heart and brain for a short time (farah, 2007). therefore, th e nurses who work on it have to be really mastering cpr because time is the main point who hold someone living. fast and right cpr method is the point on saving someone in the emergency case especially in cardiac arrest condition. methods this research design used quantitative descrip tiv e with a cross-sectional design approach. the research took place in the emergency and critical care unit in moewardi hospital of surakarta. the sample was taken by the sequential sampling method. the criteria of the samples are nurses who work in emergency and critical unit. the next was nurses who performed cpr, and nurses with minimum graduated from the diploma of nursing. the last was nurses who were not an internshi p o r orientation nurses. as a result, the total samples that involved were 30 nurses who work in emergency and critical room of the hospital. the instruments that were used were questioner form, which contains 24 multiple choice ques tio n s which used to assess nurses knowledge and nurse s skill is assessed by using a checklist that contains 13 items of sop (standard operating procedure that provided by moewardi hospital). this checklist was observed by the researcher through systematic observation. to determinate the score, the researcher used score 1 for the right answer, and score 0 for a false answer. the 24 multiple choice questions have contain ed a definition, purposes, indication, contraindication, cpr procedure, and termination of the proced u re. for the checklist that being used is contain 13 items. this research was done on may-july 2011 and it took 4 rooms, those are critical room (icu and icvcu) and emergency care unit (triage and icu). later on, the data was processed through 4 steps, those were editing, coding, e ntry data, and tabulating. the next was that the data analyz e d b y univariate and bivariate. results the research that has been done, the result that obtained is below : a. characteristics of respondents in this research, total respondents are 30 nurses who work in emergency and critical unit care, an d the table 1 described characteristics of respondents based on their gender, ages, education level and working period. indonesian journal of nursing practices 54 table 1 characteristics of respondents characteri s ti c frequency percentage (%) gender: -man -woman 16 14 53.3 46.7 ages : 24-35 >35 25 5 83.3 16.7 educati on level : di pl oma div bachel or 27 1 2 90 3.3 6.7 worki ng experi ence: 1-5 years 6-10 years 11-15 years 17 7 6 56.7 23.3 20 in table 1 showed that the frequency of man is more than women (53.3%). the total of man respondents is more probably because man strength is needed more according to their physical is stronger than women. based on ages, it can be seen on the table that ages of respondents mo s tly are in the ages of 24-25 years old, it means that in this hospital, nurses that work in emergency and critical unit care are in productive ages, where physically is really needed to give fast and right nursing care. according to the education level, th e nurses are mostly graduated from diploma in nursing. it can be defined that, most of the diploma graduation do not continue their study into bachelor degree and prefer to work directly. professional nurses are defined as a nurse that develop his knowledge through high educatio n b y completing minimum education in diploma of nursing. the next is the working period, most of the respondents are having a working period around 15 years. it is because the hospital recruits new employ. the presence of senior nurses, which have a working period of more than 10 years can give working experience to the new nurses which still lack experience related to cardiopulmonary resuscitation. the length of working experi en ce i s showing someone performance, and influencing their readiness in doing given tasks. the expectation is the longer someone working experience the better performance they may h av e (kuhnigh, 2004). b. univariate analysis methods 1).respondents distribution based on their knowledge on cardiopulmonary resuscitation (cpr) division of knowledge category is divided into tw o that are good and poor level. they are good if the result > mean or respondents which has value 1934. on the other side, there is less category if the result <means of respondents has value 0-18.the result from 30 respondents who fill 24 questione rs obtain the result as below (table 2): table 2. respondents distribution based on their knowledge related to cardiopulmonary resuscitation in critical and emergency care unit knowl edge frequency percentage (%) good poor total 7 23 30 23.3 76.7 100 23 respondents are categorized in a group which has poor knowledge (76.7%), while the respondents who have good knowledge is lesser (23.3%). from 23 respondents who categorize less knowledge, 14 of them have the working period for 1-5 years. while, 9 out of 23 respondents, has enough working period that more than 5 years. 2). respondents distribution based on their skills in performing cardiopulmonary resuscitation (cpr). in this research, the result of observing 30 skills respondent is shown in the table below (table 3): table 3. respondents distribution based on their skills on performing cardiopulmonary resuscitation (cpr) in critical and emergency care unit ski l l frequency percentage (%) good poor total 9 21 30 30 70 100 table 2 shows that most of the respondents (21 nurses) skill on performing cardiopulmonary resuscitation include in the poor category (70%), while the rest of them, 9 respondents, are categorized in good skill. unfortunately, 2 of 9 respondents which in good skill category are still having poor knowledge about cpr. skills that h av e by respondents not only from education but also from experience. respondents that performing cpr refer to standard operational procedure (sop). the sop is contained 13 items that used as a reference to evaluate either vol. 3 no. 1 juni 2019 55 the respondents performing cpr good and righ t o r not. if 13 items can be done rightly, it means respondents have performed right nursing care, but if there are any of 13 items that can not be done, it means that respondents do not give right nursing care. therefore, from those 13 items sop of cpr can show that respondents still not able to perform cpr well because most of them are stil l i n poor skill category. c. bivariate analysis method the bivariate analysis method is used to merge between nurses (respondents) knowledge and their skills on performing cpr in critical and eme rge n cy unit care in moewardi hospital of surakarta. statistic experiment that is used to analyze is the fisher exact analysis tool. researcher merging nurses knowledge and their skills as the table below (table 4): table. 4 relation between respondents knowledge and their skills on performing cpr in critical and emergency unit care in one of the hospitals in solo. knowl edge cpr ski l l total p* good poor n % n % n % good 5 16,7 2 6,7 7 23,3 0,0 14 poor 4 13,3 19 63,3 23 76,7 total 9 30 21 70 30 100 p* obtained use of fisher exact test analysis method table 4 demonstrates from 7 (23.3%) respondents who have good knowledge, 5 of them (16.7%) are having good skills on performing cpr while the other 2 of them (6.7%) are having poor skill on it. from 23 respondents (76.7%) who have poor knowledge, 4 of them (13.3%) are performing cpr well. while, the rest of it, 19 respondents (63.3%) are in a poor category on performing cpr. the result from counting used fisher exact analysi s tools with spss 16.00 for windows program is also displayed in table 4. the outcome is obtained significant values (p-value) 0,014 the conclusio n o f the test is rejecting h0 because p-value values is smaller than0,05 (0,014<0,05), so can be concluded that there is relation between nurses knowledge level and their skills on performing cardiopulmonary resuscitation in critical and emergency care unit in one of the hospitals in solo. from 30 respondents that analyzed, there are 19 of them which have poor knowledge and poor skill also on performing cpr. nursing care that referre d to sop that must be done rightly, in real practice, some of sop steps are still neglected. that was obtained according to the observation of researcher to respondents who performed cpr, where there are 3 out of 13 items in the checklist that most of them did not do. those are items no 3, 5 and 8. every nurse must have good knowledge and skills related to cpr because that is a vital procedure that must be mastered by professional nurses. discussions patient emergency care is one of the hospital services that required fast, proper, and accurate service to prevent death and deformity. one of the quality service indicators is response time, where this indicator is a process to achieve an outcome indicator that is life sustainability (halim, 2016). cardiopulmonary resuscitation knowledge i s a vital modal for nurses who work in critical and emergency care unit. in the same research from hermawan (2011), with the title relation betw ee n nurses about critical respiratory with attitu d e o n handling breath failure on neonatal in intensive care unit in pku muhammadiyah delanggu klaten. where the result is there is a relation between nurses knowledge about critical respiratory and their attitude on handling breath failure on neonatal who has critical breathing condition. knowledge level can be diffe rent because of s o me factors, one of it is educational background. it is because the respondents obtain information through education and experience on it. the relationship between education level w i th n u rs e s knowledge is a knowledge level that has an imp a ct on increasing clients knowledge about their health. other factors that also effect is working period, motivation on the study, and lack of training gi v e n by hospital about cardiopulmonary resuscitation. on the other side, from analysis data above obtained 7 respondents (23.3%) who have good knowledge, there is 5 of them (16.7%) also have good skills. according to notoadmojo (2007) explain that knowledge is one of the dominant factors that create someone action, so from that theory also explain about why there are 3 indonesian journal of nursing practices 56 respondents (6.7%) that have good knowledge b u t still have poor skills. research result of thamrin (2010) about image of nurses and midwives knowledge about cardiopulmonary resuscitation on neonatal in rsia siti fatimah makassar. the result showed that most of them (57,5%) nurses respondents have good knowledge. nurses and midwives knowledge about cardiopulmonary resuscitation on neonatal is important where knowledge is a basic foundation on creating nurses and midwives attitude on performing cardiopulmonary resuscitation fast and right. the outcome of thamrin research is in line with this research where someone (nurses) knowled ge w i ll have an impact on their attitude and their skills in performing cpr. based on table 3, which explain about nurse's skill s quality in cpr, the result of performing cardiopulmonary resuscitation is valued by doing observation toward respondents while filling a checklist when they performing cpr. later on the outcome will be divided into 2 categories, first is categorize good if the result of value >mean or respondents get value 10-13. the second is categorize poor if they have value <mean or 0-9. from 9 respondents (30%) who have good skills, there is 4 of them (13,3%) who have poor knowledge. it showed that only knowledge does not ensure that someone can perform cardiopulmonary resuscitation well. an outcome of the research displayed that 2 out of 4 of them have working experience for 5 years, the other one respondent has been working for 8 years, and the rest has worked for 15 years. besides experience and knowledge, according to oman and bell in bastable (2002), there are some other factors that influence someone skills. those are health s tatu s , environmental stimuli, and anxiety level. that research outcome is in line with the research of kuhnigk (2004), with the title skills and self value on cardiopulmonary resuscitation from nurses in hospital. from those research are obtained that cpr skills from respondents are different in education level, professional experience, on d o i n g cpr either in the past or working in the hospital. the limitations of this research are: 1. research methods using descriptive so that the result is limited on nurses who work in critical and emergency care unit in one of the hospitals in solo and the result cannot be generalized for nurses from others hospital. 2. this research only limit on the relation between nurses knowledge and their skill on cardiopulmonary resuscitation. 3. changes of statistic test from kendall tau-b become fisher exact analysis tool is because there is no any respondents who have poor knowledge and skill, conclusions respiratory and cardiac arrest inpatient can occur suddenly and unpredictable, by knowing sign s an d symptoms fast and early appropriate aid procedure, it can help to prevent worsening of th e patient condition and give maximal chance f o r th e patient to recover. therefore it is very important that nurses understanding about cpr and it needs poor knowledge also so that cpr can be done rightly, and fast on giving aid to the patient with respiratory and cardiac arrest. references abdul, halim. rottie, julia. karundeng, michael y. 2016. analisis perbedaan response time perawat terhadap pelayanan gawat darurat di unit gawat darurat di rsu gmim pancaran kasih dan di rsu tk.iii robert wolter monginsidikota manado. universitas sam ratulangi aha. (2010). guidelines cpr ecc 2010 17-07-2018, from http://www.heart.org/idc/groups/heartpublic/@wcm/@ecc/documents/downloadabl e/ucm_317350.pdf aha. (2005c). highlights of the 2005 american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. currents in emergency cardiovascular care, 16(4), 1-28. pubmed.gov alspach, g. (2005). cpr: the vanishing competency. critical care nurse, 25(6), 8-12. critical nurse care. hazinki, mary fran & others. (2015). fokus utama: pembaruan pedoman american heart association 2015 untuk cpr dan ecc. retrieved from https://eccguidelines.heart.org/wpcontent/uploads/2015/10/2015-ahaguidelines-highlights-indonesian.pdf http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-aha-guidelines-highlights-indonesian.pdf https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-aha-guidelines-highlights-indonesian.pdf https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-aha-guidelines-highlights-indonesian.pdf vol. 3 no. 1 juni 2019 57 bastable, s. b.(2002). perawat sebagai pendidik. jakarta: penerbit buku kedokteran egc indonesia health minister. 2017. infodatin: information and data center of indonesia health minister. jakarta hanafi, a. (2007). peran ruangan perawat icu dalam memberikan pelayanan kesehatan di rumah sakit. medan: usu hermawan, h. (2011). hubungan pengetahuan perawat tentang kegawatan napas dengan sikap penanganan gawat napas pada neonatus di ruang perawatan intensif pku muhammadiyah delanggu klaten. skripsi. tidak dipublikasikan stikes surya global yogyakarta kuhnigh, h & sefrin p. (2004). skills and self assessment in cardio-pulmonary resuscitation of the hospital nursing staff. mayo clinic. first aid cardiopulmonary resuscitation (cpr): first aid. retrieved from https://www.mayoclinic.org/first-aid/first-aidcpr/basics/art-20056600. thamrin, s. (2010). gambaran pengetahuan perawat dan bidan tentang resusitasi jantung paru pada neonates di rsia siti fatimah makassar. skripsi. program studi ilmu keperawatan fakultas kedokteran universitas hasanuddin makassar wardani, beni mutiara. (2013). pengaruh kualitas pelayanan terhadap kepuasan pelanggan dari sudut pandang pasien dan pendamping pasien. universitas katolik indonesia atma jaya jakarta https://www.mayoclinic.org/first-aid https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 137 muhammadiyah journal of nursing abstract background: sea cucumber contains many active compounds that have health benefi ts. the ability of therapeutic and medicine eff ects have associated with triterpen glycosides (saponin), chondrointin sulfates, glycosaminoglycan ( gags), sulfates polysacarida, sterol (glycoside and sulfates) phenolics, cerberosides, lectins, peptides, glycoprotein, glycosphingolipids and essential fatty acids. objective: to compare the eff ectiveness of sea cucumber jelly and hydrogel in chronic wound healing in the white rats. method : the research was a quasi-experiment with post test design. the number of samples was 10 rats. the rats were divided into two groups: a group was given sea cucumber jelly treatment and the other group was given hydrogel treatment. before given treatment, a 1x1 cm wound was made on each rats and then the wound was infected with e. colli. wound care was done in every 2 days. result: there was no signifi cant diff erence between the use of sea cucumber jelly and hydrogel in chronic wound healing in the white rats (p = 0,753). based on the average of healing period, sea cucumber jelly gave better eff ect than hydrogel (wound with sea cucumber jelly treatment was healed 12 days, and hidrogel in 13 days). design assessment tool was used to assess the wound. conclusion: based on the average of healing period, sea cucumber jelly gave better eff ect than hydrogel. sea cucumber jelly could be to use as the alternatives dressing. keywords: chronic wound healing, dressing, sea cucumber jelly, hydrogel. perbedaan pemberian gamat jelly dan hidrogel dalam penyembuhan luka kronik pada tikus putih hartono, yuni permatasari istanti, elsye maria rosa universitas muhammadiyah yogyakarta pendahuluan luka adalah suatu gangguan kontiniutas struktur jaringan. cedera, pembedahan atau kecelakaan menyebabkan kerusakan jaringan , gangguan pembuluh darah dan ekstravasasi konstituen darah dan hipoksia (al-waili, salom, ghamdi, 2011). masalah yang di timbulkan akibat luka sangat kompleks, baik masalah fi sik, psikologis dan masalah ekonomi. seseorang yang menderita luka akan merasakan adanya ketidak sempurnaan, yang pada akhirnya akan cenderung mengalami gangguan fi sik dan emosional. luka yang terjadi akan berdampak pada kualitas hidup bagi penderitanya, dan masalah ekonomi yang terjadi adalah besarnya biaya yang di keluarkan untuk membeli obat dan material perawatan luka. pada tahun 2004 berdasarkan data world health organisation (who) lebih dari 150 juta orang didunia menderita diabetes dan diperkirakan tahun 2025 jumlah nya akan menjadi dua kali lipat, sedangkan di amerika serikat setiap tahun nya lebih dari 1,25 juta orang menderita luka bakar dan 6,5 juta orang mengalami luka kronik, seperti: luka tekan, statis vena, atau diabetes. (ali-waili.ns,et al, 2011). data luka kronik yang terdapat di rumah sakit dr. soetomo surabaya tahun 2006 didapat 306 kasus pertahun atau 0,69% dari total pasien yang dirawat yaitu 43.825 pasien yang terdiri dari ulkus diabetic 65,3 %, ulkus dekubiktus 13.1%, trauma degloving tungkai bawah 2,9% dan luka bakar 18,6% (perdanakusuma ds,2009). perawatan luka yang profesional sangat diperlukan untuk mengurangi masalah yang ditimbulkan 138 muhammadiyah journal of nursing akibat luka. prinsif perawatan luka saat ini erat hubungannya dengan berbagai material perawatan luka yang telah dikembangkan serta adanya perubahan konsep perawatan luka dalam tatalaksana pembersihan, penutupan dan perlindungan luka. hydrogel merupakan salah satu material perawatan luka yang sangat penting karena memiliki fungsi mempertahankan kelembaban luka sehingga meningkatkan granulasi, selain itu dengan kemampuan hidrasi yang optimum hydrogel dapat melisis jaringan slough dan nekrotik oleh karena itu hydrogel memiliki kemampuan autolitic debridement. sifat lain yang dimiliki oleh hidrogel adalah tidak lengket sehingga dapat menurunkan rasa nyeri saat perawatan luka. gamat atau teripang merupakan hewan laut yang sudah sejak lama dikenal oleh masyarakat sebagai makanan dan obat tradisional. gamat mengandung berbagai senyawa aktif yang memiliki manfaat bagi kesehatan. bordbar s, anwar f, dan saari n (2011), dalam penelitian tentang , high-value components and bioactives from sea cucumbers for functional foods a review. penelitian merupakan sistematik review, menyatakan sea cucumbers/gamat memiliki nilai nutrisi seperti: vitamin a, vitamin b1 (thiamine), vitamin b2 (ribofl avin), dan mineral seperti kalsium, magnesium, iron dan zinc. angka aktivitas biologi dan farmakologi yang unik dari gamat termasuk diantaranya: antikanker, antikoagulant, anti-hipertensi, anti-infl ammasi, antimikroba, antioxidant, antithrombotic, antitumor and wound healing. kemampuan terapeutik dan efek pengobatan yang dimiliki gamat dihubungkan dengan adanya triterpen glycosides (saponin), chondrointin sulfates, glycosaminoglycan ( gags), sulfates polysacarida, sterol (glycoside and sulfates) phenolics, cerberosides, lectins, peptides, glycoprotein, glycosphingolipids and essential fatt y acids. pada penyembuhan luka gamat dapat mempercepat regenerasi sel karena kandungan asam lemak seperti: arachidonic acid (aa c20:4), eicosapentaenoic acid (epa c20:5), and docosahexaenoic acid (dha c22:6). bahan dan cara desain penelitian ini menggunakan rancangan post test design. peneliti melakukan suatu intervensi atau tindakan pada satu kelompok kemudian diobservasi hasil intervensi tersebut. penelitian ini bertujuan untuk membandingkan efektivitas pemberian gamat jelly dan hidrogel dalam penyembuhan luka kronik pada tikus putih. sampel pada penelitian ini adalah tikus putih sebanyak 10 ekor, tehnik sampling dengan quota sampling, dengan kriteria inklusi : tikus putih usia 3-4 bulan, berat badan 200-300 gram, jenis kelamin jantan, dalam keadaan sehat, tidak mengalami kelainan genetik. sedangkan kriteria eklusi: usia kurang dari 3 bulan atau lebih dari 4 bulan, berat badan kurang dari 200 gram atau lebih dari 300 gram, jenis kelamin betina, sakit atau memilki kelainan genetik.. lokasi penelitian adalah laboratorium hean stik muhammadiyah pontianak, dan penelitian ini dilaksanakan pada tanggal 5 januari 2013 hingga 8 februari t 2013. variabel pada penelitian terdiri dari : 1. variabel independen gamat jelly dan hidrogel 2. variabel dependen penyembuhan luka sedangkan langkah-langkah pengumpulan data yang dilakukan pada penelitian ini sebagai berikut : 1. tahap persiapan sebelum penelitian ini dilaksanakan oleh peneliti, terlebih dahulu peneliti mengajukan surat uji etik untuk melakukan penelitian kepada komisi etik penelitian fakultas kedokteran dan ilmu kesehatan universitas muhammadiyah yogyakarta b. setelah mendapatkan surat kelayakan etik selanjutnya peneliti melakukan minta ijin 139 muhammadiyah journal of nursing kepada penanggungjawab laboratorium hewan stik muhammadiyah pontianak. 2. tahap pelaksanaan a. mengidentifi kasi responden berdasarkan kriteris inklusi yang telah ditentukan. b. peneliti melakukan pembiusan dengan menggunakan anastesi diazepam 0.4 cc, menemui, memperkenalkan diri, membuat perlukaann 1x1 cm c. selanjutnya luka di infeksi menggunakan e. colli, untuk menciptak luka kronik d. sehari kemudian luka di rawat dengan menggunakan gamat jelly dan hidrogel e. selanjutnya peneleti melakukan perawatan luka setiap 2 hari dan mengobservasi skor perkembangan luka dengan menggunkan design. uji analisa data yang digunakan pada peneltian ini adalah: 1. analisis uniariat pada penelitian ini variabel yang dideskripsikan melalui analisis univariat adalah variabel dependen yaitu skor perkembangan luka design data yang di peroleh di hitung jumlah nya dan menghitung rata-rata lama hari penyembuhan. data yang diperoleh kemudian dihitung jumlah dan prosentase masing-masing kelompok dan disajikan dengan menggunakan tabel serta diinterprestasikan. 2. analisis bivariat untuk mengetahui hubungan antara variabel independen dan dependen dilakukan analisis bivariat dengan menggunakan uji independent sample t test. hasil penelitian ini menggunakan sample berjumlah 10 ekor tikus yang di buat pelukaan. penyajian dimulai dari karakteristik luka berdasarkan design 1. karakteristik responden a). kelompok gamat jelly no karakteristik ∑ 1 jenis kelamin jantan 5 2 usia 3-4 bulan 5 3 berat badan 200-300 gram 5 4 usia < 3 bulan 5 usia > 4 bulan 6 berat badan < 200 gram 7 berat badan > 300 gram 8 jenis kelamin betina b). kelompok hidrogel no karakteristik ∑ 1 jenis kelamin jantan 5 2 usia 3-4 bulan 5 3 berat badan 200-300 gram 5 4 usia < 3 bulan 5 usia > 4 bulan 6 berat badan < 200 gram 7 berat badan > 300 gram 8 jenis kelamin betina 2. pengkajian karakteristik luka adapun pengkajian karakteristik luka dengan menggunkan design pada masing – masing tikus yang mengalami penyembuhan adalah sebagai berikut: a). berdasarkan dept / kedalam luka pengkajian skor luka berdasarkan dept atau kedalam tergambar pada tabel diberikut ini: tabel 4.2.1 skor pengkajian dept/kedalaman luka responden gamat jelly hidrogel hari 2 hari 6 hari 10 hari 2 hari 6 hari 10 tikus 1 3 2 0 3 3 0 tikus 2 3 2 1 3 2 1 tikus 3 3 2 0 3 2 0 tikus 4 3 3 1 3 2 1 tikus 5 3 2 0 3 2 0 dari tabel di atas diketahui pada pada hari ke dua, semua tikus (tikus 1,2,3,4 dan 5) baik dari kelompok gamat jelly dan hidrogel memiliki skor 3 yaitu kedalaman luka sampai ke jaringan sub 140 muhammadiyah journal of nursing kutan. pada hari ke enam hampir semua tikus baik dari kelompok gamat jelly dan hidrogel memilki skor 2, tikus-tikus tersebut memiliki kedalam luka sampai lapisan dermis. hanya satu tikus yaitu tikus 4 dari kelompok gamat jelly yang memperoleh skor 3 dengan kedalam luka sampai lapisan subkutan. pengkajian pada hari kesepuluh diperoleh hasil dari kelompok gamat jelly terdapat 3 ekor tikus yang memperoleh skor 0 (tidak ada luka), yaitu: tikus 1, 3 dan 5, pada kelompok hidrogel terdapat 2 ekor tikus yaitu: tikus 1 dan tikus 5 , yang berarti tidak terdapat luka / tidak ada kemerahan. dan tikus yang memiliki skor 1 (satu) yaitu: tikus 2 ,4 ( gamat jelly) dan tikus 2,3 dan 4 ( hidrogel) yang berarti terdapat kemerahan persisten pada luka. b). pengkajian berdasarkan eksudat pengkajian exudat di gambarkan pada tabel di bawah ini: tabel 4.2.1 skor pengkajian exudat responden gamat jelly hidrogel hari 2 hari 6 hari 10 hari 2 hari 6 hari 10 tikus 1 1 1 0 1 1 0 tikus 2 1 1 0 1 1 0 tikus 3 1 1 0 1 1 0 tikus 4 1 1 0 1 1 0 tikus 5 1 1 0 1 1 0 dari tabel di atas dapat dilihat pada hari ke dua semua tikus baik dari kelompok gamat jelly maupun kelompok hidrogel memiliki skor 1 yang berarti luka memiliki eksudat yang ringan. pada hari keenam semua tikus msih memiliki skor 1 yang berarti luka memiliki eksudat yang ringan.dan pada hari kesepuluh tikus baik dari kelompok gamat jelly ataupun hidrogel memliki skor 0 yang berarti luka tidak memiliki eksudat. c). pengkajian skor luka berdasarkan size/ukuran luka pengkajian size / ukuran luka terlihat pada tabel dibawah ini: tabel 4.2.1 skor pengkajian size/ ukuran luka responden gamat jelly hidrogel hari 2 hari 6 hari 10 hari 2 hari 6 hari 10 tikus 1 2 1 0 2 1 0 tikus 2 2 1 1 2 1 1 tikus 3 2 1 0 2 1 1 tikus 4 2 1 1 2 1 1 tikus 5 2 1 0 2 1 0 dari data di atas pada pengkajian hari ke dua ukuran luka pada semua tikus baik kelompok gamat jelly maupun hidrogel memiilki skore 2 dengan luas luka 1x1 cm, belum tampak perubahan luas luka, luas luka masih sama seperti saat pertama kali luka di buat. pada hari keenam ukuran luas luka mulai menurun, skor ukuran luas luka pada kelompok gamat jelly dan hidrogel menurun menjadi 1, yang berarti ukuruan luas luka kurang dari 1 cm. pada hari kesepuluh terdapat 3 ekor tikus dari kelompok gamat jelly, yaitu tikus 1, 3 dan 5 yang memilki skor 0 (tidak ada luka) dan 2 ekor tikus kelompok hidrogel yang memilki skor 0 (luka tidak ada). sedangkan tikus yang memiliki skor 1 (luka <1 cm) terdapat 2 ekor tikus dari kelompok gamat jely (tikus 2 dan tikus 4 ), 3 ekor tikus dari kelompok hidrogel juga memiliki skor 1 (tikus2,3 dan 4). d). pengkajian skor luka berdasarkan infl amasi pengkajian skor luka berdasarkan infl amasi digambarkan pad tabel berikut: tabel 4.2.1 skor pengkajian infl amasi responden gamat jelly hidrogel hari 2 hari 6 hari 10 hari 2 hari 6 hari 10 tikus 1 1 0 0 1 1 0 tikus 2 1 0 0 1 1 0 tikus 3 1 0 0 1 1 0 tikus 4 1 2 0 1 1 0 tikus 5 2 1 0 1 0 0 141 muhammadiyah journal of nursing tampak pada tabel di atas pada hari kedua semua tikus baik dari kelompok gamat jelly dan kelompok hidrogel memiliki skor 1 yang berarti terdapat tanda gejala infl amasi (rubor, dolor, calor, tumor, fungsio lesi). pada hari keenam pada kelompok gamat jelly terdapat 4 ekor tikus (tikus 1,2,3, dan 5) yang memiliki skor 0 (tidak terdapat tanda gejala infl amasi, sedangan kan kelompok hidrogel yang memiliki skor 0 hanya 1 ekor tikus yaitu tikus 5. pada kelompok gamat jelli yang memperoleh skor 2 yaitu memiliki sebagian tanda infeksi( infl amasi dan bau). dan teradapat 4 ekor tikus dari kelompok hidrogel yang memiliki skor 1 yaitu tikus 1,2,3,dan 4 .pada hari kesepuluh di ketahui terdapat 10 ekor tikus baik dari kelompok gamat jelly dan hidrogel yang memiliki skor 0 yang berarti tidak terdapat tanda dan gejala infl amasi pada luka. e). pengkajian skor luka berdasarkan granulasi pengkajian skor luka berdasarkan granulasi di gambarkan pada tabel berikut: tabel 4.2.1 skor pengkajian granulasi responden gamat jelly hidrogel hari 2 hari 6 hari 10 hari 2 hari 6 hari 10 tikus 1 1 0 0 1 1 0 tikus 2 1 0 0 1 1 0 tikus 3 1 0 0 1 1 0 tikus 4 1 2 0 1 1 0 tikus 5 2 1 0 1 0 0 dari data tabel di atas dapat di lihat ada hari kedua sebanyak 8 ekor tikus dari kelompok gamat dan hidrogel memiliki skor 5 yang berarti tidak terdapat granulasi pada luka. dan terdapat 2 ekor tikus yang memiliki skor 4 terdapat jaringan granulasi < 10% pada daerah luka. di hari keenam terdapat sebanyak 4 ekor tikus dari kelompok gamat, dan 4 ekor tikus dari kelompok hidrogel yang memiliki skor 2, terdapat 1 ekor tikus dari kelompok gamat jelly yang memiliki skor 4, serta seekor tikus yang memiliki skor 3. dan di hari kesepuluh terdapat 3 ekor tikus (kelompok gamat jelly) dan 2 ekor tikus (kelompok hidrogel) yang memilki skor 0, 3 ekor tikus yang terdiri 1 ekor dari kelompok gamat jelly dan 2 ekor kelompok hidrogel memperoleh skor 1, dan dua ekor tikus kelompok memiliki nilai 2. f). pengkajian skor luka berdasarkan jaringan nekrotik pengkajian jaringan nekrotik pada hari kedua, enam dan kesepuluh tabel 4.2.1 skor pengkajian nekrosis responden gamat jelly hidrogel hari 2 hari 6 hari 10 hari 2 hari 6 hari 10 tikus 1 1 0 0 1 1 0 tikus 2 1 0 0 1 1 0 tikus 3 1 0 0 1 1 0 tikus 4 1 2 0 1 1 0 tikus 5 2 1 0 1 0 0 berdasarkan tabel di atas pada hari kedua pengkajia didapat sebanyak 4 ekor tikus dari kelompok gamat jelly yang memiliki skor 1, dan satu ekor tikus memilki skor 2. sedangkan dari kelompok hidrogel terdapat 3 ekor tikus yang memiliki skor 2 dan dua (2) ekor tikus memiliki skor 1.sedangkan pengkajian hari keenam terdapat 4 ekor tikus dari kelompok gamat jelly yang memiliki skor 0, dan 1 ekor tikus yang memiliki skor 1, sedangkan dari kelompok hidrogel semua tikus memilki skor 1. dan dim hari kesepuluh terdapat 9 ekor tikus baik dari kelompok gamat jelly maupun hidrogel yang memiliki skor 0, dan hanya satu ekor tikus yang memiliki skor 1. 3. analisi univariat sebelum menampilkan hasil analisis univariat terlebih dahulu akan di gambarkan diagram perkembangan penyembuhan luka antara tikus yang diberikan hidrogel dan gamat jelly, seperti pada diagram berikut ini: 142 muhammadiyah journal of nursing diagram 4.3.1. distribusi rata-rata hari penyembuhan luka kronis pada tikus yang diberikan hidrogel dan gamat jelly , n=5 berdasarkan diagram 4.3.1 diketahui bahwa tikus yang di rawat menggunakan dressing gamat jelly mengalami penyembuhan pada hari ke 10 terdapat 3 ekor tikus yaitu : tikus 1, tikus 3 dan tikus 5. sedangkan tikus yang menggunakan dressing hidrogel yang sembuh dalam waktu 10 hari terdapat dua ekor tikus yaitu tikus 1 dan tikus 5. sedangkan tikus yang di rawat menggunakan hidrogel sembuh dalam hari 10 terdapat 2 ekor tikus. pada tikus yang di rawat menggunakan hidrogel paling lama penyembuhannya adalah 18 hari sebanyak 1 ekor tikus, sedangkan pada tikus yang di rawat menggunakan gamat jelly waktu terlama penyembuhan nya adalah 20 hari, yaitu 1 ekor tikus. analisis univariat dalam penelitian ini menggambarkan rata-rata hari penyembuhan luka dan standar deviasi pada tikus yang mengalami luka kronik setelah diberikan dressing hidrogel dan gamat jelli. berikut ini merupakan hasil analisis univariat antara tikus yang mengalami luka kronis dengan pemberian hidrogel dan gamat jeli. tabel 4.3.2. distribusi lama hari penyembuhan luka kronik antara pemberian hidrogel dan gamat pada tikus, n=5 variabel mean standar deviasi minimalmaksimal hidrogel 13,20 3,34 10 – 18 gamat 12,40 4,33 10 – 20 hasil analisis di dapatkan rata-rata hari penyembuhan luka menggunakan hidrogel adalah 13 hari, dengan standar deviasi 3,34. paling cepat luka kronis sembuh menggunakan hidrogel yaitu 10 hari dan paling lama 18 hari. sedangkan untuk rata-rata hari penyembuhan luka menggunakan gamat jeli adalah 12 hari, dengan standar deviasi 4,33. paling cepat luka kronis sembuh menggunakan gamat jelly yaitu 10 hari dan paling lama 20 hari. berdasarkan data tersebut dapat disimpulkan bahwa luka kronis pada tikus yang diberikan gamat jeli lebih cepat sembuh bila dibandingkan dengan luka kronis yang diberikan hidrogel. 4. analisis bivariat analisis bivariat dalam penelitian ini dilakukan untuk mencari perbedaan efektifi tas antara pemberian hidrogel dan gamat jeli pada tikus yang mengalami luka kronis. analisis bivariat di lakukan melalui uji t independent, dengan hasil sebagai berikut: tabel. 4.4.1. hasil uji t independent rata-rata hari penyembuhan variabel mean standar deviasi p. value hidrogel 13,20 3,34 0, 753 gamat 12,40 4,33 rata-rata hari penyembuhan luka menggunakan hidrogel adalah 13 hari, dengan standar deviasi 3,34. sedangkan untuk rata-rata hari penyembuhan luka menggunakan gamat jeli adalah 12 hari, dengan standar deviasi 4,33. hasil uji statistik didapatkan nilai p= 0,753, berarti pada alpha 5% terlihat tidak terdapat perbedaan efektifi tas antara hidrogel dan gamat jeli dalam penyembuhan luka kronis . skor perkembangan luka pada tikus yang menggunakan dressing hidrogel pada hari kedua (2), memiliki rata-rata skor 11.6 sedangkan tikus yang menggunakan gamat jelly memiliki skor rata-rata 11.2. pada hari 143 muhammadiyah journal of nursing keenam (6) tikus yang menggunakan dressing hidrogel memiliki skore rata-rata 7.4, pada tikus yang menggunakan gamat jelly memiliki skor rata-rata 5,6. pada hari kesepuluh (10) nilai rata-rata skor pada tikus yang menggunakan hidrogel sebesar 2 sedangkan pada tikus yang menggunakan gamat jelly memiliki rata-rata skor sebesar 1,6. berdasarkan penurunan jumlah ratarata skor luas luka dapat di simpulkan bahwa luka yang menggunakan dressing gamat jelly memiliki nilai skor sedikit lebih baik di banding pada luka yang menggunakan dressing hidrogel diskusi 1. skor perkembangan luka pada tikus yang menggunakan dressing hidrogel pada hari kedua (2) rata-rata skor 11.6, pada hari keenam 7.4 dan hari kesepuluh rata-rata skor 2 2. skor perkembangan luka pada tikus yang menggunakan gamat jelly pada hari ke dua 11.2., pada hari keenam (6) skor ratarata 5,6. pada hari kesepuluh (10) nilai ratarata skor pada tikus menggunakan gamat jelly memiliki rata-rata skor sebesar 1,6. berdasarkan penurunan jumlah rata-rata skor luas luka dapat di simpulkan bahwa luka yang menggunakan dressing gamat jelly memiliki nilai skor sedikit lebih baik di banding pada luka yang menggunakan dressing hidrogel. 3. beradasar kan lama hari penyembuhan luka tidak terlihat perbedaan secara signifi kan (p= 7,53) antara kelompok gamat jelly dan hirogel, tetapi rata-rata hari penyembuhan kelompok gamat jelly sedkit lebih baik di bandingkan kelompok hidrogel. (gamat jelly 13 hari, hidrogel 12 hari). kandungan air 80-90% pada hidrogel memungkinkan terciptanya keadaan yang lembab pada daerah sekitar luka sehingga merangsang proliferasi sel-sel epitel sehingga terbentuk jaringan granulasi dari dalam luka. kandungan gamat yang berperan dalam proses penyembuhan luka adalah glycosaminoglycan (gags) merangsang pembentukan fi broblast, neovaskularisasi kemudian terbentuklah jaringan granulasi dan epitelisasi dari dasar luka serta pinggiran luka yang akhirnya menyebabkan penurunan kedalaman luka, luas luka dan peningkatan jaringan granulasi. sesuai dengan penelitian yang dilakukan oleh tong m, tuk b, hekking im, vermeij m, barritault d, van neck jw (2009). berjudul stimulated neovascularization, infl ammation resolution and collagen maturation in healing rat cutaneous wounds by a heparan sulfate glycosaminoglycan mimetic, otr4120. penelitian ini untuk mengetahui fungsi heparan sulfate glycosaminoglycan mimetic (buatan), otr 4120, terhadap penyembuhan luka. hasil penelitian ini menunjukan bahwa pengobatan dengan otr4120 merangsang resolusi peradangan dan meningkatkan neovaskularisasi. pengobatan dengan otr4120 juga meningkatkan migrasi epidermal dan proliferasi selama reepithelialization. selain itu, pembentukan jaringan granulasi dan pematangan kolagen juga meningkat. simpulan tidak terdapat perbedaan yang signifi kan antara penggunaan gamat jelly dan hidrogel dalam penyembuhan luka kronik pada tikus putih. daftar pustaka ali-waili,ns., salom.k., al ghandi, 2011, honey for wound healing, ulcer and burn, data supporting its use in clinical practice. the scientifi c world journal. volume 11. page 766-787. annie j., vaughan d., 2006, hydrogel dressing in the management of a variety of wound types: a review. journal of orthopeadic nursing. volume 9. page 1-11. elsiever. 144 muhammadiyah journal of nursing agustina, 2009, perawatan luka moderen. http://www.fkep.unpad.ac.id/2009/01/ perawatan-luka-moderen. akses 29 nopember 2011 baronoski, s., ayello, ea, 2012, wound care essensial practice principle 3rd lippincot, williams wilkins. bordbar s, anwar f, saari n, 2011, high-value components and bioactives from sea cucumbers for functional foods. journal marines drugs .volume 9 oktober 2011. 1761-1805. bryan, ra., nix,dp., 2007, acute and chronic wounds. current management concepts. third edition. louis missouri. mosby elsiever. falang v, 2005, wound bed preparation. htt p:// www.bu.edu./woundbiotech/index.html. akses 22 nopember 2011 fife.c, marissa, carter.j, 2012, wound care out come & associated cost among patien treated in us out patienwound center, http//www.medscape.com/viewartikel. akses 20 desember 2012 kaya az, turani n, akyüz m, 2005, the eff ectiveness of a hydrogel dressing compared with standard management of pressure ulcers. journal of wound care 2005 jan; vol. 14 1 ,, pp. 42-4 kusuma dharma.k, 2011, metodelogi penelitian keperawatan. panduan melaksanakan dan menerapakan hasil penelitian. trans info media, jakarta masre, yip, sirajudeen, gahazali, 2010 ,, wound healing activity of total sulfated glycosaminoglycan gags, from stichopus vastus and s t i c h o p u s hermanni sea cucumber, integumenal tissue in rats. international journal of molecular medicine and advance sciences. volume 6 issued 4, 2010, pp 4953. morris. c, 2006, wound management & dressing sellection.wound essensial, volume 1,page 176-0183. mustoe ta, o’shaughnessy k, kloeters o 2006, chronic wound pathogenesis and current treatment strategies: a unifying hypothesis .j plast reconstr surg. htt p://www.ncbi. nlm.nih.gov/pmc/articles/pmc2691645/. akses 5 nopember 2012 mulloy b, rider cc 2006, cytokines and proteoglycans: an introductory overview. biochemical society transactions 2006 jun; vol. 34 pt 3 ,, pp. 409-13 notoadmojo, soekijo 2010 ,, metodologi penelitian kesehatan. jakarta: rienaka cipta perdana kusuma d, 2009, upaya menjawab tantangan permasalahan hulu hilir luka dan koloid. surabaya. airlangga 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tuk b, hekking im, vermeij m, barritault d, van neck jw 2009, wound repair and regeneration. the wound healing society and the european tissue repair society 2009 nov-dec; vol. 17;6, pp. 840-52. wild, rahbarnia, ellner, sobotka, eberlein 2010, basic in nutrition and wound healing. journal nutrition, volume 26. page: 862 866. wong vw, crawford jd, 2013, vasculogenic cytokine in wound healing. biomed research international 2013, vol. 20; 3, pp. 19-24. zohdi, zakaria, yusop, mustapha, abdullah, 2011, sea cucumber based h y d r o g e l to treat burn wounds in rats. journal biomedicine 2011, volume 98 1, pp: 30-7. zoellner p; kapp h; smola h, 2007, clinical performance of a hydrogel dressing in chronic wounds: a prospective observational study. journal of wound care 2007 mar; vol. 16; 3, pp. 133-6 blank page jurnal mjn vol. 2 no. 2 2015.indd 41 muhammadiyah journal of nursing pendahuluan luka bakar merupakan trauma yang berdampak paling berat terhadap fi sik maupun psikologis, dan mengakibatkan penderitaan sepanjang hidup seseorang, dengan angka mortalitas dan morbiditas yang tinggi (yefta, 2003). kegawatan psikologis tersebut dapat memicu suatu keadaan stress pasca trauma atau post traumatic stress disorder (ptsd) (brunner dan suddarth, 2010). pada beberapa negara, luka bakar masih merupakan masalah yang berat, perawatannya masih sulit, memerlukan ketekunan dan membutuhkan biaya yang mahal serta waktu yang lama. perawatan yang lama pada luka bakar sering membuat pasien putus asa dan mengalami stress, gangguan seperti ini sering menjadi penyulit terhadap kesembuhan optimal dari pasien luka bakar. oleh karena itu pasien luka bakar memerlukan penanganan yang serius dari berbagai multidisiplin ilmu serta sikap dan pemahaman dari orang-orang sekitar baik dari keluarga maupun dari tenaga kesehatan sangat penting bagi support dan penguatan strategi koping pasien untuk menerima serta beradaptasi dalam menjalani perawatan lukanya juga untuk mengurangi stres psikologis sehingga mempercepat mempercepat penyembuhan luka (maghsoudi, 2010). rsup. dr.sardjito selama tahun 2012 terdapat 49 pasien luka bakar dengan angka kematian 34%, ratarata setiap bulannya terdapat 4-5 pasien baru dengan luka bakar derajat ii – iii dan luas antara 20 – 90 % yang dirawat di unit luka bakar membutuhkan lama dirawat /length of stay (los) untuk penyembuhan lukanya ratarespon adaptasi fisiologis dan psikologis pasien luka bakar yang diberikan kombinasi alternative moisture balance dressing dan seft terapi di rsup dr. sardjito yogyakarta lucia anik purwaningsih1, elsye maria rosa2 1rsup. dr. sardjito yogyakarta 2universitas muhammadiyah yogyakarta elanie_la@yahoo.com abstract background: burns are the most severe trauma impact on both physical and psychological. with the limited types of advanced dressings are available in some hospitals, many alternatives were developed based treatment of burns moist (moisture balance dressings alternative) to accelerate wound healing. non-pharmacological interventions for the treatment of psychological stress with seft therapy, the patient›s with seft therapy will be relaxed and the mind becomes calm. relaxation created very infl uential in the healing process. this study aim: to identify the physiological and psychological adaptation response of burn patients were given a combination of alternative seft moisture balance dressings and therapies. methods: action research to determine the physiological and psychological adaptation response of burn patients were given a combination of alternative moisture balance and seft therapy the sample is the total population that met the inclusion criteria. result : there were 8 respondents (march june 2014). most of the 75% of men, aged between 17-51 years, extensive of wound between 6-55% tbsa, 37.5% stage ii, stage iii 62.5%.physiological adaptation response with an wound healing indicator average 42.37 (36-49) showed that physiological adaptation response is adaptive, long time recovering the second degree on average 17.6 days (7-36 days), the average grade iii 28 , 8 days (20-40 days). psychological adaptation response with an acceptance score average 44.5 (40-50) and supported by the results of interviews all indicate an adaptive response to psychological adaptation. conclusion: psychological and physiological adaptation response following administration of a combination of alternative moisture balance dressings and therapies seft are adaptive. keywords: alternative moisture balance dressings, seft therapy, physiological adaptation, psychological adaptation 42 muhammadiyah journal of nursing rata 1 bulan, untuk kasus-kasus tertentu bisa sampai sekitar 6 bulan sampai 1 tahun (register unit luka bakar rsup. dr.sardjito, 2012). angka kejadian gangguan stres paska trauma di rs cipto mangunkusumo adalah 16,2%, paska rawat inap 21,1% dan pada rawat inap 10,7% (yefta 2003). dalam proses penyembuhan luka bakar, perlambatan penyembuhan luka (delayed healing) dapat terjadi bila sel infl amasi dan sel imunitas yang diperlukan pada fase infl amasi, proliferasi dan maturasi tidak dapat bekerja secara optimal. respon infl amasi dan imun tersebut dipengaruhi oleh beberapa faktor, salah satunya stres psikologis (yefta, 2003 dan dealey, 2005). pengaruh stres psikologis dalam penyembuhan luka sebagai berikut; stres psikologis yang buruk seperti stres, ansietas, dan depresi menunjukkan penurunan efi siensi sistem imun dan berlanjut pada terhambatnya penyembuhan luka (dealey, 2005 dan handayani, 2010). salah satu terapi nonfarmakologis untuk penanganan stres psikologis dengan seft terapi. seft (spiritual emotional freedom technique) merupakan terapi yang mampu menurunkan stres psikologis seperti ketakutan yang berlebihan secara signifi kan pada penderita gangguan fobia spesifi k (zainul, 2011). dengan seft terapi pasien menjadi rileks dan pikiran menjadi lebih tenang. relaksasi yang diciptakan tersebut dapat menstimulasi hipotalamus untuk menstimulasi kelenjar pituitari menurunkan sekresi acth dan diikuti dengan penurunan kadar glukokortikoid dan kortisol yang berperan dalam mengatur respon infl amasi, respon imun, dan pengaturan kadar gula darah yang merupakan faktor-faktor internal ini sangat berpengaruh dalam proses penyembuhan luka (kozier, 1995). tujuan dalam penelitian ini untuk mengetahui mengetahui respon adaptasi fi siologis fungsi proteksi proses penyembuhan luka dan respon adaptasi psikologis fungsi konsep diri physical self pada pasien luka bakar yang diberikan kombinasi alternative moisture balance dressing dan seft terapi. metode penelitian desain penelitian ini adalah action research untuk mengetahui respon adaptasi fi siologis dan psikologis pasien luka bakar yang diberikan kombinasi alternative moisture balance dan seft terapi. sampel adalah total populasi dengan accidental sampling yang memenuhi kriteria inklusi. pengambilan data berlangsung dalam 2 tahap, pengambilan data respon adaptasi fi siologis fungsi proteksi proses penyembuhan luka bakar dengan metode observasi menggunakan indikator noc: wound healing secondary intentt ion yang terdiri dari 10 item meliputi; (1) ukuran luka, (2) kedalaman luka, (3) resolusi bullae, (4) resolusi jaringan nekrotik, (5) tipe eksudat, (6) resolusi eksudat, (7) resolusi eritema, (8) resolusi jaringan edema, (9) granulasi dan (10) epitelisai dengan total nilai skor rentang 10–50, skor yang tinggi adalah status penyembuhan yang lebih baik menunjukkan respon adaptasi fi siologis yang efektif atau adaptif dan dilakukan selama kurang lebih 4 bulan, dari bulan maret 2014 sampai dengan juni 2014 dan data tentang respon adaptasi psikologis fungsi konsep diri physical self dengan metode pengisian kuesioner berdasarkan indikator acceptance dari noc yang terdiri 10 item meliputi; (1) perasaan tenang, (2) harga diri positif, (3) menjaga keakraban/ menjalin hubungan, (4) menyatakan perasaan tentang kesehatan, (5) menerima realita status kesehatan, (6) mencari informasi, (7) koping mengatasi masalah, (8) mengambil keputusan terkait kesehatannya, (9) pembaharuan makna kesehatan, (10) harapan, dengan total nilai skor rentang 10–50, skor yang tinggi menunjukkan respon psikologis yang adaptif, dilanjutkan dengan wawancara terstruktur dilakukan setelah responden mencapai proses penyembuhan dengan jaringan epitelisasi atau granulasi >25% 43 muhammadiyah journal of nursing tbsa (total body surface area) yang berlangsung dalam periode waktu tersebut. penelitian ini telah mendapat persetujuan dari komite etik fakultas kedokteran universitas gadjah mada dan universitas muhammadiyah yogyakarta. hasil penelitian dan pembahasan 1. karakteristik responden didapatkan 8 responden (maret-juni 2014). jenis kelamin sebagian besar (75%) laki-laki, usia rata-rata antara 1751 tahun, luas luka antara 6-55% tbsa, derajat ii 37,5%, derajat iii 62,5%. luka bakar merupakan salah satu trauma yang disebabkan akibat kontak langsung ataupun tidak langsung dengan sumber panas yang sering terjadi dalam kehidupan sehari-hari yang sebagain besar (75%) disebabkan karena kelalaian atau keteledoran baik dirumah ataupun ditempat kerja, sedangkan luas luka bakar dipengaruhi oleh penyebab kejadian luka bakar (who, 2014). hasil penelitian ini tidak berbeda jauh dengan hasil penelitian-penelitian sebelumnya yang menemukan usia antara 18 -52 tahun dengan luas luka 15-52% tbsa (gravante dan montone, 2010), dan usia terbanyak antara 20 – 40 tahun 61.1% dengan rata-rata luas luka 39%tbsa gowri et al., 2012). sementara othman (2010) menemukan luas luka dalam rentang 10–48%tbsa terdapat pada responden dalam rentang usia antara 18–45 tahun, yang juga terbukti pada hasil penelitian ini. peneliti juga sependapat bahwa luka bakar merupakan trauma yang disebabkan sebagain besar karena kelalaian di rumah ataupun di tempat kerja, dapat terjadi pada usia tersebut yang tergolong dengan usia produktif, dimana pada usia tersebut fungsi dan peran adalah sebagai pekerja, sehingga sangat dimungkinkan kejadian trauma banyak terjadi saat melakukan aktivitas dalam bekerja. luas luka bakar sangat dipengaruhi oleh penyebab terjadinya luka bakar dan situasi saat terjadinya luka bakar. usia merupakan faktor yang mempengaruhi penyembuhan luka, terdapat perbedaan penyembuhan pada tingkat usia anak dan dewasa, suriadi (2007) menyatakan pada anakanak penyembuhan luka dan kontraksi terjadi dengan cepat dari pada dewasa, pada usia dewasa terjadi ada suatu penurunan vaskularitas dermal, penurunan densitas kolagen, elastin, fragmentasi elastin, dan penurunan jumlah sel mast, akan tetapi tingkatan penyembuhan adalah batas normal (suriadi, 2007; bryant, 2006; carvile, 2007). dalam penelitian ini untuk menghindari faktor pengaruh usia terhadap penyembuhan, usia sudah terlebih dahulu dikontrol dengan menjadikan usia antara 15 – 55 tahun sebagai responden. pada penelitian ini didapatkan usia termuda 17 tahun dan usia tertua 51 tahun. luas luka pada luka bakar juga merupakan faktor yang mempengaruhi penyembuhan, semakin luas luka bakar akan meningkatkan insiden infeksi karena kulit merupakan barier utama tubuh kita sehingga semakin luas luka bakar, imunitas tubuh menjadi semakin menurun. berdasarkan dari hasil temuan dan teori diatas peneliti sependapat bahwa penyembuhan luka pada luka bakar sangat dipengaruhi oleh usia, luas luka dan derajat luka. 2. respon adaptasi fisiologis respon adaptasi fi siologis fungsi proteksi proses penyembuhan luka sebagai berikut: a. evaluasi proses penyembuhan luka hasil penelitian berdasarkan pengamatan dengan menggunakan skala indikator noc: wound healing secondary intentt ion terdiri dari 10 item meliputi; (1) ukuran luka, (2) kedalaman luka, (3) resolusi bullae, (4) resolusi jaringan nekrotik, (5) tipe eksudat, (6) resolusi eksudat, (7) resolusi eritema, (8) resolusi jaringan edema, (9) granulasi dan (10) epitelisai dengan total nilai skor rentang 10–50, skor yang tinggi adalah status 44 muhammadiyah journal of nursing penyembuhan yang lebih baik menunjukkan respon adaptasi fi siologis yang efektif atau adaptif pada siklus 1, siklus 2, siklus 3 sebagai berikut: grafik 1. evaluasi proses penyembuhan luka berdasarkan skor wound healing noc pada siklus 1, siklus 2, siklus 3. grafi k 1. memaparkan hasil evaluasi proses penyembuhan luka berdasarkan skor wound healing noc pada siklus 1, siklus 2 dan siklus 3 sebagai berikut: siklus 1 setelah dilakukan perawatan luka bakar dengan metode alternative moisture balance dressing dan sebelumnya dilakukan seft terapi terlebih dahulu 1 kali putaran selama kurang lebih 15 menit, berdasarkan nilai skor wound healing noc didapatkan hasil rata-rata nilai skor 21,22 dengan nilai skor terendah 13 dan tertinggi 29, dilihat dari 10 item indikator yang meliputi: (1) ukuran luka sebagian besar 7 responden (87,5%) dengan nilai skor 1 artinya luka belum tereduksi, (2) kedalaman luka yang bervariasi sebagian besar dengan nilai skor 3 artinya kedalaman luka derajat ii, (3) resolusi bullae sebagian besar 4 responden (50%) dengan nilai skor 3 artinya sebagian bullae pecah, (4) resolusi jaringan nekrotik sebagian besar 3 responden (37,5%) dengan nilai skor 1 artinya tidak ada resolusi jaringan nekrotik, (5) tipe eksudat sebagian besar 6 responden (75%) dengan nilai skor 2 artinya tipe eksudat serous, encer, berair,(6) resolusi eksudat sebagian besar 5 responden (62,5%) dengan nilai skor 2 artinya sangat sedikit resolusi eksudat, (7) resolusi eritema sebagian besar 37,5% dengan nilai skor 1 artinya tidak ada resolusi eritema kulit sekitar luka, (8) resolusi jaringan edema sebanyak 3 responden (37,5%) dengan nilai skor 2 artinya terdapat sedikit resolusi edema ≤ 25%, (9) granulasi sebagian besar 5 responden (62,5%) dengan nilai skor 2 artinya terisi jaringan granulasi ≤ 25% dari luas luka, (10) epitelisasi sebagian besar 5 responden (62,5%) dengan nilai skor 2 artinya terisi jaringan epitelisasi ≤ 25% dari luas luka. hal ini menunjukkan proses penyembuhan luka belum efektif, sehingga diperlukan tindak lanjut tindakan perawatan luka dengan kombinasi alternative moisture balance dressing dan seft terapi pada sistem regulator dengan pemberian topikal terapi sesuai derajat dan warna dasar luka kemudian ditutup kassa steril tebal 5 lapis dan dilakukan seft terapi 2 kali putaran. setelah dilakukan tindak lanjut pelaksanaan perawatan luka sesuai dengan status perkembangan luka dengan pemberian topikal terapi sesuai derajat dan warna dasar luka, kemudian ditutup kassa tebal 5 lapis dan dilakukan seft terapi 2 kali putaran, menunjukkan skor wound healing noc mengalami peningkatan nilai skor, didapatkan hasil rata-rata nilai skor 31,12 dengan nilai skor terrendah 24 dan tertinggi 42. dan dilihat dari 10 item indikator, terdiri dari: (1) ukuran luka sebagian besar 5 responden (62,5%) dengan nilai skor 2 artinya terdapat reduksi luka 1-24% dari luas luka, (2) kedalaman luka sebagian dengan nilai skor 4 artinya kedalaman luka derajat ii, (3) resolusi bullae sebagian besar 7 responden (87,5%) dengan nilai skor 4 artinya seluruh bullae pecah, (4) resolusi jaringan nekrotik sebagian besar 3 responden (37,5%) dengan nilai skor 4 artinya resolusi jaringan nekrotik 76-99%, (5) tipe eksudat sebagian besar 6 responden (75%) dengan nilai skor 2 artinya tipe eksudat serosangeous, encer, merah pucat atau pink,(6) resolusi eksudat 45 muhammadiyah journal of nursing bervariasi sebanyak 3 responden (32,5%) dengan nilai skor 3 artinya sedikit resolusi eksudat, (7) resolusi eritema sebagian besar 37,5% dengan nilai skor 3 artinya sebagian warna kulit normal antara 26 – 75%, (8) resolusi jaringan edema sebanyak 4 responden (37,5%) dengan nilai skor 3 artinya terdapat sebagian resolusi edema ≤ 25%, (9) granulasi sebagian besar 3 responden (37,5%) dengan nilai skor 3 artinya sebagian terisi jaringan granulasi ≥ 25 ≤ 75% dari luas luka, (10) epitelisasi sebagian besar 3 responden (37,5%) dengan nilai skor 3 artinya terisi jaringan epitelisasi ≥ 25-≤ 75% dari luas luka. hal ini menunjukkan proses penyembuhan luka berlangsung efektif, sehingga pelaksanaan tindakan perawatan luka tetap dilanjutkan dengan pemberian topikal terapi sesuai derajat dan warna dasar luka kemudian ditutup kassa steril tebal 5 lapis dan dilakukan seft terapi 2 kali putaran. siklus 3 setelah dilakukan pelaksanaan tindak lanjut perawatan luka sesuai status perkembangan luka dengan pemberian topikal terapi sesuai derajat dan warna dasar luka, ditutup kassa tebal 5 lapis dan dilakukan seft terapi 2 kali, skor wound healing noc mengalami peningkatan nilai skor, didapatkan hasil rata-rata nilai skor 42,37 dengan nilai skor terrendah 36 dan tertinggi 49. dilihat dari 10 item indikator, didapatkan: (1) ukuran luka sebanyak 4 responden (50%) dengan nilai skor 5 artinya terdapat reduksi luka 76 – 100%, (2) kedalaman luka yang bervariasi sebagian besar 5 responden dengan nilai skor 4 artinya kedalaman luka derajat ii, (3) resolusi bullae sebagian besar 5 responden (62,5%) dengan nilai skor 5 artinya menyeluruh bekas bullae kering, (4) resolusi jaringan nekrotik sebagian besar5 responden (62,5%) dengan nilai skor 5 artinya menyeluruh tidak ada jaringan nekrotik, (5) tipe eksudat sebagian besar 3 responden (37,5%) dengan nilai skor 5 artinya tidak ada eksudat, (6) resolusi eksudat sebagian besar 6 responden (75%) dengan nilai skor 4 artinya resolusi eksudat sedang, (7) resolusi eritema keseluruhan 8 responden (100%) dengan nilai skor 4 artinya sebagian warna kulit normal antara 76 – 99%, (8) resolusi jaringan edema sebagian besar 5 responden (62,5%) dengan nilai skor 4 artinya terdapat sebagian besar resolusi edema 76-99%, (9) granulasi sebagian besar 5 responden (62,5%) dengan nilai skor 4 artinya terisi jaringan granulasi 76-99% dari luas luka, (10) epitelisasi sebagian besar 5 responden (62,5%) dengan nilai skor 4 artinya terisi jaringan epitelisasi 7699% dari luas luka. hal ini menunjukkan penyembuhan luka efektif, proses penyembuhan berlangsung lebih baik dengan hasil penyembuhan luka sebagian besar completed, pada derajat ii dan derajat iii sebagian besar (87,5%) terisi jaringan granulasi dan epitelisasi antara 75 – 100% dari luas luka. pada penelitian ini alternative moisture balance dressing pada sistem regulator dengan pemberian topical terapi sesuai derajat dan warna dasar luka serta balutan yang tebal 5 lapis merupakan salah satu upaya untuk menciptakan suasana lembab pada luka dan mencegah penguapan, dengan suasana lembab membantu peningkatan migrasi dini epitel juga dan meningkatkan akslerasi angiogenesis serta mencegah degradasi luka, sehingga menciptakan respon adaptasi fi siologis fungsi proteksi penyembuhan luka yang adaptif. hal ini dibuktikan dengan hasil temuan pada penelitian ini dimana hasil penyembuhan luka sebagaian besar completed. b. lama waktu proses penyembuhan luka berdasarkan derajat kedalaman luka lama waktu proses penyembuhan luka bakar derajat ii dan derajat iii, seperti pada grafi k.2 pada siklus 3 ini didapatkan lama waktu penyembuhan berdasarkan derajat luka, derajat ii rata-rata 17,66 hari (tercepat 7 hari dan terlama 35 hari), lama waktu penyembuhan derjat iii rata-rata 28,6 hari, (tercepat 17 hari dan terlama 46 muhammadiyah journal of nursing 40 hari). hasil penelitian ini berbeda dengan penelitian gravente (2010) menemukan lama waktu penyembuhan derajat ii minimal 5 hari maksimal 12 hari sedangkan untuk derajat iii minimal 21 hari, maksimal 29 hari. grafik 2. evalusi lama waktu proses penyembuhan luka berdasarkan derajat hal ini dimungkinkan karena dipengaruhi oleh faktor penyebab terjadinya luka bakar. hasil penelitian ini sesuai pendapat demling & way (2001) dimana pada luka bakar derajat ii dangkal dapat sembuh dalam waktu 10–14 hari. pada luka bakar derajat ii dalam yang mengenai seluruh ketebalan dermis memerlukan waktu kesembuhan lebih lama sampai 25–35 hari. pada luka bakar derajat iii sembuh lebih lama, lebih dari 35 hari. derajat kedalaman luka pada luka bakar juga merupakan faktor yang mempengaruhi proses penyembuhan, semakin dalam derajat luka akan mempengaruhi proses proliferasi pada pembentukan epitelisasi atau granulasi jaringan (yefta, 2003). berdasarkan dari hasil temuan dan teori diatas peneliti sependapat bahwa penyembuhan luka pada luka bakar sangat dipengaruhi derajat kedalaman luka. 3. respon adaptasi psikologis respon adaptasi psikologis fungsi konsep diri physical self setelah dilakukan seft terapi dengan menggunakan indikator noc: acceptance (penerimaan diri) (1) perasaan tenang, (2) harga diri positif, (3) menjaga keakraban/ menjalin hubungan, (4) menyatakan perasaan tentang kesehatan, (5) menerima realita status kesehatan, (6) mencari informasi, (7) koping mengatasi masalah, (8) mengambil keputusan terkait kesehatannya, (9) pembaharuan makna kesehatan, (10) harapan, dengan total nilai skor rentang 10–50, skor yang tinggi menunjukkan respon psikologis yang adaptif, dengan hasil sebagai berikut: grafik 3. evaluasi respon psikologis berdasarkan nilai skor acceptance grafi k.3 memaparkan hasil evaluasi respon adaptasi psikologis fungsi konsep diri physical self setelah dilakukan seft terapi menggunakan indikator noc: acceptance (penerimaan diri) didapatkan nilai skor rata-rata 44,5 dengan skor minimal 40 dan skor maksimal 50. hal ini menunjukkan respon psikologis fungsi konsep diri physical self setelah diberikan seft terapi yang efektif atau adaptif, dan didukung dari hasil wawancara diketahui tingkat penerimaan (acceptance) terhadap realita dan harapan serta motivasi sebagai berikut: perasaan setelah dilakukan seft terapi didapatkan seluruh (8) responden mengungkapkan merasa tenang dan nyaman, ikhlas dan pasrah, suka cita dan nyeri berkurang, tingkat penerimaan diri (acceptance) terhadap realita; perasaan responden terhadap 47 muhammadiyah journal of nursing kondisi fi sik didapatkan sebanyak 7 responden mengungkapkan tidak merasa malu, tidak merasa rendah diri, ikhlas, tidak merasa terganggu, sedangkan 1 responden megungkapkan kadangkadang merasa malu. harapan dan motivasi responden terhadap kondisi kesehatan seluruh (8) responden mengungkapkan berharap cepat sembuh, berkumpul dengan keluarga dan dapat bekerja lagi. hal yang sama ditemukan oleh bakara (2010) menemukan hasil bahwa terdapat perbedaan yang bermakna antara tingkat depresi, kecemasan, dan stres sebelum dan sesudah intervensi seft antara kelompok intervensi dan kelompok kontrol (p<0,05). intervensi seft membantu menurunkan depresi, kecemasan, dan stres pada pasien ska. zainuddin (2009) mengatakan bahwa dalam seft membawa subyek pada kondisi tenang dan relaks, merasakan nafas, menyadari kehadiran tuhan dalam diri, serta mengarahkan untuk kembali pada diri sejati (fi trah). saat melakukan seft, subyek dianjurkan melakukannya dalam kondisi meditative (yakin, khsyuk, ikhlas, pasrah, dan syukur). jika demikian, efek seft akan terasa lebih efektif. sementara itu ketukan (tapping) ringan yang dilakukan pada titik-titik energi meridian selain meningkatkan vaskularisasi sesuai dengan teori gate control yang dikemukakan oleh melzack & well, 1965 (dalam rajin, 2012) akan menutup substansi gelatinosa (sg) pada medulla spinalis dan menghalangi impuls nyeri menuju otak. ketukan dapat menutup sg karena dihantarkan melalui serabut syaraf yang memiliki diameter lebih besar daripada serabut syaraf nyeri. jika ada suatu zat dapat mempengaruhi substansi gelatinosa didalam gate control, zat tersebut dapat digunakan untuk pengobatan nyeri (koizer et al 1995 dan rajin 2012) berdasarkan hasil temuan dan teori diatas peneliti sependapat bahwa terapi seft dengan berdoa akan meningkatkan subjective feeling dari kesejahteraan dan rasa peduli, hal ini menimbulkan harapan positif, menciptakan ketenangan dan relaksasi pada diri responden. pada penelitian ini respon adaptasi psikologis: penerimaan diri yang adaptif, berupa terciptanya ketenangan, relaksasi dan harapan positif pada diriresponden. kondisi ini merangsang sistem endokrin untuk menstimuli penurunan hormon acth yang diikuti oleh penurunan glukokortikoid dan kortisol. penurunan kadar glukokortikoid dan kortisol akan merangsang peningkatan respon imun dan respon infl amasi yang diperlukan pada penyembuhan luka sehingga penyembuhan luka dapat berlangsung cepat (nursalam 2009). simpulan berdasarkan hasil penelitian tentang kombinasi alternative moiusture balance dressing dan seft terapi dalam meningkatkan respon adaptasi psikologis dan proses penyembuhan luka bakar di rsup dr.sardjito dan setelah dilakukan analisa serta pembahasan, maka dapat dirumuskan beberapa kesimpulan sebagai berikut : 1. respon adaptasi fisiologis fungsi proteksi proses penyembuhan luka pasien luka bakar yang diberikan kombinasi alternative moisture balance dressing dan seft terapi adalah adaptif. proses penyembuhan luka berlangsung lebih baik dan efektif dengan hasil penyembuhan luka sebagian besar complete, pada derajat iii dan derajat ii sebagian besar (87,5%) terisi jaringan granulasi dan epitelisasai antara 75 -100 % dari luas luka. 2. respon adaptasi psikologis fungsi konsep diri physical self pasien luka bakar yang diberikan seft terapi adalah adaptif, sebagai berikut: a. perasaan menjadi tenang dan nyaman, ikhlas dan pasrah, suka cita dan nyeri berkurang. b. penerimaan terhadap kondisi fisik: tidak merasa malu, tidak merasa rendah diri, ikhlas, tidak merasa terganggu. 48 muhammadiyah journal of nursing c. harapan dan motivasi responden terhadap kondisi kesehatan berharap cepat sembuh, berkumpul dengan keluarga dan dapat bekerja lagi. saran 1. kombinasi alternative moisture balance dressing dan seft terapi bisa dijadikan sebagai prosedur tetap untuk memberikan respon adaptasi fisiologis fungsi proteksi yang adaptif dalam meningkatkan prosesgranulasi dan epitelisasi pada penyembuhan luka sehingga dapat memperpendek los. 2. alternative moisture balance dressing bisa dijadikan clinical pathway dalam penatalakasanaan luka bakar. 3. seft terapi bisa dijadikan sebagai prosedur tetap non farmakologi untuk meningkatkan respon psikologis penerimaandiri yang adaptif dan membantu memberikan perasaan nyaman, ketenangan dan menurunkan tingkat nyeri sehingga dapat meningkatkan mutu asuhan keperawatan. 4. perlunya pelatihan seft terapi bagi perawat untuk meningkatkan ketrampilan sebagai komplementer terapi untuk membantu proses penyembuhan sehingga dapat meningkatkan cost effective. 5. bagi peneliti lain yang ingin melanjutkan penelitian ini bisa dilakukan dengan menambah jumlah sampel yang lebih besar atau menggunakan subyek penelitian dengan tingkat stress psikologis yang tinggi seperti pada penyakit dengan terminal stage seperti pada kanker. daftar pustaka bakara md. (2010). pengaruh spiritual emotional freedom technique (seft) terhadap tingkat gejala depresi, kecemasan, dan stres pada pasien sindrom koroner akut (ska) non percutaneous coronary intervention (pci). tesis. universitas padjadjaran. bandung bryant, ruth a. (2006) acute & chronic wounds: current management concepts. third edition.mosby elsevier. united states of america brunner & suddarth. (2010). textbook of medical surgical nursing (12th ed.). usa: lippincott carvile k.(2007). wound care manual (5th ed.). australia: silver chain nursing association dealey c. (2005). the care of wound: a guide for nurse (3th.ed.). australia: blackwell demling rh & way. (2001). burn modules. available in website: diakses 10 desember 2012 dari http://www.burnsurgery.org gravante p, montone a. (2010). a retrospective anaysis of ambulatory burn patients: focus on wound dressing and healing times. ann r coll surgical england 92:118-123 doi 10.1308/003588410x12518836439001 gowri s, vijaya na, powar r, honnungar r, mallapur md. (2012). epidemiologi and outcame of burn injury. j indian acad forensic med. october-december 2012, vol.34, no.4 falanga v. wound bed preparation. available from : diakses 10 desember 2012 dari url:http://www.bu.edu./woundbiotech/ index.html. 2005 handayani tn. (2010). pengaruh pengelolaan depresi dengan latihan pernafasan yoga (pranayama) terhadap perkembangan proses penyembuhan ulkus diabetikum di rumah sakit pemerintah aceh. tesis. universitas indonesia. jakarta kozier, erb, oliveri. (1995). fundamentals of nursing. concepts, process and practice (8th ed.). california: addison-wesley publishing company,inc maghsoudi h, monshizadeh s. (2010). comparative study of the burnwound healing properties saline-soaked 49 muhammadiyah journal of nursing dressing and silver sulfadiazine in rats. indian j surg (januari-february 2011) 73 (1):24-27 doi 10.1007/s12262-010-0169-2 nursalam. (2009). model holistik berdasar teori adaptasi roy dan pni sebagai upaya modulasi respon imun. disampaikan pada seminar nasional keperawatan. surabaya. othman n, kendrick d. (2010). epidemiology of burn injury in the east mediterronean region: a systematic review. bmc public health, 1083. http:www.biomedicentral. com/1471-2458/10/83 rajin m. (2012).terapi spiritual emotional freedom technique (seft) untuk meningkatkan kualitas tidur pasien pasca operasi di rumah sakit. skripsi. universitas pesantren darul ulum. jombang suriadi. (2007). manajemen luka. romeo grafika. pontianak who burn update (2014). diakses tanggal 6 juli 2014 dari www.who.int/mediacentre/ factsheets/fs.365/en/ johnson et all. (eds.). (2000). nursing outcames classification (noc) (2nd ed.). st.louis, missouri : mosby yefta, moenajat. (2003) . luka bakar pengetahuan klinis praktis. edisi revisi. jakarta: balai penerbit fkui zainul, anwar. (2011). model terapi seft (spiritual emotional freedom – technique) untuk mengatasi gangguan fobia spesifik. jurnal mjn vol. 2 no. 2 2015.indd 1 muhammadiyah journal of nursing pendahuluan demam tifoid merupakan suatu penyakit infeksi sistemik yang disebabkan oleh salmonella typhi (simanjuntak, 2009). angka kematian demam tifoid di indonesia masih tinggi dengan case fatality rate sebesar 10% (nainggolan, 2001). tingginya angka morbiditas dan mortalitas karena demam tifoid, menggerakkan berbagai pihak berupaya untuk menyelesaikan masalah ini. peran perawat dalam hal ini salah satunya adalah memberikan asuhan keperawatan dengan pemberian terapi komplementer. salah satu tanaman obat yang secara empiris biasa digunakan sebagai obat tradisional adalah sirih merah (piper crocatum). berdasarkan kekerabatannya, sirih merah satu genus dengan sirih (piper betle linn) (sudewo, 2007). senyawa-senyawa yang terdapat dalam sirih merah adalah fl avanoid, polifenol, saponin, alkaloid, tanin dan minyak atsiri yang sering diteliti dan mengandung efek anti bakteri (sudewo, 2007). hasil penelitian sebelumnya menunjukkan bahwa ekstrak daun sirih merah mampu menghambat pertumbuhan dan membunuh staphylococcus aureus (gram positif) pada konsentrasi 25% serta mampu menghambat pertumbuhan dan membunuh escherichia coli (gram negatif) pada konsentrasi 6,25% (farida, et al 2009). escherichia coli mempunyai beberapa kesamaan dengan salmonella typhi. pertanyaan masalahnya adalah: apakah ekstrak daun sirih merah (piper crocatum) efektif dalam menghambat pertumbuhan dan membunuh salmonella typhi? efektifi tas ekstrak daun sirih merah (piper crocatum) terhadap kadar hambat minimum dan kadar bunuh minimum bakteri salmonella typhi moch . achwandi1, azizah khoiriyati2, soewito3 1stikes bina sehat ppni mojokerto 2,3universitas muhammadiyah yogyakarta moch.achwandi@yahoo.co.id abstract research background : typhoid fever is a systemic infectious disease caused by salmonella typhi. the incidence rate in indonesia is still high at 600000-1500000 patients annually with a cfr of 10%. the high rates of morbidity and mortality, moving the parties attempt to resolve this issue. the role of the nurse in this case one of them is to provide nursing care to the provision of complementary therapies. one of the medicinal plant commonly used empirically for complementary therapies is red betel (piper crocatum). objective: to determine concentration of red betel leaf extract (piper crocatum) eff ectiveness against minimum inhibitory concentration (mic) and minimum bactericidal concentration (mbc) bacteria salmonella typhi. method: type of laboratory experimental studies in vitro with posttest only control group design. red betel leaf extract has been created by default then tested on salmonella typhi bacteria. the test method has been conducted with serial dilutions of liquid dilution. repetition 4 times. statistical test used was the kruskalwallis test. results : the results showed that the extract of red betel leaf has a mic which can not be determined because of the turbidity of the suspension and mbc extract at a concentration of 12.5 %. conclusion : eff ectiveness of red betel leaf extract against salmonella typhi bacteria mic can not be determined. red betel leaf extract is eff ective against the bacteria salmonella typhi mbc. dose of red betel leaf extract is eff ective against the bacteria salmonella typhi mbc is at a concentration of 12.5%. keywords: red betel (piper crocatum) – minimum inhibitory concentration minimum bactericidal concentration salmonella typhi 2 muhammadiyah journal of nursing penelitian ini bertujuan untuk mengetahui konsentrasi ekstrak daun sirih merah (piper crocatum) yang efektif terhadap kadar hambat minimal (khm) dan kadar bunuh minimal (kbm) bakteri salmonella typhi. hasil dari penelitian ini dapat dijadikan dasar penelitian berikutnya sekaligus sebagai evidence based nursing practice dalam perawatan komplementer pada pasien dengan demam typoid. metode penelitian desain penelitian. penelitian ini adalah penelitian eksperimental laboratoris secara in vitro dengan postest only control group design dan menggunakan metode dilusi. metode ini digunakan untuk mengetahui konsentrasi ekstrak sirih merah yang efektif terhadap kadar hambat minimal (khm) dan kadar bunuh minimal (kbm) bakteri salmonella typhi. dilakukan 2 tahap, yaitu tahap pengujian bahan di media cair untuk menentukan khm, dilanjutkan dengan tahap penggoresan pada media tsa (tripton soya agar) untuk menentukan kbm. bahan uji yang digunakan adalah daun sirih merah (piper crocatum) sebanyak 2 kg yang diambil secara acak dari pohonnya. daun yang diambil adalah daun yang masih segar, tidak terlalu muda (berumur kurang dari 2 bulan) atau sudah terlalu tua/menguning. daun ini diambil dari pohon sirih di wilayah desa janti, kecamatan jogoroto, kabupaten jombang, jawa timur. bakteri uji yang digunakan adalah salmonella typhi biakkan murni dari laboratorium mikrobiologi dan parasitologi fakultas kedokteran universitas muhammadiyah yogyakarta yang sebelumnya telah dilakukan beberapa tes identifi kasi. variabel bebas dalam penelitian ini adalah ekstrak daun sirih merah dengan konsentrasi 50%, 25%, 12,5%, 6,25%, 3,125%, 1,5625%. variabel terikatnya adalah pertumbuhan salmonella typhi. ditetapkan dengan melihat kekeruhan pada tabung untuk menentukan khm dan jumlah koloni salmonella typhi pada media tsa untuk menentukan kbm. penentuan khm dan kbm. prosedur penelitian pertama-tama adalah persiapan alat dan bahan serta sterilisasi alat, kemudian dilanjut dengan pembuatan ekstrak daun sirih merah dengan konsentrasi 100%. selanjutnya ekstrak diencerkan melalui perbandingan 1 gr ekstrak dengan aquades streril 1 ml (berat/ volume), sehingga didapatkan konsentrasi awal 50%. kemudian siapkan 8 tabung raksi dan berikan nomor 1-8. tabung 1 merupakan hasil pengenceran ekstrak dengan konsentrasi 50%. aquades steril dimasukkan ke dalam tabung 2-6 masing-masing 1 ml. dari tabung 1 diambil 1 ml dan masukkan ke dalam tabung 2, campur hingga homogen. tabung 2 diambil 1 ml untuk di masukkan dalam tabung 3 dan seterusnya sampai tabung ke-6 (konsentrasi terkecil). diambil 1 ml dari tabung ke-6 dan dimasukkan ke dalam tabung ke-7 untuk digunakan sebagai kontrol negatif. dimasukkan suspensi salmonella typhi 1 ml ke dalam tabung 1-6 dan tabung ke-8 untuk kemudian dijadikan sebagai kontrol positif. semua tabung diinkubasi selama 18-24 jam pada suhu 37oc. nilai khm ditentukan dengan melihat kekeruhan seluruh tabung. dengan menggunakan ose steril, setiap tabung diambil 1 ose dan digoreskan pada media tsa dan inkubasi pada suhu 37oc selama 18-24 jam. nilai kbm ditentukan dengan melihat media tsa dalam piring petri dengan konsentrasi ekstrak terkecil yang masih mampu membunuh bakteri, ditandai dengan tidak adanya pertumbuhan koloni bakteri salmonella typhi. analisa data. penelitian ini menggunakan software spss untuk analisa data. uji statistik kruskal-wallis untuk mengetahui apakah ada perbedaan jumlah koloni bakteri salmonella typhi pada pemberian ekstrak daun sirih merah dengan konsentrasi yang berbeda. uji mann-whitney digunakan untuk mengetahui kelompok mana yang memiliki perbedaan. uji korelasi pearson digunakan untuk mengetahui kekuatan korelasi 3 muhammadiyah journal of nursing dan arah korelasi antara ekstrak daun sirih merah dengan jumlah koloni bakteri salmonella typhi. hasil penelitian kadar hambat minimal. hasil pengamatan pada tabung reaksi setelah diinkubasi selama 18-24 jam didapatkan garis hitam yang berada di belakang tabung tidak ada yang terlihat kecuali pada tabung kontrol negatif (-). tabung kontrol negatif (-) adalah tabung yang paling jernih, sedangkan tabung yang lainnya terlihat keruh. semakin tinggi konsentrasi ekstrak sirih merah, semakin keruh. seharusnya tabung dengan konsentrasi ekstrak paling tinggi yang paling jernih. hal ini terjadi akibat dari keruhnya ekstrak, maka semakin tinggi konsentrasi semakin meningkat tingkat kekeruhannya seperti yang terlihat pada gambar 1, sehingga khm tidak dapat ditentukan secara kualitatif. gambar 1. perbandingan tingkat kekeruhan tiap konsentrasi ekstrak daun sirih merah terhadap bakteri salmonella typhi setelah diinkubasi. kadar bunuh minimal. hasil uji dilusi cair dilakukan penanaman dengan metode streaking pada media tsa untuk mengetahui kbm. setelah itu dilakukan penghitungan jumlah koloni pada masing-masing konsentrasi dan perulangannya dengan alat colony counter. berdasarkan jumlah koloni, diperoleh kbm pada konsentrasi 12,5%. pada konsentrasi tersebut tidak terdapat pertumbuhan bakteri sama sekali. dapat terlihat pola dimana semakin tinggi konsentrasi ekstrak daun sirih merah, jumlah koloni bakteri salmonella typhi semakin berkurang (tabel 1). tabel 1. perbedaan jumlah koloni bakteri salmonella typhi pada pemberian ekstrak daun sirih merah dengan konsentrasi yang berbeda. konsentrasi bahan uji (b/v) jumlah koloni rata ratai ii iii iv 0% (kontrol positif) 257 192 245 237 232,75 1,5625% 131 145 120 130 131,5 3,125% 78 77 74 76 76,25 6,25% 32 65 54 68 54,75 12,5% 0 0 0 0 0 25% 0 0 0 0 0 50% 0 0 0 0 0 p* 0,000 *diuji dengan kruskal-wallis uji kruskal-wallis dilakukan untuk mengetahui apakah ada perbedaan jumlah koloni bakteri salmonella typhi setelah pemberian ekstrak daun sirih merah dengan berbagai konsentrasi yang berbeda. dari hasil uji kruskal-wallis yang telah dilakukan, didapatkan nilai p = 0,000, seperti terlihat pada tabel 2. oleh karena p<0.05, maka dapat diambil kesimpulan “paling tidak terdapat perbedaan jumlah koloni bakteri salmonella typhi yang tumbuh pada media tsa di setiap perlakuan”. uji mann-whitney dilakukan untuk mengetahui perbedaan yang bermakna pada jumlah koloni bakteri antara dua macam konsentrasi yang berbeda. seperti terlihat pada tabel 3. terdapat perbedaan jumlah koloni bakteri yang bermakna antara semua kelompok jika dibandingkan satu persatu terhadap konsentrasi dibawah 12,5% karena nilai p<0,05. namun tidak terdapat perbedaan jumlah koloni yang bermakna di atas konsentrasi 12,5% karena nilai p=1. dapat diartikan bahwa tidak terdapat penurunan jumlah koloni yang bermakna pada peningkatan konsentrasi berikutnya setelah konsentrasi 12,5 % (p>0,05). 4 muhammadiyah journal of nursing tabel 2. nilai p uji komparasi antara dua konsentrasi ekstrak sirih merah yang berbeda terhadap jumlah koloni bakteri salmonella typhi konsentrasi bahan uji dan jumlah koloni 0% 1,5625% 3,125% 6,25% 12,5% 25% 50% 232,75 131,5 76,25 54,75 0 0 0 0% 232,75 0.021 0.021 0.021 0.014 0.014 0.014 1,5625% 131,5 0.021 0.021 0.021 0.014 0.014 0.014 3,125% 76,25 0.021 0.021 0.021 0.014 0.014 0.014 6,25% 54,75 0.014 0.014 0.014 0.014 0.014 0.014 12,5% 0 0.014 0.014 0.014 0.014 1.000 1.000 25% 0 0.014 0.014 0.014 0.014 1.000 1.000 50% 0 0.014 0.014 0.014 0.014 1.000 1.000 tabel 3. hubungan antara variabel dependen (jumlah koloni bakteri salmonella typhi) dengan variabel independen (konsentrasi ekstrak sirih merah) rata-rata koloni konsentrasi sirih merah pearson correlation (r) -.971** sig. (2-tailed) (p) .006 uji korelasi pearson selanjutnya dilakukan untuk menganalisis hubungan antara variabel dependen (jumlah koloni bakteri salmonella typhi) dengan variabel independen (konsentrasi ekstrak sirih merah). seperti terlihat pada tabel 4, hasil uji korelasi pearson menunjukkan nilai p=0,006 (p<0,05) yang berarti terdapat korelasi yang bermakna antara dua variable. pearson correlation coeffi cient (r) menunjukkan nilai -0,971 yang berarti menunjukkan korelasi yang sangat kuat. nilai negatif menunjukkan korelasinya berbanding terbalik, artinya semakin tinggi konsentrasi ekstrak daun sirih merah, maka semakin rendah jumlah koloni bakterinya. pembahasan kadar hambat minimal. uji efektifi tas ekstrak daun sirih merah (piper crocatum) terhadap kadar hambat minimal dan kadar bunuh minimal bakteri salmonella typhi dalam penelitian ini dilakukan dengan metode delusi. dipilih metode ini karena memiliki kelebihan dibandingkan dengan metode difusi. metode delusi lebih peka dan terjamin homogenitas antar media, bahan uji dan suspensi bakteri. bahan uji lebih mudah berinteraksi dengan bakteri karena suspensi bakteri tersebar merata (pratiwi, 2008). dengan metode ini dapat diketahui kadar hambat minimal (khm) dan kadar bunuh minimal (kbm) terhadap bakteri. kekeruhan pada konsentrasi ekstrak 50%, 25%, 12,5% sampai dengan tabung kontrol negatif yang hanya berisi 1 ml ekstrak dengan konsentrasi 1,5625% tanpa penambahan bakteri, berangsur-angsur menurun mulai dari warna hijau tua sampai dengan kuning jernih. penyebab kekeruhan diduga antara lain disebabkan oleh kandungan saponin yang ada pada ekstrak sirih merah. beberapa saponin mempunyai sifat asam karena adanya gugus karboksil pada aglikon dan atau gugus gula (didik, 2004). kelarutan protein akan meningkat jika diberikan perlakuan asam yang berlebih. ini terjadi karena ion positif pada asam akan menyebabkan protein yang semula bermuatan netral menjadi bermuatan positif dan menyebabkan kelarutannya bertambah, sehingga tabung menjadi keruh(suhardi, 1992). jadi, perbedaan kekeruhan bukan disebabkan karena ada atau tidaknya bakteri tetapi karena konsentrasi ekstrak. semakin tinggi konsentrasi ekstrak, maka tingkat kekeruhan semakin tinggi, 5 muhammadiyah journal of nursing sehingga khm tidak dapat ditentukan. kadar bunuh minimum. data penelitian menunjukkan kadar bunuh minimum ekstrak sirih merah terhadap bakteri salmonella typhi diperoleh pada konsentrasi 12,5%, dimana pada konsentrasi tersebut tidak terdapat pertumbuhan koloni bakteri salmonella typhi sama sekali pada empat kali pengulangan. berdasarkan hasil uji kruskal-wallis didapatkan nilai signifi kansi 0,000 (p>0,05) yang berarti paling tidak terdapat perbedaan efek pada pemberian tiap konsentrasi ekstrak daun sirih merah terhadap pertumbuhan bakteri salmonella typhi. hasil uji korelasi menunjukkan r = 0,971. tanda negatif menunjukkan hubungan yang terbalik yaitu semakin tinggi konsentrasi ekstrak daun sirih merah semakin sedikit jumlah koloni bakteri salmonella typhi yang tumbuh. nilai 0,971 menunjukkan koefi sien korelasi yang sangat kuat. hasil analisis diatas membuktikan bahwa kemungkinan besar bakteri salmonella typhi mati karena ekstrak sirih merah adalah sangat besar. sirih merah mengandung zat-zat tertentu yang memiliki efek antimikroba. zat-zat itu adalah flavonoid, polifenol, alkaloid, tanin, saponin, dan minyak atsiri (sudewo, 2007). flavonoid termasuk zat antibakteri. mekanisme kerja dari fl avonoid adalah dengan merusak dinding sel bakteri, mikrosom dan lisosom sebagai hasil interaksi fl avonoid dengan dna bakteri. selain itu, gugus hidroksil yang terdapat pada struktur senyawa fl avonoid menyebabkan perubahan komponen organik dan transpor nutrisi pada bakteri terganggu (ardo, 2005). selain itu, kandungan fl avonoid pada ekstrak daun sirih merah mampu menghambat enzim topoisomerase ii (dna girase). enzim ini merupakan enzim penting dalam proses replikasi dan transkripsi dna bakteri. terhambatnya enzim topoisomerase ii akan berdampak pada terhambatnya proses replikasi dan transkripsi dna bakteri (sanarto, et al , 2011). polifenolat bersifat koagular terhadap protein (dwijoseputro, 1994). dinding sel bakteri salmonella typhi tersusun atas peptidoglikan. struktur dasar peptidoglikan adalah sebuah selubung yang menyelimuti sel yang tersusun dari utas-utas peptidoglikan yang berdampingan satu sama lain dan dihubungkan dengan ikatan silang tetrapeptida yang terbuat dari asam amino (miller dan pegues, 2000). sifat koagular dari polifenol ini akan mengakibatkan permukaan dinding sel bakteri salmonella typhi menjadi berkerut dan akhirnya rusak. alkaloid juga mengganggu komponen penyusun peptidoglikan sel sehingga tidak terbentuk utuh. polifenol dan alkaloid akan mengakibatkan kerusakan dinding bakteri salmonella typhi dan bakteri akan mati. sanarto dkk (2011), menjelaskan bahwa tanin yang juga dimiliki oleh ekstrak daun sirih merah mempunyai sifat spasmolitik. diduga dapat mengkerutkan dinding sel atau membran sel sehingga mengganggu permeabilitas sel itu sendiri. akibat terganggunya permeabilitas, sel tidak dapat melakukan aktifi tas hidup sehingga pertumbuhannya terhambat atau bahkan mati. tanin juga diduga mampu menghambat pertumbuhan bakteri dengan cara menginaktivasi enzim. apabila kerja enzim terganggu dalam mempertahankan kelangsungan aktivitas mikroba, maka akan mengakibatkan enzim membutuhkan energi dalam jumlah besar untuk aktivitasnya. akibatnya energi pertumbuhan menjadi berkurang, sehingga aktivitas mikroba menjadi terhambat dan lisis apabila berlangsung lama. saponin bekerja menurunkan tegangan permukaan dan merusak dinding sel. minyak atsiri akan mengganggu proses terbentuknya dinding sel sehingga tidak terbentuk atau kalau terbentuk tidak sempurna. kerusakan pada dinding sel mengakibatkan membran sel tidak mempunyai pelindung yang berdampak pada hilangnya sifat semi permeabilitas membran sel tersebut (kholil, et al, 2013). perihal ini akan 6 muhammadiyah journal of nursing menyebabkan keluar masuknya zat-zat seperti air, enzim-enzim tidak terseleksi. dampak lebih lanjut adalah terganggunya metabolisme sel sehingga proses pembentukan atp untuk pertumbuhan sel terhambat. jika proses ini berlanjut, maka akan menimbulkan kematian sel bakteri. penelitian ini menunjukkan bahwa ekstrak daun sirih merah memiliki daya anti bakteri terhadap bakteri salmonella typhi secara in vitro. pengujian antibakteri dengan menggunakan metode dilusi cair menunjukkan hasil kadar bunuh minimal (kbm) pada konsentrasi 12,5%. pernyataan ini didukung oleh penelitian yang sudah dilakukan sebelumnya oleh juliantina (2009) yang menyampaikan bahwa ekstrak daun sirih merah (piper crocatum) mempunyai kemampuan menghambat pertumbuhan dan membunuh bakteri gram positif dengan bakteri uji staphylococcus aureuspada konsentrasi 25% dan kemampuan menghambat pertumbuhan dan membunuh bakteri gram negatif dengan bakteri uji escherichia colipada konsentrasi 6,25%. penelitian mutmainah (2012) tentang pengaruh pemberian ekstrak daun sirih merah (piper crocatum) terhadap gambaran histopatologi luka insisi kulit tikus putih yang terinfeksi staphylococcus aurius14 dan penelitian uji efektifi tas ekstrak daun sirih merah (piper crocatum) terhadap bakteri aeromonas hidrophila secara in vitro memperkuat penelitian ini. hal ini menunjukkan bahwa ekstrak daun sirih merah (piper crocatum) mempunyai zat aktif anti bakteri, termasuk pada salmonella typhi. pembuatan ekstrak daun sirih merah (piper crocatum) dalam penelitian ini dengan menggunakan pelarut etanol 70%. ekstrak etanol mempunyai aktivitas antimikroba yang lebih kuat dibandingkan dengan ekstrak air. suksmawan (2004) telah membuktikan dalam penelitian uji aktivitas antimikroba ekstrak etanol dan ekstrak air daun ketapang (terminalia catappa l., combretaceae). semua ekstrak etanol dan ekstrak air daun ketapang menunjukkan adanya aktivitas antimikroba. akan tetapi, diameter hambat ekstrak etanol daun ketapang lebih besar dibandingkan dengan ekstrak air daun ketapang, yang berarti ekstrak etanol mempunyai aktivitas lebih kuat dibandingkan dengan ekstrak air (rudhy, 2004). reveny (2011) menyampaikan dalam penelitiannya tentang daya antimikroba ekstrak dan fraksi daun sirih merah, bahwa ekstrak etanol mempunyai aktivitas antimikroba lebih kuat daripada fraksi etanol dan fraksi n-heksan, sedang fraksi air tidak efektif. pendapat tersebut menguatkan bahwa pemilihan pembuatan ekstrak dengan etanol mempunyai aktivitas antimikroba yang lebih baik dibandingkan dengan ekstrak air, fraksi etanol, fraksi n-heksan maupun fraksi air. penelitian tentang daya hambat dan daya bunuh ekstrak daun sirih merah (piper crocatum) terhadap bakteri salmonella typhi dengan metode dilusi cair dapat dibuktikan secara in vitro. tetapi menurut tahapan penelitian skrining obat, belum dapat digunakan langsung sebagai obat standar untuk terapi komplementer pada pasien dengan typhoid karena adanya perbedaan-perbedaan kondisi antara in vitro dan in vivo. simpulan hasil penelitian tentang efektifi tas ekstrak daun sirih merah (piper crocatum) terhadap kadar hambat minimal dan kadar bunuh minimal bakteri salmonella typhi menunjukkan bahwa: 1. efektifi tas ekstrak daun sirih merah (piper crocatum) terhadap kadar hambat minimal (khm) bakteri salmonella typhi tidak dapat ditentukan. 2. ekstrak daun sirih merah (piper crocatum) efektif terhadap kadar bunuh minimal (kbm) bakteri salmonella typhi. 3. dosis ekstrak daun sirih merah (piper crocatum) yang efektif terhadap kadar bunuh minimal (kbm) bakteri salmonella typhi adalah pada konsentrasi 12,5%. 7 muhammadiyah journal of nursing saran 1. hasil penelitian ini belum dapat diaplikasikan secara langsung untuk terapi pada pasien dengan typhoid. perlu dilakukan penelitian lanjutan secara in vivo pada hewan coba maupun probandus karena adanya perbedaan kondisi secara in vitro dengan in vivo. 2. untuk pembuatan ekstrak sirih merah, penggunaan pelarut etanol sudah terbukti mempunyai aktivitas antimikroba yang lebih baik dibandingkan dengan ekstrak air, fraksi etanol, fraksi n-heksan maupun fraksi air. 3. penelitian lebih lanjut sangat dibutuhkan sehingga penggunaan ekstrak sirih merah (piper crocatum) untuk terapi komplementer alternatif pada pasien dengan typhoid bisa segera digunakan. daftar pustaka ardo, sabir. 2005. aktivitas antibakteri fl avonoid propolis trigona sp terhadap bakteri streptococcus mutans (in vitro). htt p:// ml.scribd.com/ doc/94817415/aktivitasantibakteri-flavonoid-propolis-trigonasp-terhadap-bakteri. diakses tanggal 26 april 2014. pukul 10.57. dwidjoseputro d. 1994. dasar-dasar mikrobiologi. djambatan, jakarta. gunawan didik, 2004. ilmu obat alam (farmakognosi) jilid i. penebar swadaya. jakarta. farida, juliantina r., dewa ayu citra, bunga nirwani, dkk. 2009. manfaat sirih merah (piper crocatum) sebagai agen bakterial terhadap bakteri gram positif dan bakteri gram negatif. jurnal kedokteran dan kesehatan indonesia 1(1). diakses tanggal 28 september 2013 pukul 16.28 dari htt p://journal.uii.ac.id/index.php/ jkki. kusuma ratih w. 2011. uji efektifi tas ekstrak daun sirih merah (piper crocatum) terhadap bakteri aeromonas hidrophila secara invitro. universitas airlangga, surabaya: artikel ilmiah. miller si, pegues da., 2000. salmonella species, including salmonella typhi. in: mandell, douglas, and bennett s’s principles and practice of infectious disease, 5th ed. mandel gl, bennett je, dorlin r (editors). churchill livingstone. mutmainnah a. 2012. pengaruh pemberian ekstrak daun sirih merah (piper crocatum) terhadap gambaran histopatologi luka insisi kulit tikus putih yang terinfeksi staphylococcus aurius. universitas airlangga surabaya: artikel ilmiah. nainggolan, r. 2011. karakteristik penderita demam tifoid. medan: fakultas kesehatan masyarakat universitas sumatera utara pratiwi, st. 2008. mikrobiologi farmasi.erlangga. jakarta rahmanto kholil, utami sri hastuti, agug witjoro, 2013. pengaruh ekstrak daun sanseviera (sanseviera trifasciata var laurentis) terhadap penghambatan staphyilococcus aureus dan escherichia coli secara in vitro. diakses tanggal 7 januari 2014 pukul 13.20. reveny j. 2011. daya antimikroba ekstrak dan fraksi daun sirih merah (piper betle linn), jurnal ilmu dasar, januari 2011; 12(1): 6-12, fakultas farmasi universitas sumatra utara. diakses tanggal 16 maret 2014 pukul 13.15. dari htt p://jurnal.unej.ac.id/ index.php/jid/ article/download/79/56. rudhy, suksmawan; asep gana s; elin yulinah s. 2004. uji potensi antimikroba ekstrak daun ketapang (terminalia catappa l.), sekolah farmasi itb. diakses tanggal 19 maret 2014 pukul 10.25 dari htt p://bahan-alam. fa.itb.ac.id. sanarto, santoso; rita rosita; debby sartika mahardhika. 2011. uji efektifi tas ekstrak sirih merah (piper crocatum) sebagai antimikroba terhadap bakteri klebsiella pneumonia. htt p://old.fk .ub.ac.id. diakses tanggal 14 pebruari 2014 pukul 14.30. 8 muhammadiyah journal of nursing sanarto, santoso; soemardini; novia lucy rusmayanti. 2011. ekstrak etanol daun kersen (muntingia calabura) sebagai antimikroba terhadap bakteri salmonella typhi secara in vitro. diakses tanggal 14 pebruari 2014 pukul 14.25 dari htt p://old.fk .ub.ac.id. simanjuntak, c. h, 2009. demam tifoid, epidemiologi dan perkembangan penelitian. cermin dunia kedokteran no. 83. sudewo, b. 2007. basmi penyakit dengan sirih merah. agromedia pustaka. jakarta suhardi, 1992. khitin dan khitosan. pusat antar universitas pangan dan gizi ugm, yogyakarta. indonesian journal of nursing practices 14 ijnp (indonesian journal of nursing practices) vol 4 no june 1, 2020 : 14-20 muhammad zulfatul a’la1, zumrotul farikhah1, mulia hakam1 1universitas jember corresponding author: muhammad zulfatul a'la email: m.zulfatul@unej.ac.id nurses' attitude toward end of life care in emergency departement and intensive care unit in rural hospital article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.41103 abstract background: death is a psychological and physical event that affects patients caring for, especially in emergency departement (ed) and the intensive care unit (icu). patients and families need the end of life care from a health professional, including nurses. nurses need to have knowledge, skill, attitude, and interpersonal competencies to provide end of life care. objective: this study aimed to explored differences of attitudes towards dying care between ed and icu ward nurses in a rural hospital. method: variable in this study was the nurse's attitude. this study used a quantitative comparative cross-sectional research design. the samples were 24 nurses from the emergency ward and 16 from the intensive care unit who were recruited by total sampling. data were collected to use frommelt attitudes towards the care of the dying care form b indonesian version (fatcod-bi). result: the results revealed that nurses' attitudes toward caring for dying patients in the ed were 101.42±6.646 (30-150) on average, and in the intensive care unit was 106.44±7.633 (30-150) on average. nurses in the icu had a more positive attitude than the ed (p = 0.034). there are differences between the proportion of respondents based on gender, level of education, length of time working in the emergency ward, and icu. the result showed gender, level of education, and range of time working could influence nurses' attitudes towards caring for dying patients in the emergency ward and icu. conclusion: there is a difference between nurses' attitudes towards eolc in the ed and icu room at rural hospitals. moreover, the icu nurses have a more positive attitude than ed nurses. keywords: caring; dying patients; emergency department; icu; nurse's attitudes introduction patients generally experience deaths in the terminal phase, especially in the emergency departement (ed), intensive care unit (icu), and inpatient rooms (beckstrand et al., 2017). patients need end of life care such as reducing symptoms and family support when entering the process of grieving (gama, barbosa, vieira, 2012). death is a psychological and physical event that affects not only the patient who experiences it but also the people around them, including health professionals (gama, barbosa, vieira, 2012). fear, anxiety, distress, and sadness can occur in families and health professionals when facing patients with death (buglass, 2010). end of life care (eolc) is an essential concept in of palliative care (national consensus project for quality palliative care, 2009). a nurse is involved in the process of dying directly (gastmans, 2012). the care delivered is the management of symptoms related to death and the psychological, social, spiritual 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/6114 vol. 4 no. 1 june 2020 15 support (higgs, 2010). nurses are essential health care providers that provided caring processes in icu, emergency room, and home. therefore, nurses need knowledge and skills to offer effective eolc. also, attitude toward eolc and interpersonal competencies need to be improved by nurses (ali & ayoub, 2010). the ed and icu have several similarities in characteristics of care. firstly, ed and icu received the patient who is in advanced illness. moreover, both of them require specialized health care providers (doctors, nurses, assistants, etc.). therefore, nurses in the ed and icu need special skills or expertise. secondly, ed and icu have aim to life-saving in the terminal patient, so the resuscitation procedure is mostly applied. therefore, the death process occurs in those rooms regularly. thirdly, ed and icu have an inappropriate environment for patients and families because it is no particular room for the family, so it affects the quality of eolc (beckstrand et al., 2017). eolc in the ed is a challenge for nurses because the ed is the first place to receive patients in the hospital setting (decker et al., 2015). decker et al. (2015) stated that it is several barriers to conduct eolc in the emergency room, such as lack of time, low priority, lack of privacy, and unsuitable environment. otherwise, in icu, it has different characteristics and obstacles for applying eolc. icu is a place for patients with complicated medical conditions (baliza et al., 2013). the study in icu revealed that icu has several obstacles to the provision of eolc, including the lack of nursing staff, lack of communication between patients, doctors, and family members (beckstrand et al., 2017). a nurse can implement the eolc, including giving attention and direction related to appropriate treatment, providing social support for patients and families, delivering interventions to reduce pain response, discussing the death process with patients, and listening to the client's wishes for end of life (who, 2014). moreover, the principles of dying care are delivering a patient to a peaceful death (gloss & hospitals, 2017). nursing interventions in eolc supposed to be based on a positive attitude of caring for dying patients. a positive attitude of nurses in the care process can influence the effectiveness of eolc (gallagher et al., 2015). the results of the study stated that negative nurses' attitudes, such as apathy, fear, and anxiety, could reduce the level of quality of care in dying patients (grubb & arthur, 2016). the attitude of nurses towards eolc care is essential to explore as a reference and evaluation of the eolc process given to clients in the emergency room and icu. moreover, the concept of eolc in rural hospitals is an essential issue because rural hospitals have unique services and have limited access and infrastructure (bakitas et al., 2015). however, according to rainsford et al. (2017) illustrates that eolc in the rural area is still lack of article that discussed this issue. based on the background that has been stated, it is interesting to explore nurses 'attitudes towards the end of life and to compare nurses' attitudes in the ed and icu in rural hospitals. method a quantitative study is applied in this study and used a comparative descriptive survey method. this study utilized a cross-sectional approach (polit & beck, 2009). in this study, researchers used a comparative analysis (comparison) to distinguish or compare nurses' attitudes towards eolc in ed and icu. the sampling technique used in this study is a nonprobability sampling. the sampling method in this study is total sampling with a total number of 40 respondents consisting of 24 nurses in ed and 16 nurses in the icu at two rural hospitals in jember. the research data was taken from december 2018 to january 2019. nurse attitude toward eol utilized the fatcod-bi questionnaire (the frommelt attitudes toward care of the dying care form b (fatcod-b) indonesian version). the fatcod-b questionnaire consisted of 30 statement items. the fatcod-b instrument consists of favorable and unfavorable statements. the statement items included in the favorite statement are items number 1, 2, 4, 16, 18, 20, 21, 22, 23, 24, 25, 27, and 30 (a’la, 2016). the favorable statement has a score of 1 (strongly disagree) and a score of 5 (strongly agree) and the other items included in the unfavorable statement. the likert scale started from 1 (strongly agree) until 5 (strongly disagree) is used. the total score is between 30 and 150. the higher score described that is more positive the attitude toward the end of life care (tait et al., 2015). the frommelt attitudes towards care of the dying care form b indonesian journal of nursing practices 16 (fatcod-b) indonesian version has been tested for reliability by a'la (2016) using cronbach's alpha. the results of the reliability test were 0.86. the validity range of each statement item is 0.651-0.713. fatcod-bi used two domains in its discussion, namely domain i (positive attitude towards caring for dying patients domain) and domain ii (perception of patient care based on family and patient domains). fatcod-bi used two domains in its discussion, namely domain i (positive attitude towards caring for dying patients domain) and domain ii (perception of patient care based on family and patient domains). domain i of fatcod-bi consists of item number 1, 2, 3, 5, 6, 7, 8, 9, 11, 13, 14, 15, 17, 26, 29, 30. domain ii of fatcod-bi consists of item number 4, 10, 12, 16, 18, 19, 20, 21, 22, 23, 24, 25, 27, and 28 (henoch et al., 2013). the ethical committee of faculty of dentistry, university of jember, has approved this research with numbers 237 / un25.8 / kepk / dl / 2019. before filling out the questionnaire, the respondent received informed consent. moreover, patients have the autonomy to choose to participate in the research process. data analysis using spss 20. the t-test is used to analyze the comparison of nurses' end of life attitude in ed and icu because the data are normally distributed. furthermore, to see the difference in the proportion of respondents' characteristics in ed and icu nurses, researchers used the chi-square test. results table 1 explained that the average respondent's age working in ed was 32.25 years. otherwise, in the icu, the average was 34.88 years. the independent t-test results found that there was no difference in the average age (p-value > 0.05). moreover, the proportion of male nurses in ed (n = 15, 62.5%) was more than women (n = 9, 37.5%). however, in icu, the proportion of females is more than male. chisquare test showed that there was a difference in the proportion of gender in ed and icu (p-value <0.05). also, in education level, it showed that it was a difference in the proportion in ed and icu with a p-value of 0.046 (p-value <0.05). nevertheless, it was no homogeneity in gender and level of education proportion (p-value >0.05). table 1. description of characteristics of respondents in nurses (n=40). characteristic of respondent ed (n=24) icu (n=16) p-value (n) % (n) % ages (mean±sd) 32,25 ±6,045 34,88 ±3,810 0,132a gender male female 15 9 62,5 37,5 4 12 25,0 75,0 0,045b* level of education nursing diploma nursing bachelor nurse profession 13 1 10 54,2 4,2 41,7 10 4 2 62,5 25,0 12,5 0,046b* work experience <5 years 5-10 years 10-15 years >15 years 8 13 3 0 33,3 54,2 12,5 0 0 7 4 5 0 43,8 25,0 31,3 0,003b* religion muslim non-muslim 24 0 100,0 0 16 0 100,0 0 marriage status no married married 5 19 20,8 79,2 16 100 0,071b experience in caring for dying patient yes no 21 3 87,5 12,5 16 100 0,262b training experience in caring for dying patient yes no 14 10 58,3 41,7 4 12 25,00 75,00 0,080b a non-paired t-test bchi square *have a correlation nurses in ed who have less than five years experience amounted to 8 people, 5-10 years there were 13 people, and 10-15 years amounted to 3 people. while in the icu room, there are no nurses who have work experience of fewer than five years. chi-square test results between the length of work and workplace variables (emergency room and icu) showed that there was a difference between the number of nurses working in the emergency room and icu based on the length of work with p-value 0.003 (p-value <0.05). in the emergency room, some nurses are just starting to enter the workforce so that their experience is <5 years. while in the icu room, there are no nurses who have work experience <5 years, and there are nurses who have been senior or have worked for >15 years. all nurses are muslim (100%), and there are five unmarried emergency nurses and 19 married nurses, while 16 nurses who worked in the icu; all of them were married. nurses who have experience dealing with dying patients are 37 people (92.5%), vol. 4 no. 1 june 2020 17 and the number of nurses who have no experience dealing with dying patients is three people (7.5%). three nurses who have never dealt with patients near death are working in the emergency room. all nurses who worked in the icu (n = 16) had faced patients dying. the number of nurses who had attended the training of patient care before death 16 people consisting of 14 nurses in the emergency room and four nurses in the icu room. whereas, who had never received training in dying care patients consisted of 10 emergency nurses and 12 icu nurses. overall, more nurses have never attended training than those who have ever participated in the training. tabel 2. the difference in the nurse's attitude toward eolc (n=40) variable fatcod-bi total p-value ed icu mean (sd) mean (sd) domain i (positive attitude towards caring for dying patients domain) 53,13 (6,924) 54,00 (4,050) 53,48 (5,896) 0,618 domain ii (perception of patient care based on family and patient domains) 48,29 (5,162) 52,44 (5,151) 49,95 (5,491) 0,017* fatcod bi total 101,42 (6,646) 106,44 (7,633) 103.43 (7,393) 0,034* *have differences table 2 described the nurses' attitudes towards eolc in the ed and icu at rural hospitals. overall the average attitude in the icu (106.44) is higher than in the ed (101.42). furthermore, according to the fatcod-bi domain, the domain i described that attitude toward eolc in icu (54.00) was higher than in the ed (53.13). domain ii also showed that the attitude toward eolc in icu (52.44) was higher than in the emergency room (48.29). moreover, table 2 described that there is a difference between nurses' attitudes towards eolc in the ed and icu with a pvalue=0.034 (p <0.05). however, if it was tested in each domain, domain i showed no difference attitude with a p-value=0.618 (p> 0.05), and domain ii showed a different attitude between nurses in ed and icu with a p-value=0,017 (p <0.05). discussion the results showed that there were nurse's attitude differences in ed and icu towards eolc. the attitude of nurses in the icu was more positive rather than in the ed. based on each domain, the results showed a difference in domain ii (perception of patient care based on family and patients). tripathy et al. (2017) stated that in the icu, most family members had a contribution for eolc, especially supportive care. this study also revealed that families often discuss with nurses and always appreciate the role of nurses in the icu (tripathy et al., 2017). moreover, beckstrand et al. (2017) stated that there are many obstacles experienced by emergency nurses in applying eolc. these obstacles will affect the attitude of the nurses in the ed towards eolc. some of these obstacles are family who contacts the nurse frequently to ask about the patient's condition. at the same time, nurses also have to take care of other patients, and another obstacle is the emergency room design that does not allow for the privacy of patients with dying or grieving family members. therefore, it will affect the attitude of nurses and perceptions of dying patient care based on family and patients. the difference in nurses' attitudes toward eolc in ed and icu is also influenced by the lack of time for dying in the emergency room, low priority, lack of privacy, and an inappropriate er environment (decker et al., 2015). nurses cannot apply eolc in one patient only because many patients need help quickly and appropriately. otherwise, in rural hospitals, the quantity of specialized nurses is a central problem. nurses also seldom discussed with patients and family about the feelings because of the lack of privacy in ed (decker et al., 2015). barriers and obstacles in eolc can affect the ability of nurses to communicate with patients and families regarding eolc (gurung & timalsina, 2018). moreover, the results of this study were supported by previous research, which states that the nurse's work environment can influence nurses' attitudes towards eolc (kassa & murugan, 2014). homogeneity test in the characteristics of respondents between nurses in the ed and icu showed that religion, age, marital status, experience caring for dying patients, and the experience of receiving dying care training was homogenous. however, sex, work experience, and level of education were no homogeneous, or there are differences in proportions between nurses in the ed and icu. based on these results, gender, education level, and work experience factors might influence indonesian journal of nursing practices 18 nurses' attitudes towards eolc. furthermore, based on previous research, gender is one of the factors that influence a nurse's attitude towards eolc. according to yaqoob et al. (2018), there was a relationship between gender and the attitude of nursing students towards eolc. other studies also revealed that women are considered to have a more positive attitude towards caring for dying patients than men (lancaster et al., 2017). in addition, feminism could affect the attitude of caring for dying patients (a'la et al., 2018; dunn et al., 2005). work experience may affect attitude toward eolc and affect the differences of nurses in the ed and icu. the result showed that nurses in the icu have more extensive working experience compared to emergency room nurses so that they can influence attitudes towards eolc. also, these results were supported by previous studies. in turkey, the result showed that there were differences in attitudes between groups of nurses who worked from 2 years to 5 years and groups from 5 years to 10 years (ozcelik et al., 2018). education level has also could influence nurses' attitudes towards eolc. according to dunn et al. (2005), who analyzed nurses' attitudes in sweden, found that education level is the best predictor of positive attitudes in caring for dying patients (lancaster et al., 2017). another study in iran also revealed a significant relationship between education level and attitudes towards death (ali & ayoub, 2010). balung and kalisat hospitals are hospitals located in rural areas or peripheral hospitals in jember regency. in rural areas, there are many emergency cases, so that rural hospitals are the first referral for local communities, even though human resources and facilities are still incomplete and under the standard. this situation may increase the risk of death of patients both in the ed and icu due to delays in the referral of patients who are in an emergency and require prompt, appropriate, and adequate health facilities (green et al., 2017). therefore, the positive attitude of nurses towards eolc in the ed and icu in rural hospitals is needed to improve the quality of service to patients. the development of eolc in rural hospitals also needs to be developed both in the ed and icu. a positive attitude towards eolc in the ed nurses and icu nurses could be an initial step in the development of eolc services in rural hospitals. according to researchers, the differences in nurses' attitudes towards eolc in the ed and icu may be caused by the environmental factor in both areas. in the ed, the patient lacked privacy so that affecting eolc services. otherwise, in the icu, the time for caring is 24 hours, and in general, patient in icu is treated for a long time. for further research, it needs to examine the relationship between sex, education level, and also the experience of working nurses with nurses 'attitudes towards eolc because it can be factors that influenced attitude toward eolc. conclusion there is a difference between nurses' attitudes towards eolc in the ed and icu room at rural hospitals. moreover, the icu nurses have a more positive attitude than ed nurses. the proportion of characteristics respondents based on sex, education level, and length of work was no homogeneous. therefore, it could be a factor in differences of attitude toward eolc. the development of eolc in rural hospitals can begin with improving attitudes of caring for dying patients through training or refreshing knowledge to nurses. however, this study still has limitations because it was conducted on heterogeneous samples. for further research, it needs to examine the relationship between sex, education level, work experience with nurses' attitudes towards eolc to heterogeneous samples. references a'la, m. z. 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(2018). undergraduate final year nursing students’ attitudes toward caring for dying patients: bahrain’s experience. clinical nursing studies, 6(4), 53-58. https://doi.org/10.5430/cns.v6n4p53 117 muhammadiyah journal of nursing abstract background: turp syndrome is one of the complications in patients with post-turp. the prevalence of this case in the fi rst pku muhammadiyah hospital of yogyakarta mortality rate was 4.7% of the 168 action turp. this case requires preventive action by composing one tool for early detection of turp syndrome. objective: develop a tool to detect the turp syndrome. methods: this mixed method research method. qualitative action research method. samples were seven nurses and one urologist. research from april to june 2014 the instrument is fgd guide. test the validity of using triangulation experts. quantitative methods with validity and reliability. the sample was 21 nurses and conducted in july 2014 questionnaire intrumennya are signs and symptoms of turp syndrome. test the validity of the pearson product moment and reliability testing using cronbach alpha. two of these methods implemented in rs pku muhammadiyah yogyakarta i and ii. results: qualitative methods produce 15 items signs and symptoms of turp syndrome. quantitative methods to test the validity of the fi fteen items that generate valid because the count is greater r r table (n = 21, 5% signifi cance value of 0.433). reliability test results of 0.930, meaning that this tool reliable. this tool categorizes into three turp syndrome is negative, mild, moderate, and heavy. conclusion: it has been structured tool for early detection of turp syndrome. keywords: bph, turp syndrome, tool pendahuluan transurethral resection of the prostate (turp) merupakan tindakan non-invasif yang dilakukan pada pasien yang mengalami benign prostate hyperlpasia (bph) stage moderat atau berat selain open prostatectomy (lucia et al, 2013). indikasi dilakukan turp apabila pasien dengan gejala sumbatan yang menetap, progresif akibat pembesaran prostat, atau tidak dapat diobati dengan terapi obat lagi, gejala-gejala dari sedang sampai berat, volume prostat kurang dari 60 gram dan pasien cukup sehat untuk menjalani operasi(quinte health care, 2009). turp dapat menimbulkan beberapa komplikasi antara lain ejakulasi retrograde (60-90%), infeksi saluran kemih yang disebabkan oleh kolonisasi bakteri pada prostat (2%), persistent urinary retention ketika pulang dari rumah sakit dengan terpasang katheter (2.5%), stricture bladder (2-10%), striktur uretra (10%) dan komplikasi kardiak (acute myocardial infarction ami)3. selain itu terdapat komplikasi yang dapat membahayakan kondisi pasien yaitu sindrom turp. sindrom ini merupakan komplikasi yang terjadi pada pasien post operasi turp yang didefi nisikan dengan kelebihan volume cairan selama irigasi yang menyebabkan hiponatremia dan hipervolemia (gravenstein, 1997; moorthy, 2002; hawary, 2009; dan hawary, 2009). karakteristik dari sindrom turp syndrome adalah kebingungan mental, mual dan muntah, hipertensi, bradikardi dan gangguan pengelihatan. hal itu dikarenakan dilusi hiponatremia (serum natrium <125 meq/l) yang awalnya muncul saat terjadinya perforasi kapsular atau sinus yang kemudian dilanjutkan dengan irigasi cairan. pasien dengan anestesi spinal menunjukkan tidak bisa tenang, sumarno adi subrata, tri wulandari kesetyaningsih, yuni permatasari istanti, rahmah adiy_subrata@yahoo.co.id penyusunan turp syndrome tool assessment 118 muhammadiyah journal of nursing gangguan cerebral dan gemetaran. ketiga hal ini adalah tanda dan gejala minimal sampai jika kurang mendapatkan intervensi spesifi k dapat mengakibatkan kolap kardiovaskuler, kegagalan multi organ dan bahkan kematian (marszalek, 2009; claybon, 2009; dan hawary, 2009). kejadian sindrom turp sangat cepat, dapat terjadi 15 menit setelah operasi selesai hingga 24 jam (swaminathan dan tormey, 1981). sehingga apabila tidak dilakukan pemeriksaan post operasi turp secara dini, maka dikuatirkan telah sindrom turp yang mengakibatkan kematian. prevalensi kasus ini di inggris selama dua puluh tahun terakhir menunjukkan insiden sindrom turp ringan ke sedang adalah 0,5% hingga 8% dengan angka kematian 0,2% hingga 0,8%. sedangkan untuk kategori berat mencapai 25 % (reich et al, 2008). di indonesia khususnya di rs pku muhammadiyah yogyakarta adalah 4,7 % dari 168 tindakan turp (data rekam medis, 2013). dari data ini menunjukkan bahwa sindrom turp merupakan masalah yang serius yang membutuhkan intervensi khusus berupa tool untuk mendeteksi secara dini tanda dan gejalanya. pengembangan tool ini adalah untuk mendeteksi awal turp syndrome dengan melihat tanda dan gejala melalui tiga sistem utama yaitu sistem saraf pusat (gelisah, sakit kepala, bingung, koma, kejang, gangguan pengelihatan, mual muntah), sistem kardiorespirasi (hipertensi, hipotensi, bradikardi, takikardi, takipnue, hipoksia, edema paru) dan sistem metabolik ginjal (hiponatremia, hiperglisinemia, hemolisis intravaskular, gagal ginjal akut). berawal dari permasalahan di atas perlu disusun sebuah tool untuk mendeteksi dini sindrom turp yang bisa digunakan oleh perawat dan dokter. karena selama ini belum ada penanganan atau pengkajian spesifi k tentang sindrom turp sehingga hal ini merupakan kelemahan. maka dari itu dengan tersusunnya tool ini harapannya bisa menekan seminimal mungkin mortalitas et causa sindrom turp. hasil akhir dari penelitian ini adalah tool untuk deteksi dini sindrom turp dengan beberapa kategori yaitu negatif, ringan, sedang dan berat. masingmasing kategori memiliki batasan karakteristik tertentu yang kemudian hasilnya dikonsultasikan ke urolog untuk mendapatkan terapi lanjutan. metode penelitian ini menggunakan mixed-method yaitu penggabungan antara metode kualitatif dan kuantitatif. 1. kualitatif a. desain penelitian desain yang digunakan adalah action research dengan menggunakan tiga siklus dan setiap siklus ada empat fase (professional learning and leadership development directorate, 2010; koshy, 2005; dan creswell, 2012). yaitu: 1. plan. dalam tahap ini dilakukan identifi kasi permasalahan, pengumpulan informasi melalui studi pendahuluan dan studi literatur terkait, penyusunan tool dalam bentuk kuesioner, mengembangkan pertanyaan melalui kuesioner, penentuan metode dan tempat penelitian. tujuan akhir dari tahap ini adalah terbentuknya instrumen wawancara ke responden penelitian (dokter, perawat), rencana waktu serta tempat pelaksanaan focus group discussion. 2. action tahap ini adalah implementasi dari tahap pertama yaitu pengumpulan data dengan wawancara kepeda perawat berkaitan dengan tanda dan gejala sindrom turp, mengumpulkan hasil wawancara. tujuan akhir dari tahap ini adalah terkumpulnya data hasil wawancara. 3. observe tahap ini adalah tahap observasi dari dua tahap sebelumnya yaitu dengan menganalisa bukti dan mengevaluasi penemuan 119 muhammadiyah journal of nursing dalam wawancara, mendiskusikan hasil dengan triangulasi ke perawat, dokter, untuk menginterpretasikan hasil. tujuan akhir dari tahap ini adalah hasil analisa data dan triangulasi dalam bentuk naratif serta terbentuknya turp syndrome tool assessment sementara. 4. refl ection tahap ini adalah tahap terakhir dalam proses penelitian ini yaitu dengan mengevaluasi total tiga tahap sebelumnya (plan, action dan observe). jika hasil belum sesuai, maka dilakukan pengulangan kembali dari tahap pertama. tujuan akhir tahap ini adalah turp syndrome tool assessment dan rencana tindak lanjut. b. populasi dan sampel populasi penelitian ini adalah seluruh perawat dan urolog rs pku muhammadiyah i dan ii yogyakarta. sedangkan sampelnya adalah tujuh responden dan satu dokter urolog. c. lokasi dan waktu penelitian dilakukan di rs pku muhammadiyah i dan ii yogyakarta pada bulan april hingga juni 2014. d. batasan pengertian batasan pengertian dalam penelitian ini adalah sindrom turp yaitu sindrom karena intoksikasi cairan irigasi yang ditandai dengan disorientasi, nyeri kepala, gangguan kesadaran (koma), pengelihatan menurun, mual dan muntah, hipertensi, takikardi, takipnue, suara paru ronchi, abnormalitas crt, gangguan natrium, gangguan kalium, penurunan kadar hemoglobin (anemia), gangguan kadar ureum dan kreatinin, edema ekstrimitas bawah. e. instrumen penelitian instrumen yang digunakan dalam penelitian ini adalah panduan fgd dengan perawat dan panduan triangulasi ke dokter urolog. f. uji validitas uji validitas dalam penelitian ini adalah dengan triangulasi data ke dokter urolog. g. cara pengumpulan data pengumpulan data dilakukan di rumah sakit pku muhammadiyah i dengan fgd dengan tujuh perawat yang memenuhi kriteria inklusi. proses diskusi dilakukan sebanyak tiga fase siklus. siklus pertama dan kedua dilakukan dengan perawat. siklus ketiga, triangulasi data ke dokter urolog. h. pengolahan dan metode analisis hasil proses fgd dan triangulasi ke doker urolog ditranskripkan ke dalam tulisan, dilakukan coding, disusun kesimpulan tanda dan gejala sindrom turp. i. kesulitan penelitian peneliti mengalami kesulitan dalam beberapa kondisi. misalnya responden memiliki kesibukan tersendiri dengan pasien ketika akan di mulai kegiatan fgd yang berdampak acara di mulai tidak tepat waktu, keterbatasan waktu dari responden sehingga proses fgd tidak berlangsung lama, responden perlu diingatkan kembali akan jadwal fgd karena seringkali lupa. solusi dari permasalahan ini adalah fgd tetap dilaksanakan meskipun waktunya tidak seperti yang dijadwalkan, peneliti menghubungi satu per satu dari responden untuk menghadiri fgd. j. etika penelitian penelitian ini telah lolos uji etik di tim etik universitas muhammadiyah yogyakarta. di antara etika penelitian ke responden adalah: 1) informed consent (lembar persetujuan menjadi responden) memberi informasi tentang mekanisme atau proses penelitian sebagai calon responden, sehingga mampu memahami dan dapat berpartisipasi secara sukarela penelitian. 120 muhammadiyah journal of nursing 2) anonymity (tanpa nama) peneliti tidak akan mencantumkan nama responden di dalam hasil penelitian. 3) independece to refuse responden memiliki hak untuk menolak mengisi kuesioner. 2. kuantitatif a. desain penelitian pendekatan yang digunakan dalam metode kuantitatif adalah uji validitas dan reliabilitas karena hasil akhir dari penelitian ini adalah sebuah tool sehingga diperlukan dua uji diatas. b. populasi dan sampel populasi penelitian ini adalah seluruh perawat dan urolog rs pku muhammadiyah i dan ii yogyakarta. sedangkan sampelnya adalah dua puluh satu perawat yang pernah merawat pasien post turp dan bersedia menjadi responden. c. lokasi dan waktu penelitian penelitian dilakukan di rs pku muhammadiyah i dan ii yogyakarta pada bulan juli 2014. d. variabel penelitian variabel dalam penelitian ini adalah lima belas tanda dan gejala sindrom turp disorientasi, nyeri kepala, gangguan kesadaran (koma), pengelihatan menurun, mual dan muntah, hipertensi, takikardi, takipnue, suara paru ronchi, abnormalitas crt, gangguan natrium, gangguan kalium, penurunan kadar hemoglobin (anemia), gangguan kadar ureum dan kreatinin, edema ekstrimitas bawah. e. defi nisi operasional no variabel definisi skala pengukuran 1 disorientasi kehilangan daya untuk mengenal lingkungan, terutama yang berkenaan dengan waktu tempat dan orang yang diukur melalui observasi langsung ke pasien. ordinal 2 nyeri kepala rasa tidak nyaman di seluruh bagian kepala dari dagu hingga belakang kepala. variabel ini diukur dengan menanyakan ke pasien. interval 3 koma suatu keadaan hilangnya kesadaran dan kewaspadaan, serta ketidakmampuan untuk dibangunkan. variabel ini diukur dengan melakukan pemeriksaan glascow coma scale (gcs) interval 4 gangguan pengelihatan penurunan fungsi ketajaman pengelihatan. variabel ini diukur dengan menanyakan ke pasien tentang suatu objek. ordinal 5 mual dan muntah suatu rasa ketidaknyamanan yang berasal dari abdomen berupa rasa ingin atau sudah mengeluarkan makanan atau minuman yang sudah dikonsumsi. variabel ini diukur dengan menanyakan ke pasien. interval 6 hipertensi meningkatnya tekanan darah sistolik dan diastolik melebihi 140/90 mmhg. variabel ini diukur dengan menggunakan tensimeter. satuan:mmhg 7 takipnue meningkatnya frekuensi pernafasan melebihi >25x permenit. variabel ini diukur melalui observasi ekspansi dada atau bedside monitor. interval 8 takikardi peningkatan frekuensi jumlah nadi melebihi 101x/menit. variabel ini diukur dengan meraba nadi radialis di pergelangan tangan pasien. satuan: x/menit interval 9 abnormal crt sebuah keadaan perlamaan kembalinya darah diperifer melebihi > 3 detik. variabel ini diukur dengan menekan salah satu kuku tangan pasien hingga tampak putih kemudian amati waktu kembali menjadi merah. satuan: detik interval 121 muhammadiyah journal of nursing no variabel definisi skala pengukuran 10 suara ronchi suara abnormal paru yang terdengar saat ekspirasi yang disebabkan edema sehingga menyempitkan jalan nafas. variabel ini diukur dengan meletakkan stetoskop di thorak dan meminta pasien untuk bernafas. nominal 11 hipona-tremia menurunnya konsentrasi natrium hingga <135 mmol/l. variabel ini diukur dengan pengambilan darah dan diperiksa di laboratorium. satuan: mmol/l interval 12 gangguan kalium peningkatan konsentrasi kalium dalam darah melebihi 5,0 mmol/l. variabel ini diukur dengan pengambilan darah dan diperiksa di laboratorium. satuan: mmol/l interval 13 anemia penurunan kadar hemoglobin hingga < 12 g/dl. variabel ini diukur dengan melakukan pengambilan darah dan diperiksa di laboratorium. satuan:g/dl interval 14 peningkatan ureum dan kreatinin meningkatnya kadar ureum kreatinin sebagai penanda ada defi siensi fungsi ginjal. variabel ini diukur dengan melakukan pengambilan darah dan diperiksa di laboratorium. satuan: mg/dl interval 15 edema kaki pembengkakan tungkai bawah sebagai dampak penumpukan cairan pada kaki. variabel ini diukur dengan menekan area tibia anterior dengan ibu jari. satuan: mm interval f. instrumen penelitian instrumen dalam penelitian ini adalah kuesioner pertanyaan tentang tanda dan gejala sindrom turp yang terdiri dari lima belas pertanyaan. g. uji validitas dan reliabilitas uji validitas dalam penelitian ini menggunakan product moment pearson dengan signifi kansi 5%. sedangkan untuk uji reliabilitas menggunakan alpha cronbach dengan signifi kansi 5%. kedua fi tur tersebut ada dalam software spss 15.0 for windows. h. cara pengumpulan data pengumpulan data dilakukan dengan menyebar kuesioner ke perawat yang pernah merawat pasien post turp dan bersedia menjadi responden. i. pengolahan dan meode analisis data data dikumpulkan dari dua puluh satu responden yang kemudian dilakukan input hasil jawaban ke spss untuk dilakukan uji validitas dan reliabilitas. j. kesulitan penelitian kesulitan yang dialami adalah nilai validitas dari masing-masing item tidak dapat dilakukan dalam sekali uji sehingga perlu dilakukan beberapa kali uji untuk mendapatkan hasil yang diharapkan. peneliti sudah menyebar kuesioner dalam jumlah tiga puluh, namun belum semuanya dikembalikan karena ada yang belum terisi sehingga hal ini merupakan kesulitan tersendiri dalam mendapatkan jumlah sampel yang diinginkan. k. etika penelitian penelitian ini telah lolos uji etik di tim etik universitas muhammadiyah yogyakarta. di antara etika penelitian ke responden adalah: 1) informed consent (lembar persetujuan menjadi responden) memberi informasi tentang mekanisme atau proses penelitian sebagai calon responden, sehingga mampu memahami dan di harapkan dapat berpartisipasi secara sukarela dan tidak ada unsur paksaan. 122 muhammadiyah journal of nursing 2) anonymity (tanpa nama) peneliti tidak akan mencantumkan nama responden di dalam hasil penelitian. 3) independece to refuse responden memiliki hak untuk menolak mengisi kuesioner. hal tersebut tidak memiliki efek negatif terhadap pemberian pelayanan keperawatan di bangsal. kerangka penelitian hasil a. karakteristik tempat penelitian prevalensi kasus bph pada tahun 2013 di rs pku muhammadiyah i yogyakarta sejumlah 144 kasus dan untuk tindakan turp sejumlah 168 kesempatan tindakan. pasien yang meninggal dunia post turp dalam kurun waktu =< 24 jam ada 1 pasien (0,59%) dan setelah >= 48 jam ada 7 pasien (4,1 %). jadi total ada 8 pasien (4,76 %). sedangkan pada kurun waktu januari hingga juni tahun 2014 ada sejumlah 49 kasus bph dan untuk tindakan turp sejumlah 59 kesempatan tindakan. tidak ada pasien yang meninggal dunia post turp dalam kurun waktu =< 24 jam dan setelah >= 48 jam. rs pku muhammadiyah i yogyakarta menyediakan beberapa bangsal yang digunakan untuk merawat pasien post turp, diantaranya multazam, arofah, raudhah, imc, muzdalifah, icu, shofa, zam-zam, dan marwa. perawat yang berdinas di bangsal-bangsal tersebut pernah merawat pasien post turp. akan tetapi, dalam pelayanan sehari-hari yang berkaitan dengan pasien post turp belum memiliki tool untuk mendeteksi dini sindrom turp. maka dari itu, penyusunan tool yang berfungsi untuk mendeteksi sindrom tersebut adalah salah satu langkah strategis untuk menekan prevalensi kematian pasien post turp seminimal mungkin. b. hasil analisis statistic uji validitas dengan menggunakan dua puluh satu responden yang kemudian hasilnya dianalisis dengan product moment pearson terhadap lima belas item pertanyaan menghasilkan semua item valid karena hasil r hitung lebih besar daripada r tabel pada signifi kansi 5% = 0,433 dengan n= 21. 1. hasil uji reliabilitas hasil uji reliabilitas dengan menggunakan alpha cronbach terhadap kuesioner menghasilkan nilai 0,930. interpretasinya, secara statistik kuesioner tersebut reliabel karena nilai r hitung lebih besar daripada r tabel (n =21 nilai 0,433). 123 muhammadiyah journal of nursing hal ini menunjukkan bahwa alat ukur yang digunakan dalam penelitian ini mempunyai keandalan sebagai alat ukur, di antaranya diukur melalui konsistensi hasil pengukuran dari waktu ke waktu jika fenomena yang diukur tidak berubah. hasil uji validitas terhadap setiap item tool hasil uji validitas item pertanyaan r tabel dengan n = 21 (signifi kansi 5%) r hitung hasil disorientasi 0, 433 0,826 valid nyeri kepala 0, 433 0,864 valid koma 0, 433 0,809 valid penurunan penglihatan 0, 433 0,826 valid mual muntah 0, 433 0,606 valid hipertensi 0, 433 0,587 valid takipnue 0, 433 0,838 valid takikardi 0, 433 0,684 valid abnormal crt 0, 433 0,826 valid ronchi 0, 433 0,810 valid peningkatan natrium 0, 433 0,434 valid gangguan kalium 0, 433 0,710 valid penurunan hemoglobin 0, 433 0,548 valid peningkatan ureum dan kreatinin 0, 433 0,679 valid edema kaki 0, 433 0,576 valid pembahasan 1. siklus pertama fase ini terdiri dari identifi kasi permasalahan melalui studi pendahuluan, studi literatur, menyusun panduan fgd dan menentukan tempat serta jadwal fgd (professional learning and leadership development directorate, 2010). identifi kasi masalah dilakukan peneliti dengan studi pendahuluan berkaitan dengan kasus sindrom turp yang pernah terjadi di rs pku muhammadiyah yogyakarta. studi literatur yang dilakukan oleh peneliti adalah membandingkan tanda dan gejala melalui teori dengan kasus di klinik. peneliti berusaha memahami konsep sindrom tersebut supaya mendapatkan data yang sesuai ketika proses fgd dilakukan. langkah ini adalah implementasi langkah yang pertama dengan melaksanakan fgd. peneliti menanyakan ke responden berkaitan dengan sindrom turp. menurut responden pertama, tanda dan gejala pasien sindrom turp adalah gelisah, penurunan kesadaran, hipotensi, bradikardi, kreatinin meningkat, hiponatremia, hipokalemia. pasien sindrom turp mengalami gangguan kesadaran (koma), hiponatremia bahkan sampai kejang dan meninggal dunia (demirel, 2012). hal ini terjadi karena cairan irigasi masuk ke pembuluh darah melalui area yang direseksi sehingga menganggu kadar natrium dalam darah. literatur lain mengatakan bahwa operasi turp akan meningkatkan resiko hiponatremia dan sindrom turp (issa, 2004). di samping itu, pasien dengan hiponatrema juga mengalami mual dan muntah sebagai efek negatif dari kadar natrium di bawah 125 – 130 mmol/liter(reynolds et al, 2006). hasil yang didapatkan pada fase observe adalah diskusi berjalan sesuai rencana, responden memberikan informasi yang cukup banyak. hanya saja sebagian responden belum menyampaikan informasi tentang tanda dan gejala sindrom turp karena belum pernah merawat pasien dengan sindrom tersebut, dalam menjalani fase plan, action dan observe, responden antusias dalam diskusi, antar responden mampu berkomunikasi sesuai dengan topik diskusi. peneliti melanjutkan ke siklus yang kedua guna melengkapi data yang kurang. 124 muhammadiyah journal of nursing 2. siklus kedua tahapan pada fase ini sama dengan siklus pertama yaitu mengidentifi kasi permasalahan yang muncul pada siklus sebelumnya dan menentukan jadwal untuk pelaksanaan diskusi. fase action ini adalah fase fgd tahap kedua. pada tahap ini peneliti mendapatkan tambahan data bahwa pasien post turp yang ingin dilakukan pengkajian dengan tool ini harus dilakukan screening terlebih dahulu berkaitan dengan penyakit penyerta yaitu diabetes mellitus, congestive heart failure dan acute kidney injury (hawary, 2009; ladevic, 2008; dan o’donnel, 2009). responden mengurutkan tanda dan gejala berdasarkan sering atau tidaknya gejala tersebut muncul. misalnya, menempatkan disorientasi di awal pengkajian karena kebingungan adalah satu dari sekian tanda dari sindrom turp. kemudian diikuti nyeri kepala, penurunan kesadaran, gangguan pengelihatan, mual dan muntah. begitu juga dengan sistem kardiorespirasi serta ginjal dan metabolisme, tanda dan gejala diurutkan berdasarkan sering atau tidaknya ditemukan pada pasien. pada siklus kedua ini peneliti sudah mulai menemukan homogenitas data dari responden, tercatat beberapa data yang homogen dengan diskusi sebelumnya sehingga penulis memutuskan untuk melanjutkan siklus ketiga dengan melakukan validasi data ke salah satu urolog di rs pku muhammadiyah i yogyakarta. 3. siklus ketiga peneliti menyimpulkan hasil diskusi-diskusi sebelumnya dalam bentuk form sementara pengkajian sindrom turp. peneliti juga melakukan kontrak tempat dan waktu dengan urolog untuk triangulasi pakar. pada tahap ini peneliti menyampaikan hasil diskusi yang berupa form pengkajian ke urolog. urolog menyampaikan bahwa form ini nantinya bisa digunakan pada saat intraoperatif dan pasca operatif karena sindrom turp muncul pada dua fase operasi tersebut. urolog menyampaikan bahwa pemeriksaan awal terhadap penyakit penyerta sangat penting karena ada beberapa penyakit yang memiliki tanda dan gejala seperti sindrom turp sehingga hal tersebut bisa mengganggu pemeriksaan. informasi yang disampaikan oleh urolog adalah bersifat tambahan dan validasi dari tanda serta gejala sindrom turp. ada satu tanda yang dinilai urolog bukan bagian dari sindrom turp yaitu nyeri genital. nyeri genital adalah efek samping dari pemasangan kateter pada pra, intra dan post operatif. pada tahap ini peneliti melakukan evaluasi total dari diskusi sebelumnya dan triangulasi pakar yang kemudian menyimpulkannya menjadi sebuah form pengkajian sindrom turp. artinya, form ini sudah terbentuk menjadi sebuah tool untuk mendeteksi dini sindrom turp. namun perlu diujikan validitas dan reliabilitas dengan statistik agar hasil penelitian dapat dipertanggungjawabkan secara akademis nilai lebih dari penelitian ini. 4. pembahasan analisis statistik hasil uji reliabilitas dengan menggunakan alpha cronbach di spss 15 for window menunjukkan hasil 0,930 pada n= 21 dengan signifi kansi 5% adalah 0,433. hal ini menunjukkan bahwa alat ukur yang digunakan dalam penelitian ini mempunyai keandalan sebagai alat ukur, di antaranya diukur melalui konsistensi hasil pengukuran dari waktu ke waktu jika fenomena yang diukur tidak berubah. sedangkan hasil uji validitas menunjukkan hasil bahwa semua item valid. di antaranya disorientasi, nyeri kepala, koma, gangguan pengelihatan, mual dan muntah, hipertensi, ronchi, takikardi, abnormal capillary refi ll time (crt), takipnue, penurunan natrium, gangguan kadar kalium, penurunan hemoglobin, peningkatan kadar ureum dan kreatinin, edema ekstimitas bawah. 125 muhammadiyah journal of nursing 5. hasil akhir turp syndrom tool assessment turp syndrome scale nama pasien : ............................................... alamat : ............................................... umur :.....................................tahun ukuran besar prostat : ............................................... tanggal pengkajian : ............................................... no rekam medis : ............................................... penyakit penyerta : a) hipertensi b) diabetes mellitus c) congestive heart failure d) acute kidney injury e) lain-lain................................................................. no tanda dan gejala hasil pemeriksaan 1 sistem saraf pusat a. kebingungan disorientasi tempat, waktu, orang (5) disorientasi tempat dan waktu (4) disorientasi tempat dan orang (3) disorientasi waktu dan orang (2) non disorientasi (0) b. nyeri kepala 7 10 : berat (3) 4 6 : sedang (2) 1 3 : ringan (1) 0 : tidak nyeri (0) c. kesadaran (glascow coma scale) skor < 5 : koma (4) skor 8-10 : stupor (3) skor 11-12 : somnolent (2) skor 12-13 : apatis (1) skor 14-15 : composmentis (0) d. gangguan penglihatan pandangan tidak jelas (1) pandangan jelas (0) e. mual dan muntah mual dan muntah (2) mual tapi tidak muntah (1) tidak mual dan tidak muntah (0) 2 cardiovaskuler dan respirasi a. tekanan darah hipertensi : >140/90 mmhg (2) hipotensi : <100/90 mmhg (1) normal : 101/90 139/90 mmhg (0) b. pola pernafasan takipnue : > 25x/menit (2) bradipnue : < 18 x/menit (1) normal : 18-24 x/menit (0) no tanda dan gejala hasil pemeriksaan c. nadi takikardi : >101 x/menit (2) bradikardi : < 50 x/menit (1) normal : 51 – 100 x/menit (0) d. capillary refi ll time (crt) abnormal : > 3 detik (1) normal : < 3 detik (0) e. suara paru (tanda edema) ronchi (1) vesikuler (0) 3 fungsi ginjal dan metabolik a. natrium < 120 mmol/l : sangat rendah (2) 120 135 mmol/l : rendah (1) 135 145 mmol/l : normal (0) b. kalium > 5,0 meq/l : tinggi (2) < 3,5 meq /l : rendah (1) 3,5 – 5,0 meq/l : normal (0) c. hemoglobin < 12 g/dl : rendah (1) 12 – 14 g/dl : normal (0) d. kreatinin >1,3 mg/dl : tinggi (1) 0,6 – 1,3 mg/dl : normal (0) e. ureum > 50 mg/dl : tinggi (1) 10 – 50 mg/dl : normal (0) f. edema ekstrimitas bawah + 4 : 8 mm (hilang >2 menit) (4) + 3 : 6 mm (hilang >1 menit) (3) + 2 : 4 mm (hilang 10 – 15 detik) (2) + 1 : 2 mm (cepat hilang) (1) tidak ada pitt ing edema (0) total skor catatan: hasil skor pemeriksaan dilaporkan ke dokter urolog kategori: a. skor total 0 “nol” : sindrom turp negatif b. skor total 1 16 : sindrom turp ringan c. skor total 17 24 : sindrom turp sedang d. skor total 25 34 : sindrom turp berat kesimpulan penelitian ini telah menghasilkan sebuah tool untuk mendeteksi dini sindrom turp. tool ini terdiri dari lima belas pengkajian tanda dan gejala sindrom turp yang semuanya telah diuji validitas dan reliabilitas yang hasilnya adalah semua item valid dan reliabel. 126 muhammadiyah journal of nursing saran peneliti memberikan saran kepada peneliti selanjutnya yang berkesempatan yaitu agar hasil penelitian ini dikonversi menjadi sebuah software sistem pakar untuk deteksi dini sindrom turp sehingga bisa digunakan di komputer bangsal rawat inap, icu dan ruang operasi rumah sakit yang menerima operasi bph metode turp. tool ini dilakukan uji validitas ke pasien yang mengalami sindrom turp dalam jumlah yang mencukupi. daftar pustaka claybon, m. 2009. turp syndrome. htt p anes. med.umich.edu/vault/1000944-turp.pdf. (diakses 14 februari 2014) creswell, j., 2012. educational research: planning, conducting, and evaluating quantitative and qualitative research (4thed.).upper saddle river, nj: pearson education data rekam medis, 2013. data prevalensi kasus bph dan tindakan turp selama 2013 rs pku muhammadiyah i yogyakarta. demirel. 2012. turp syndrome and severe hyponatremia under general anaesthesia. bmj case report november. htt p://www.ncbi. nlm.nih.gov/pubmed/23166168 (diakses 8 juni 2014) gravenstein. 1997. transurethral resection of the prostate (turp) syndrome: a review of the pathophysiology and management. international anastesia research society 84: 438-465 hallin a, hammar n, persson pg. 2000. incidence of acute myocardial infarction and causespecifi c mortality after transurethral treatments of prostatic hypertrophy. urology, 55:236-240 hawary, a. 2009. transurethral resection prostate syndrome – almost gone but not forgott en. j endourologi. united kingdom issa, m. 2004. dilutional hyponatremia of turp syndrome: a historical event in the 21st century. adult urology. elsevier. koshy v. 2005. action research for improving practice. a practical guide. paul chapman publishing. htt p://www.actionlearning. com.au/classes/actionresearch/books/ book-actionresearchforimprovingpracti ce.pdf (diakses 21 februari 2014) ladevic, n. 2008. extremely rapid development of transurethral resection of the prostate syndrome. vojnosanit pregl. jul;65(7):56971. htt p://www.ncbi.nlm.nih.gov/ pubmed/18700469 (diakses 5 juli 2014) lucia, cd, famminella gd, rengo g. 2013. risk of acute myocardial infarction after transurethral resection of prostate in elderly. bmc surgery, 13 (suppl 2):s35. http://www.biomedcentral.com/14712482/13/s2/s35marszalek. m. 2009. transurethral resection of the prostate. european association of urology moorthy k. 2002. serum electrolytes in turp syndrome –is the role of potassium under-estimated?. iknrdiisahn nj.a a mnoaeosrtht. h2y00, p2;h 4il6i p(6 :) s :e 4r4u1-m4 4p4 o’donnel, a. 2009. anaesthesia for transurethral resection of the prostate. contin educ anaesth crit care pain 9 (3): 92-96. htt p:// ceaccp.oxfordjournals.org/content/9/3/92. full (diakses 5 juli 2014) olson, j, peters, s. 2011. pulmonary edema and cardiac arrest complicating transurethral resection of the prostate and turp syndrome. chest journal.;140(4_ meetingabstracts):152a. doi:10.1378/ chest.1114237 professional learning and leadership development directorate. 2010. action research in education guideline second edition (e-book). new south wales department of education and training. https://www.det.nsw.edu.au/proflearn/ docs/pdf/actreguide.pdf (diakses 21 127 muhammadiyah journal of nursing februari 2014) quinte health care. 2009. transurethral resection prostate. htt p://www.qhc.on.ca/ photos/custom/qhctransurethral%20 resection%20of%20prostate%20(turp). pdf (diakses 4 januari 2014) reich o, gratz ke c, bachmann a. 2008. morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients. j urol; 180:246–249. reynolds rm, padfi eld pl, seckl jr. 2006. disorder of sodium balance. bmj:332:702-705 htt p:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc1410848/ (diakses 9 juni 2014) swaminathan r, tormey wp. 1981. fluid absorption during transurethral prostatectomy [lett er]. br j urol;282:317 blank page 45 muhammadiyah journal of nursing abstract implementation of leader nurse in roles and functions management to nurses safety was infl uenced byseveral factors.the purposeof this studywere to investigate the most associating factors that related to implementation ofrolesandfunctions management of head nurse in the application of nursing safety. this study used correlativedescriptiveresearchmethod. the research samplewere 40 people and used total samplingtechniques. personality factorsand socialorganizations havea signifi cant association withthe implementation ofrolesandfunctions management of head nurseto nursing safety application(p= 0,036andp=0,004). personalityand socialorganizations neededthe attention of hospital managementthrough evaluation ofotherfactorsthat could be increasing the implementation of leader nurse roleand function management to application of nurses safety. key word : role and functions, management, head nurse, nursing safety penguatan peran dan fungsi manajemen kepala ruang melalui faktor kepribadian dan sosial organisasi novita kurnia sari, hanny handiyani, rr. tutik sri haryati universitas indonesia email : novita.psikumy@gmail.com pendahuluan rumah sakit merupakan salah satu tempat yang berisiko tinggi menyumbang terjadinya kecelakaan kerja untuk perawat (kho, carbone, lucas & cook, 2005). kecelakaan kerja untuk perawat meliputi penyakit infeksi, kekerasan fi sik, cidera ergonomik, paparan bahaya bahan kimia, cidera benda tajam, dan gangguan kesehatan mental. lingkungan kerja yang sehat mendukung perilaku perawat dalam menjaga keselamatan (foley, 2004; who, 2010). perilaku perawat menjaga keselamatan diri harus terus ditingkatkan. faktor yang paling berpengaruh membentuk lingkungan kerja yang sehat meliputi 6 faktor: faktor tuntutan kerja fi sik, tuntutan kognitif, kepribadian perawat, fi sik organisasi, organisasi sosial, dan organisasi profesi (rnao, 2006). kegiatan menjaga keselamatan diri perawat bukan hanya tanggung jawab individu perawat, namun juga merupakan tanggung jawab manajemen di rumah sakit. peran manajemen terdiri dari peran interpersonal, informasional, dan pengambilan keputusan (robins, 2003). fungsi manajemen diidentifi kasi menjadi lima fungsi yaitu perencanaan, pengorganisasian, pengaturan staf, pengarahan, dan pengendalian (marquis & huston, 2012). fenomena di beberapa rs pku muhammadiyah daerah istimewa yogyakarta ternyata hampir sama bahwa peran dan fungsi manajemen dalam penerapan keselamatan perawat belum dilakukan secara optimal oleh kepala ruang. sementara itu, kejadian kecelakaan kerja pada perawat seperti nsi, lbp, kelelahan dan 46 muhammadiyah journal of nursing kejenuhan saat bekerja ternyata sering terjadi. bahkan beberapa perawat harus menjalani perawatan intensif karena laminektomi, tertular hbv, dan tb. penelitian mengenai peran dan fungsi manajemen kepala ruang sudah pernah dilakukan di beberapa rs pku muhammadiyah di yogyakarta. namun penelitian yang terkait dengan pelaksanaan peran dan fungsi manajemen dalam penerapan keselamatan perawat belum pernah dilakukan. berdasarkan uraian dan fenomena tersebut, peneliti tertarik untuk meneliti faktor-faktor yang berhubungan dengan pelaksanaan peran dan fungsi manajemen kepala ruang pada penerapan keselamatan perawat di beberapa rs pku muhammadiyah daerah istimewa yogyakarta. metodologi penelitian penelitian ini merupakan penelitian korelatif deskriptif.teknik pengambilan sampel total sampling dengan jumlah sampel 40 kepala ruang dari empat rs pku muhammadiyah di d.i. yogyakarta. kuesioner untuk menilai faktor determinan terdiri dari 38 pertanyaan nilai validitas pada 29 butir pernyataan (skala likert) antara 0,413 – 0,899 dengan nilai reliabilitas 0,644. nilai validitas pada 9 butir pernyataan (skala gutmann) antara 0,400 – 0,819 dengan nilai reliabilitas 0,772. kuesioneruntuk mengukur faktor-faktor determinan nilai validitas pada 36 butir pernyataan antara 0,390 – 0,824 dengan nilai reliabilitas 0,692. kuesioner juga sudah dilakukan validitas isi oleh pakar manajemen. penelitian ini dilakukan selama 2 minggu dan sudah menggunakan prinsip-prinsip etik yang ada. kepala ruang menyetujui untuk ikut serta dalam penelitian ini dengan menandatangani lembar persetujuan dan memahami proses penelitian. analisis univariat pada penelitian ini disajikan dalam bentuk distribusi frekuensi dan prosentase. analisis bivariat menggunakan fisher exact test kecuali untuk tingkat pendidikan dengan peran dan fungsi manajemen menggunakan chisquare. analisis multivariat tidak dilakukan karena tidak ada satupun variabel yang bisa dimasukkan ke dalam pemodelan. hasil penelitian dan pembahasan tabel 1 ini menunjukkan karakteristik kepala ruang menurut usia, jenis kelamin, masa kerja, tingkat pendidikan dan pelatihan. tabel 1. karakteristik kepala ruang menurut usia, masa kerja, jenis kelamin, pendidikan, dan pelatihan rs pku muhammadiyah di yogyakarta, tahun 2012 (n=40) variabel frekuensi (n) prosentase (%) usia < 35 tahun ≥ 35 tahun 12 28 30,0 70,0 total 40 100,0 jenis kelamin laki-laki perempuan 11 29 27,5 72,5 total 40 100,0 masa kerja < 10 tahun ≥ 10 tahun 16 24 40,0 60,0 total 40 100,0 pendidikan spk diii s1 2 11 27 5,0 27,5 67,5 total 40 100,0 pelatihan pernah tidak pernah 30 10 75,0 25,0 total 40 100,0 tabel 2. memperlihatkan faktor-faktor yang berhubungan dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatan perawat. 47 muhammadiyah journal of nursing tabel 2. faktor-faktor yang behubungan dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatan perawat rs pku muhammadiyah di yogyakarta tahun 2012 (n=40) variabel frekuensi (n) prosentase (%) tuntutan kerja fisik rendah tinggi 37 3 92,5 7,5 total 40 100,0 tuntutan kognitif rendah tinggi 14 26 35,0 65,0 total 40 100,0 kepribadian individu kurang baik baik 20 20 50,0 50,0 total 40 100,0 fisik organisasi kurang baik baik 39 1 97,5 2,5 total 40 100,0 sosial organisasi kurang baik baik 11 29 27,5 42,5 total 40 100,0 organisasi profesi kurang baik baik 40 100,0 0,0 total 40 100,0 tabel 3. menyajikan gambaran pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatan perawat. tabel 3. pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatan perawat rs pku muhammadiyah di yogyakarta tahun 2012 (n=40) pelaksanaan peran dan fungsi manajemen frekuensi (n) prosentase (%) kurang baik baik 3 37 7,5 92,5 total 40 100,0 tabel 4. menyajikan hubungan faktor kepribadian individu dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam pelaksanaan keselamatan perawat. tabel 4. hubungan faktor kepribadian individu dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapankeselamatanperawat rs pku muhammadiyah di yogyakarta, tahun 2012 (n=40) peran dan fungsi total or pkurang baik baik kepribadian n % n % n % kurang baik baik 3 0 15 0 17 20 85 100 20 20 100 100 0,850 0,036* total 3 7,5 37 92,5 40 100 *bermakna pada α<0,05 tabel 5. menyajikan hubungan sosial organisasi dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatan perawat tabel 5.1. hubungan faktor sosial organisasi dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatanperawat rs pku muhammadiyah di yogyakarta, tahun 2012 (n=40) peran dan fungsi total or p kurang baik baik sosial organisasi n % n % n % kurang baik baik 3 0 27,3 0,0 8 29 72,7 100 11 29 100 100 0,004* total 3 7,5 37 92,5 40 100 *bermakna pada α<0,05 karakteristik kepala ruang seperti pada tabel 1. menunjukkan bahwa sebagian besar kepala ruang berusia ≥ 35 tahun. sesuai dengan hasil penelitian lin, et.al (2009) sebagian besar 48 muhammadiyah journal of nursing usia kepala ruang antara 30-55 tahun. kortrba (2010) juga mendapatkan hasil yang sama bahwa usia kepala ruang antara 36-45 tahun. kornspan & etz el (2001) menyatakan bahwa semakin tinggi usia maka seseorang akan memiliki kematangan karir. kepuasan dalam karir dan kepercayaan diri yang besar dalam bekerja berbanding lurus dengan usia seseorang (aryee & debrah, 2006). jenis kelamin kepala ruang mayoritas perempuan. hal ini sesuai dengan paradigma di masyarakat bahwa perawat adalah pekerjaan perempuan. hasil penelitian simamora (2005) menunjukkan bahwa kepala ruang perempuan jumlahnya lebih banyak dibandingkan laki-laki. waugaman & lohrer (2000) menyatakan bahwa sebagian besar perawat perempuan cenderung memberikan pelayanan yang lebih baik kepada klien dibandingkan dengan perawat laki-laki. masa kerja kepala ruang sebagian besar > 10 tahun. salah satu syarat menjadi kepala ruang adalah perawat yang minimal telah bekerja di ruang rawat selama 2-5 tahun (depkes ri, 1999). sehingga manajemen rumah sakit memilih perawat yang masa kerjanya minimal > 5 tahun. tingkat pendidikan kepala ruang mayoritas s1 keperawatan. hal ini sesuai dengan syarat menjadi kepala ruang yaitu memiliki tingkat pendidikan minimal diii keperawatan (depkes ri, 1999). semakin tinggi tingkat pendidikan maka semakin baik pula kemampuan seseorang dalam memecahkan masalah. maka diperlukan kepala ruang dengan tingkat pendidikan yang baik mengingat kepala ruang bertanggung jawab terhadap pelayanan dan asuhan keperawatan. kepala ruang mayoritas pernah mengikuti pelatihan yang berhubungan pengelolaan ruang rawat. pelatihan dilakukan dengan tujuan untuk meningkatkan kemampuan seseorang. pelatihan pengelolaan ruang rawat menjadi syarat untuk menjadi kepala ruang (depkes ri, 1999). sehingga diharapkan pengelolaan ruang rawat dapat dilakukan dengan lebih baik jika kepala ruang telah mengikuti pelatihan pengelolaan ruang rawat. tuntutan kerja fi sik mayoritas dipersepsikan rendah oleh kepala ruang. tuntutan kerja fi sik ini antara lain beban kerja, jadwal dinas, angkat berat, paparan berbahaya dan substansi infeksius, serta ancaman terhadap keselamatan individu (rnao, 2006). pekerjaan-pekerjaan tersebut di ruangan keperawatan lebih banyak dilakukan oleh perawat pelaksana sehingga kelelahan dan stres kerja lebih banyak dialami perawat pelaksana dibandingkan dengan kepala ruang (kusuma, 2009). hal ini dikarenakan kepala ruang lebih bertanggung jawab pada hal-hal yang bersifat manajerial seperti perencanaan jumlah tenaga, pengembangan pelayanan keperawatan, ketepatan penggunaan sop, penentuan dan pemantauan kebutuhan alat (depkes, 1999). tuntutan kerja kognitif mayoritas dipersepsikan tinggi oleh kepala ruang. yang termasuk dalam faktor ini antara lain: kerumitan pekerjaan di lahan praktik, keamanan pekerjaan, hubungan antaranggota kelompok, tuntutan emosi, kejelasan dan ketegangan peran (rnao, 2006; squires, 2010). kepala ruang dituntut untuk tetap memberikan motivasi kepada perawat pelaksana dan memberikan dukungan dalam menjalankan tugas keperawatan. hasil penelitian arini (2012) menyatakan bahwa kemampuan kepala ruang dalam manajemen konfl ik berhubungan dengan motivasi dan kemampuan perawat menjalankan asuhan keperawatan. selain itu, kepala ruang juga mempunyai tanggung jawab manajerial yang besar dalam ruang rawat. faktor kepribadian individu dipersepsikan oleh kepala ruang dengan proporsi sama. catalano (2011) menyatakan hal yang sama dengan hasil penelitian ini dimana skor kepribadian perawat berada pada proporsi yang sama. skor kepribadian perawat semuanya berada pada rentang nilai rata-rata. hasil penelitian ini berbeda dengan penelitian riggio & taylor (2000) yang menyatakan perawat dengan kepribadian yang baik cenderung akan menampilkan performa 49 muhammadiyah journal of nursing kerja yang baik pula. faktor fi sik organisasi mayoritas dipersepsikan kurang baik oleh kepala ruang. faktor fi sik organisasi ini meliputi penjadwalan dinas perawat, akses mendapat peralatan untuk keselamatan perawat, kebijakan keselamatan dan keamanan perawat (trinkoff , 2007). hasil penelitian ini sama dengan penelitian yang dilakukan oleh gadner, hawkins, fogg, & latham (2007) dimana sebagian besar perawat yang keluar dari tempat kerjanya dikarenakan lingkungan kerja yang kurang baik. faktor sosial organisasi mayoritas dipersepsikan baik oleh kepala ruang. faktor sosial organisasi ini meliputi stabilitas organisasi, komunikasi dan struktur hubungan atasanbawahan, dan budaya belajar serta dukungannya (rnao, 2006). sejalan dengan yang dikemukakan oleh batch, bannard & windsor (2006) bahwa komunikasi yang baik di dalam sebuah organisasi akan membangun interaksi diantara anggota organisasi dengan baik pula. apker, ford, & fox (2003) juga mengemukakan hal yang sama bahwa manajer harus berada dalam lingkungan pekerjaan yang mendapat dukungan penuh dari organisasi berkaitan dengan komunikasi suportif yang dilakukan terhadap semua anggota di dalam organisasi. faktor organisasi profesi dipersepsikan kurang baik oleh kepala ruang. faktor organisasi profesi ini meliputi pengawasan praktik, level otonomi, lingkup praktik dan hubungan interdisiplin (rnao, 2006). frank (2005) menyatakan hal yang berbeda dengan hasil penelitian ini. sebagian besar perawat merasakan bahwa dukungan organisasi profesi membawa manfaat besar antara lain membuat perawat lebih aktif, mendapatkan banyak informasi terbaru terkait profesinya, dan bisa saling terhubung dengan perawat lain. hubungan antara faktor tuntutan kerja fi sik dengan pelaksanaan peran dan fungsi manajemen kepala ruang menunjukkan bahwa mayoritas kepala ruang yang tuntutan pekerjaan fi siknya rendah cenderung memiliki peran dan fungsi manajemen baik dibandingkan dengan kepala ruang yang tuntutan pekerjaan fi siknya tinggi menunjukkan kemungkinan yang lebih kecil memiliki peran dan fungsi manajemen yang baik.tuntutan pekerjaan fi sik yang diterima kepala ruang seperti pembuatan jadwal dinas yang baik untuk perawat pelaksana dianggap sebagai bagian dari pekerjaan sehingga pekerjaan ini dipersepsikan mudah oleh kepala ruang. kepala ruang tetap mampu menjalankan peran dan fungsi manajerialnya dengan baik sehingga keselamatan perawat tetap terjamin. hal ini sejalan dengan pendapat chase (2010) bahwa kompetensi manajer di ruang rawat lebih kepada bagaimana membangun komunikasi yang efektif, mempertahankan perawat, disiplin yang efektif dan pengambilan keputusan. hasil penelitian menunjukkan hasil mayoritas kepala ruang yang tuntutan kerja kognitifnya rendah cenderung memiliki peran dan fungsi manajemen baik dibandingkan kepala ruang yang tuntutan kerja kognitifnya tinggi menunjukkan kemungkinan yang lebih kecil untuk melaksanakan peran dan fungsinya secara baik. hasil penelitian berry, gillespie, gates, & schafer (2011) menunjukkan bahwa produktivitas kerja didukung oleh beban kerja kognitif yang diterima. hal ini sesuai dengan hasil penelitian ini dimana kepala ruang dengan tuntutan kerja kognitif rendah akan memiliki produktivitas yang baik sehingga pelaksanaan peran dan fungsi manajemen dalam penerapan keselamatan perawat dapat dilakukan dengan baik pula. faktor kepribadian individu meliputi komitmen terhadap perawatan klien, nilai dan etik pribadi, daya tahan, kemampuan adaptasi dan nilai-nilai kemuhammadiyahan. hasil penelitian didapatkan kepala ruang yang kepribadiannya baik mayoritas memiliki peran dan fungsi manajemen secara baik. hasil penelitian ini sesuai dengan penelitian mustofa (2010) yang 50 muhammadiyah journal of nursing menyatakan bahwa sikap dan kepribadian perawat akan menentukan kinerjanya. hasil penelitian chase (2010) juga menyatakan hal yang sama bahwa kepala ruang harus mempunyai kompetensi individual yang baik, diantaranya adalah kepribadian. hasil penelitian ini mempunyai hubungan yang bermakna antara variabel kepribadian dengan pelaksanaan peran dan fungsi kepala ruang dalam penerapan keselamatan perawat. salah satu faktor pendukungnya adalah nilainilai kemuhammadiyahan. kepala ruang rs pku muhammadiyah di yogyakarta adalah kader muhammadiyah. rs pku muhammadiyah di yogyakarta secara rutin menyelenggarakan program darul arqam dan baitul arqam untuk refreshing nilai-nilai al islam dan kemuhammadiyah. sehingga diharapkan kepribadian sebagai kader muhammadiyah tetap melekat pada diri kepala ruang (pp muhammadiyah, 2012). hasil penelitian menunjukkan bahwa mayoritas kepala ruang yang mempersepsikan faktor fi sik organisasinya baik cenderung memiliki peran dan fungsi manajemen yang baik. hasil penelitian ini sesuai dengan hasil penelitian buheli (2012) yang menyatakan bahwa terdapat hubungan antara lingkungan fi sik rumah sakit dengan kinerja perawat. fisik organisasi yang baik akan mendorong kepala ruang untuk menampilkan kinerjanya dengan baik pula, sehingga pelaksanaan peran dan fungsi manajemen semakin baik pula dalam penerapan keselamatan perawat. hasil penelitian ini menunjukkan bahwa mayoritas kepala ruang yang mempersepsikan faktor sosial organisasinya baik cenderung memiliki peran dan fungsi manajemen yang baik pula. hal ini sesuai dengan penelitian simbolon & nasution (2011) bahwa lingkungan sosial organisasi berpengaruh secara signifi kan terhadap kinerja perawat. semakin baik lingkungan sosial organisasinya maka kinerja kepala ruang akan semakin yang berarti mampu melaksanakan peran dan fungsi manajemen dalam penerapan keselamatan perawat dengan baik pula. hasil penelitian ini bermakna signifi kan terhadap hubungan antara faktor sosial organisasi dengan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatan perawat. faktor sosial organisasi ini meliputi iklim organisasi, budaya organisasi, dan nilai-nilai organisasi. penelitian al rizal (2012) menyatakan bahwa budaya organisasi memberikan pengaruh positif terhadap kinerja perawat. hasil penelitian ini menunjukkan bahwa semua kepala ruang mempersepsikan faktor organisasi profesi kurang baik. yang termasuk dalam faktor organisasi profesi adalah hubungan interdisiplin dan dukungan organisasi profesi. hasil penelitian ini tidak sama dengan penelitian schamalenberg (2009) dimana didapatkan hubungan positif antara komunikasi perawat-tim kesehatan dengan keselamatan kerja perawat. rosenstein (2002) juga menyatakan hal yang sama bahwa komunikasi perawat-tim kesehatan yang baik akan meningkatkan kepuasan kerja perawat. hasil analisis statistik menunjukkan tidak ada hubungan antara usia dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatan perawat. hasil ini sama dengan hasil penelitian dewi (2011) yang menyatakan bahwa tidak ada hubungan antara usia dengan penerapan keselamatan pasien. hasil penelitian shirey (2009) menyatakan hal yang sama dimana didapatkan usia tidak mempunyai hubungan yang bermakna dengan performa kerja perawat manajer. hubungan antara jenis kelamin kepala ruang dengan peran dan fungsi manajemen diperoleh bahwa mayoritas kepala ruang yang berjenis kelamin laki-laki cenderung memiliki peran dan fungsi manajemen yang baik dibandingkan kepala ruang perempuan.hasil penelitian ini sesuai dengan penelitian dewi (2011) bahwa jenis kelamin perawat tidak mempunyai hubungan 51 muhammadiyah journal of nursing yang bermakna dengan penerapan keselamatan perawat dan pasien. menurut gibson, ivancevich, dan donelly (1997) bahwa laki-laki dan perempuan memiliki kemampuan kognitif dan mental yang sama. paradigma di masyarakat juga tidak membedakan jenis kelamin. hal ini terbukti dengan kepala ruang yang dipilih oleh institusi rumah sakit tidak membedakan antara laki-laki maupun perempuan. hubungan antara masa kerja dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatan perawat menunjukkan bahwa kepala ruang yang masa kerja < 10 tahun cenderung memiliki peran dan fungsi manajemen yang baik.penelitian ini menunjukkan hal yang berbeda karena ternyata masa kerja bukan menjadi penentu produktivitas kerja seseorang. banyak faktor yang menjadi penyebab antara lain tuntutan pekerjaan yang tinggi, kurangnya dukungan rekan kerja dan organisasi, konfl ik kerja/ keluarga yang berkepanjangan dan kurangnya kemampuan individu untuk menerima tantangan pekerjaan yang diterima. hubungan tingkat pendidikan dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penelitian ini menunjukkan sebagian besar kepala ruang dengan tingkat pendidikan spk cenderung memiliki peran dan fungsi manajemen yang baik.pada penelitian ini walaupun didapatkan kepala ruang yang tingkat pendidikannya spk 100% memiliki peran dan fungsi manajemen baik, namun jumlahnya hanya 2 kepala ruang. sedangkan kepala ruang yang tingkat pendidikannya diii dengan peran fungsi baik ada 11 orang dan s1 25 orang. angka ini tetap menunjukkan bahwa semakin tinggi tingkat pendidikan maka semakin besar kemungkinan kepala ruang untuk melaksanakan peran dan fungsi manajemen dalam penerapan keselamatan perawat. hal ini karena tingkat pendidikan yang tinggi diasumsikan akan memiliki pengetahuan dan ketrampilan yang lebih baik dalam menyelesaikan permasalahan. hasil penelitian menunjukkan kepala ruang yang tidak pernah mengikuti pelatihan cenderung memiliki peran dan fungsi manajemen yang baik dibandingkan dengan yang pernah mengikuti pelatihan.banyak faktor yang menyebabkan pada penelitian ini pelatihan tidak memberi makna terhadap hubungannya dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan perawat. pelatihan yang dilihat pada penelitian ini adalah pelatihan yang dilakukan setahun terakhir. prosentase masa kerja perawat yang sebagian besar ≥ 10 tahun, dimungkinkan kepala ruang telah mengikuti pelatihan 2 tahun kebelakang. pelatihan diharapkan bisa meningkatkan kemampuan seseorang sampai pada ranah psikomotor, namun kemungkinan pelatihan yang didapatkan baru bisa sampai pada ranah kognitif saja. jika dilihat dari sisi jumlah maka sebenarnya kepala ruang yang mengikuti pelatihan dan memiliki peran dan fungsi manajemenn yang baik ada 27 orang, lebih banyak dibandingkan dengan yang tidak mengikuti pelatihan ada 10 orang. simpulan karakteristik responden menunjukkan sebagian besar kepala ruang berusia ≥ 35 tahun, jenis kelamin perempuan, masa kerja > 10 tahun, pendidikan s1, dan pernah mengikuti pelatihan pengelolaan ruang rawat. faktor determinan menunjukkan sebagian besar kepala ruang mempersepsikan tuntutan kerja fi sik rendah, tuntutan kognitif tinggi, fi sik organisasi kurang baik, sosial organisasi baik, organisasi profesi kurang baik dan proporsi sama untuk kepribadian individu. pelaksanaan peran dan fungsi kepala ruang sebagian besar dipersepsikan baik. tidak ada hubungan yang bermakna antara karakteristik kepala ruang dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatan perawat 52 muhammadiyah journal of nursing tidak ada hubungan yang bermakna antara faktor tuntutan kerja fi sik dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan kesela-matan perawat. tidak ada hubungan yang bermakna antara faktor tuntutan kognitif dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan kesela-matan perawat. ada hubungan yang bermakna antara faktor kepribadian dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatan perawat tidak ada hubungan yang bermakna antara faktor fi sik organisasi dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatan perawat. ada hubungan yang bermakna antara faktor sosial organisasi dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatan perawat. tidak ada hubungan yang bermakna hubungan antara faktor organisasi profesi dengan pelaksanaan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatan perawat. tidak ada faktor determinan yang paling berpengaruh terhadap pelaksanaan peran dan fungsi kepala ruang dalam penerapan keselamatan perawat. tidak ada karakteristik kepala ruang yang paling berpengaruh terhadap pelaksaan peran dan fungsi kepala ruang dalam penerapan keselamatan perawat. saran rs perlu mengupayakan pendidikan lanjut bagi kepala ruang sampai dengan s1. hal ini karena dilihat dari hasil penelitian pelaksanaan peran dan fungsi manajemen memiliki kecenderungan untuk semakin meningkat seiring dengan peningkatan tingkat pendidikan. manajemen rs pku muhammadiyah perlu melaksanakan pelatihan terkait kompetensi kepala ruangan maupun keselamatan perawat. hal ini karena dilihat dari hasil penelitian pelaksanaan peran dan fungsi manajemen memiliki kecenderungan untuk semakin baik pada kepala ruang yang telah mengikuti pelatihan. manajemen rs pku muhammadiyah perlu melakukan evaluasi terhadap faktor-faktor yang berhubungan dengan peran dan fungsi manajemen kepala ruang dalam penerapan keselamatan perawat. kepala ruang perlu melakukan refreshing mengenai pelaksanaan peran dan fungsi manajemen dan melakukan evaluasi kegiatankegiatan yang berhubungan dengan keselamatan perawat peneliti selanjutnya disarankan untuk melakukan penelitian lebih lanjut mengenai sub faktor lain dalam faktor determinan yang mempengaruhi pelaksanaan peran dan fungsi manajemen kepala ruang. penelitian dengan metode observasi bisa ditambahkan agar lebih lengkap data yang bisa didapatkan dan dengan pendekatan kualitatif maupun kuantitatif. *mahasiswa fik-ui majanemen keperawatan ** & *** staf dasar keperawatan dan keperawatan dasar fik-ui daftar referensi al rizal, h. m. 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(2001). analisis kemampuan manajemen kepala ruangan di ruang rawat inap rsup dr m. djamil padang.tesis. universitas indonesia. diunduh melalui http://eprints.lib.ui.ac.id/ id/eprint/6828 pada 8 januari 2013. jurnal mjn vol. 2 no. 2 2015.indd 51 muhammadiyah journal of nursing abstract low back pain caused by decreasing discus space and narrowing foramen invertebralis which can produce irritation of the nerve roots and with radiating back pain. the purpose of this research is to determine the eff ectiveness of medula spinalis belt (msb) to reduce pain in coal workersin coal workers. design of the research was quasy experimental with pre-post test design with control group design. the population were 30 people of which 15 persons for the intervention group and 15 the control group, and spinal cord belt as a tool made by researcher. data collection was performed by measuring the intensity of pain using the vas, at the time before and after the intervention, and analysis done by t test (paired t-test and independent t test). the result showed that there was a decrease in the average of intensity of low back pain in the intervention group after using the medula spinalis belt. there was an increase in the average of intensity of low back pain in the control group after the post-test, and there is a signifi cant diff erence between the intensity of low back pain in the post-test of treatment group and the control group with p-value = 0.000. there were two risk factor of lbp which are age and gender occurred from multivariate analysis with beta -0,32, sig 0,049. the use of medula spinalis belt can reduce the intensity of low back pain. the use of medula spinalis belt in patients with low back pain will serve to control the pain because it can limit or support the lumbar movement, so it is suggested to coal workers to use medula spinalis belt to reduce pain in patients with lower back pain. key words: medula spinalis belt (msb), low back pain, pain pendahuluan nyeri punggung merupakan keluhan yang sering dijumpai pada kehidupan sehari-hari. diperkirakan hampir semua orang pernah mengalami nyeri punggung semasa hidupnya. nyeri punggung bawah tetap menjadi beban kesehatan masyarakat yang utama diseluruh dunia industri, dari data epidemiologi menunjukkan nyeri punggung bawah masuk pada urutan yang ke 19 dengan presentase 27 %, dan prevalensi dirasakan seumur hidup sebanyak 60 % (demoulin 2012). menurut world health organization (who), 2-5% dari karyawan di negara industri tiap tahun mengalami nyeri punggung bawah, dan 15% dari absenteisme di industri baja serta industri perdagangan disebabkan karena nyeri punggung bawah (sakinah et al 2010). penanganan nyeri punggung bawah umumnya bervariasi, mengikut studi, jenis pekerjaan, misalnya seperti lumbar support, dari hasil penelitian menunjukkan masih terdapat 17% responden yang tidak patuh menggunakan lumbar support dari 46% responden yang memenuhi syarat penelitian, pada saat melakukan aktivitas pekerjaan rumah sehingga lumbar support yang dipakai pekerja tidak memberikan dampak yang baik, karena tidak patuh, pada penelitian ini lumbar support seharusnya dipakai terus menerus ketika pekerja melakukan pekerjaan rumah untuk memeberikan hasil yang diharapkan (pepijn et al 2010). peneliti menggunakan msb karena alat tersebut didesain sedemikian rupa dengan menggunakan karet dan kain sebagai pelapis karet serta plastik yang bisa berfungsi menguatkan alat dan mencegah alat lepas pada liza f.l, djauhar.ismail, titih huriah program studi magister keperawatan, program pascasarjana universitas muhammadiyah yogyakarta lizaefrisnal@ymail.com medula spinalis belt (msb) terhadap penurunan nyeri penderita nyeri punggung bawah pada pekerja batu bata 52 muhammadiyah journal of nursing saat dipakai dengan tujuan alat tersebut menekan bagian punggung bawah pekerja, sehingga menghindari pergeseran atau peregangan pada medula spinalis pekerja pada saat bekerja karena pengaruh sering mengangkat beban yang berat. dari hasil studi pendahuluan yang dilakukan penulis, pada tiga orang pekerja pembuat batu bata, diperoleh hasil bahwa ke tiganya mengalami keluhan nyeri punggung bawah, akibat sering mengangkat beban yang berat dan sering membungkuk ketika bekerja. dari latar belakang tersebut diatas, maka peneliti tertarik untuk melakukan penelitian pemakaian msb terhadap penurunan nyeri penderita nyeri punggung bawah pada pekerja batu bata, di kota bengkulu. metode penelitian ini menggunakan desain pratest dan pasca-test dengan pemilihan, quasy eksperimental (nursalam 2013), dimana dalam penelitian ini peneliti akan melibatkan kelompok kontrol dan kelompok perlakuan, kemudian kelompok kontrol dan kelompok perlakuan tersebut masing-masing akan dilakukan pre-test yaitu berupa pengukuran skala nyeri, kemudian untuk pemakaian alat msb di berikan pada kelompok perlakuan saja, sedangkan pada kelompok kontrol tidak, kemudian setelah satu minggu kedua kelompok tersebut yaitu kelompok kontrol dan kelompok perlakuan keduanya samasama dilakukan pengukuran skala nyeri kembali, desain penelitian ini sering dikenal dengan pre post test design with control group. pada penelitian ini teknik penetapan sampel, peneliti lakukan pada dua kelompok responden yaitu kelompok perlakuan dan kelompok kontrol kemudian pembagiannya dilakukan sesuai dengan yang dikehendaki peneliti (purposive sampling) yaitu dari 30 responden peneliti bagi menjadi 15 orang untuk kelompok kontrol yang bekerja di bentiring kota bengkulu dan 15 orang untuk kelompok perlakuan bekerja di desa nakau kabupaten bengkulu tengah, kota bengkulu. penelitian dilakukan di desa nakau kabupaten bengkulu tengah dan di bentiring kota bengkulu, bulan november tahun 2014. variable penelitian ini menggunakan 2 variabel yaitu variabel bebas dan variabel terikat. variabel bebas dalam penelitian ini adalah penggunaan alat msb, sedangkan variabel terikat dalam penelitian ini adalah nyeri punggung bawah. hasil analisis univariat tabel 1. distribusi frekuensi karakteristik responden berdasarkan umur pada kelompok intervensi dan kelompok kontrol (n=30). karakteristik kelompok intervensi (n=15) kelompok kontrol (n=15) p usia dalam tahun (mean ±sd) 45,93±9,83 35,60±15,74 0,042* jenis kelamin (f, %) 0,71**laki-laki 7 (23,3) 6 (20,0) perempuan 8 (26,7) 9 (30,0) *p < 0, 05 based on independent t-tests **p < 0,05 based on chi square test tabel 1. menunjukkan bahwa ada perbedaan karakteristik umur dan tidak ada perbedaan untuk jenis kelamin antara kelompok intervensi dan kontrol. tabel 2 distribusi frekuensi karakteristik nyeri responden berdasarkan umur pada kelompok intervensi (n=15) dan kelompok kontrol (n=15) kategori usia dalam tahun frekuensi skala nyeri sebelum intervensi (mean ±sd) skala nyeri setelah intervensi (mean ±sd) 17-25 tahun 4 orang 4,50±1,73 4,50±1,73 26-45 tahun 17 orang 4,59±2,32 3,35±1,73 46-60 tahun 5 orang 5,40±1,81 1,60±1,34 60-73 tahun 4 orang 4,25±1,25 2,25±1,50 based on data primer 2014 53 muhammadiyah journal of nursing tabel 2. menunjukkan bahwa karakteristik skala nyeri sebelum intervensi paling tinggi dirasakan pada kelompok usia 46-60 tahun dan karakteristik skala nyeri setelah intervensi paling tinggi dirasakan pada kelompok usia 17-25 tahun berdasarkan usia, penurunan skala nyeri yang paling besar adalah pada kelompok usia 46-60 tahun. tabel 3. distribusi frekuensi karakteristik nyeri responden berdasarkan jenis kelamin pada kelompok intervensi dan kelompok kontrol (n=30) jenis kelamin frekuensi skala nyeri sebelum intervensi (mean ±sd) skala nyeri setelah intervensi (mean ±sd) laki-laki 13 orang 5,15±2,03 3,54±1,80 perempuan 17 orang 4,29±1,96 2,71±1,75 based on data 2014 tabel 3. menunjukkan bahwa karakteristik skala nyeri sebelum intervensi paling tinggi dirasakan pada jenis kelamin laki-laki dan karakteristik skala nyeri setelah intervensi paling tinggi dirasakan pada jenis kelamin laki-laki berdasarkan jenis kelamin, penurunan skala nyeri yang paling besar adalah pada jenis kelamin perempuan. analisis bivariat tabel 4 perubahan skala nyeri responden sebelum dan setelah menggunakan medula spinalis belt (msb) pada kelompok intervensi dan kelompok kontrol responden skala nyeri mean diff erence (95% ci) psebelum (mean±sd) setelah (mean±sd) kelompok intervensi 5,93±1,83 2,27±1,90 2,62 , 4,70 0,00 kelompok kontrol 3,40±1,24 3,87±1,30 -1,15 , 0,22 0,16 p <0, 05 based on paired t-test sumber: data primer 2014. tabel 4 menjelaskan bahwa pada kelompok intervensi terdapat penurunan skala nyeri sedangkan pada kelompok kontrol tidak terdapat penurunan skala nyeri tabel 5 nilai selisih skala nyeri responden sebelum dan setelah menggunakan medula spinalis belt (msb) (n=30) skala nyeri kelompok intervensi (mean±sd) kelompok kontrol (mean±sd) mean diff erence (95% ci) p nilai selisih 3,67±1,87 -4,7±1,24 2,94 , 5,32 0,00 p <0, 05 based on independent t-test table 5 menunjukkan bahwa perbedaan rata-rata perubahan skala nyeri sebelum dan setelah menggunakan msb pada kelompok intervensi dan kelompok ontrol sebesar 4,13 point. berdasarkan hasil uji statistik independent sample t-test didaparkan nilai pvalue = 0,00. nilai p< 0,05 sehingga dapat disimpulkan bahwa terdapat perbedaan perubahan skala nyeri antara kelompok intervensi dengan kelompok kontrol secara signifi kan analisis multivariat tabel 6 hasil analisis bivariat faktor resiko yang berhubungan dengan nyeri faktor resiko p usia 0,029 jenis kelamin 0,21 intervensi medula spinalis belt (msb) 0,012 p< 0,25 based on data primer 2014 hasil analisis bivariat, untuk usia, jenis kelamin, dan intervensi msb menunjukkan semua variabel mempunyai nilai p <0,25 sehingga dapat dilanjutkan keanalisis selanjutnya. 54 muhammadiyah journal of nursing tabel 7 hasil analisis regresi linier antara usia jenis kelamin dan intervensi medula spinalis belt (msb) terhadap kejadian nyeri punggung bawah pada pekerja batu bata faktor resiko beta sig constant 4,80 0,01 usia 0,34 0,063 jenis kelamin -0,33 0,051 intervensi medula spinalis belt (msb) -0,32 0,049 p< 0,05 based on regresi linier table 7 menunjukkan nilai konstan untuk skala nyeri menunjukkan terdapat perubahan skala nyeri tanpa ada kontribusi dari variabel lain adalah 4,80. hasil analisis regresi linier didapatkan intervensi medula spinalis belt merupakan faktor yang paling mempengaruhi penurunan skala nyeri. pembahasan analisis univariat hasil penelitian menunjukkan terdapat perbedaan umur responden pada kelompok intervensi dan kelompok kontrol ada perbedaan. hasil ini menunjukkan bahwa responden pada penelitian ini heterogen. rata-rata skala nyeri responden setelah perlakuan pada kelompok intervensi dan kelompok kontrol yaitu pada skala nyeri minor atau ringan nyeri yang sangat ringan, nyeri yang tidak nyaman dan nyeri yang dapat ditoleransi. usia merupakan faktor yang memperberat terjadinya npb, sehingga biasanya diderita oleh orang berusia lanjut karena penurunan fungsifungsi tubuhnya terutama tulangnya sehingga tidak lagi elastis seperti diwaktu muda. penelitian telah memperlihatkan bahwa resiko dari nyeri punggung bawah meningkat pada pasien yang semakin tua, tetapi ketika mencapai usia sekitar 65 tahun resiko akan berhenti meningkat. tetapi saat ini sering ditemukan orang berusia muda sudah terkena nyeri punggung bawah. bahkan anak-anak dan remaja saat ini semakin beresiko mengalami nyeri punggung. hasil penelitian menunjukkan bahwa rata-rata usia pekerja kelompok intervensi yang mengalami nyeri punggung bawah adalah usia 45 tahun dan usia rata-rata pekerja pada kelompok kontrol yang mengalami skala nyeri adalah usia 35 tahun. low back pain menyerang perempuan dan laki-laki sama banyak dan serangan biasanya terjadi pada umur 30-50 tahun. low back pain juga dapat terjadi pada lansia, diskus intervebralis akan mengalami perubahan sifat ketika usia bertambah tua (nurlis et al 2012). dari hasil penelitian salah satu nyeri yang sering terjadi pada manusia adalah nyeri punggung, umumnya terjadi pada orang dewasa usia 33-35 tahun bahkan lebih (sumekar 2010). hasil penelitian menunjukkan terdapat hubungan antara umur dengan keluhan low back pain dikarenakan pada umur setengah baya, kekuatan dan ketahanan otot mulai menurun sehingga resiko terjadinya keluhan otot meningkat. semakin bertambahnya umur seseorang, semakin tinggi risiko orang tersebut mengalami penurunan elastisitas pada tulang (lukman dan ningsih 2009). hal ini sesuai dengan teori kapasitas kerja seseorang untuk melakukan pekerjaan sampai batas waktu tertentu, sejalan dengan bertambahnya umur yang dilaluinya. semakin bertambahnya umur, maka akan terjadi proses fi brosis dan klasifi kasi pada tulang belakang berurutan dan saling berdekatan sehingga memudahkan timbulnya rasa nyeri pada daerah tulang belakang (putranto 2014). pada penelitian ini skala nyeri berdasarkan usia, setelah dilakukan perlakuan mengalami penurunan pada tahap nyeri yang ringan. hal ini sejalan dengan hasil penelitian yang dilakukan oleh kelompok studi persatuan dokter saraf seluruh indonesia (perdossi) bahwa ditemukan 18,13% penderita low back pain dengan rata-rata nilai nyeri berada pada nyeri sedang sampai berat. intensitas nyeri responden sesudah dilakukan 55 muhammadiyah journal of nursing terapi paling banyak berada di nyeri ringan (13). sesuai dengan hasil diatas dapat disimpulkan tingkat nyeri sesudah dilakukan terapi paling banyak berada pada nyeri ringan (erika 2012). dari hasil analisis peneliti faktor penyebab nyeri punggung bawah pada pekerja batu bata, karena proses degenaratif tubuh dari pekerja itu sendiri kemudian penyebab pendukung dari proses tersebut adalah seringnya reponden mengangkat beban yang berat ketika bekerja. dari hasil penelitian menunjukkan bahwa krakteristik responden kelompok intervensi dan kelompok kontrol secara keseluruhan tidak ada perbedaan dengan p-value 0,71 (>0,05). responden perempuan lebih banyak dari lakilaki, menunjukkan bahwa respon nyeri lebih dirasakan oleh perempuan, dan setelah diberikan perlakuan rata-rata skala nyeri yang dirasakan oleh responden berdasarkan jenis kelamin pada skala nyeri minor/ringan. (laki-laki: 3,54 dan perempuan 2,71) pada penelitian ini perempuan lebih banyak dari pada laki-laki hal ini dikarenakan pada wanita terjadi menstruasi dan proses menopause yang menyebabkan kepadatan tulang berkurang akibat penurunan hormon esterogen. penelitian analisis korelasi bahwa jenis kelamin dari hasil penelitian diperoleh hasil bahwa penderita low back pain yang telah berkunjung ke rsud prof. dr. margono soekarjo purwokerto lebih banyak perempuan (60,98%) daripada lakilaki (39,02%) (kurniasih 2010). fenomena yang ditemukan oleh peneliti berdasarkan pengamatan dari seluruh perempuan yang menjadi responden penelitian rata-rata sebagai ibu rumah tangga, selain bekerja mencetak batu bata, mereka juga mengerjakan pekerjaan rumah, hal ini juga yang menjadi faktor pendukung timbulnya nyeri punggung bawah, karena kurangnya waktu istirahat pada responden dan menyebabkan kurangnya kebugaran jasmani. keluhan otot jarang ditemukan pada orang yang dalam kegiatan kesehariannya memiliki waktu yang cukup untuk beristirahat. sebaliknya orang yang pekerjaannya memerlukan pengerahan tenaga besar, namun tidak memiliki waktu cukup untuk beristirahat, risiko untuk mengalami keluhan otot akan meningkat. penelitian yang menyatakan adanya suatu hubungan antara kebugaran jasmani dan nyeri punggung bawah tidak konsisten. nyeri punggung bawah lebih sering terjadi pada orang yang memiliki kekuatan yang kurang disbanding dengan tuntutan tugas. pada beberapa penelitian, kapasistas konsumsi o2 yang rendah belum diketahui memperidiksi kejadian nyeri punggung bawah. orang-orang dengan kebugaran jasmani paling rendah dapat mengalami peningkatan bahaya kesehatan terhadap cedera punggung (syahrul 2012). analisis bivariat hasil penelitian menunjukkan bahwa terdapat penurunan skala nyeri pada kelompok intervensi setelah menggunakan medula spinalis belt (msb). hal ini terlihat dari adanya penurunan skala nyeri yang dirasakan responden. pada sebagian besar penderita nyeri punggung bawah memiliki kecenderungan untuk mengalami perbaikan dalam jangka waktu dua minggu sampai tiga bulan. selama periode waktu ini, saat keluhan nyeri punggung bawah berada dalam proses resolusi, atau apabila nyeri punggung bersifat kronis, maka perlu dipertimbangkan penata laksanaan konserpatif yang tepat (garfi n 2002). tirah baring yang lebih lama cenderung memperberat keadaan karena menimbulkan pelemahan otot yang berperan menyangga tulang belakang. selain tirah baring, ada pilihan terapi konserpatif tinggal atau kombinasi yang sering disarankan untuk mengurangi nyeri dan memungkinkan rehabilitasi tulang belakang bagian bawah. pergerakan yang dilakukan oleh seseorang dalam aktiviats sehari-hari kalau aktivitas gerakan tersebut salah, dan sering terjadi terus menerus bisa menimbulkan masalah pada punggung bawah (scholtes 2013). 56 muhammadiyah journal of nursing peneliti menggunakan msb untuk mengatasi hal tersebut alat yang peneliti desain sendiri yang bermanfaat untuk mengurangi atau menghilangkan nyeri punggung bawah, msb dibuat dari bahan yang sederhana yaitu dari karet dan kain, serta alat penguat yang berfungsi untuk menghindari alat lepas pada saat dipakai yang terbuat dari bahan plastic, msb difungsikan atau bermanfaat untuk memberikan kenyamanan pada punggung bagian bawah pada saat bekerja, terutama untuk mengurangi nyeri pada saat melakukan aktivitas berat seperti pada pekerja batu bata. sama hal nya dengan teori yang menyatakan bahwah corset braces/alat penahan tulang belakang yang elastis, ebuah corset brace sering dianjurkan untuk membatasi pergerakan tulang belakang pasca fusi lumbalis. brace ini membantu mengurangi pergerakan tulang belakang sementara fusi sedang menyembuh dengan cara menghambat pergerakan membungkuk ke depan (garfi n 2002). skala nyeri pada responden yang mengalami nyeri punggung bawah, yang diperoleh untuk kelompok kontrol tetap tidak berubah selama periode penelitian dibandingkan dengan kelompok intervensi yang menggunakan sabuk elastis, sehingga nyeri pada kelompok intervensi terjadi penurunan sedangkan pada kelompok kontrol tidak (dalichau 2000). penelitian menunjukkan bahwa low back pain dengan penggunaan korset lumbal dan back exercise memang menurunkan nyeri. pemakaian lumbal korset merupakan alat pelindung diri pada region punggung bawah yang dibuat sedemikian rupa sehingga dapat berfungsi membantu mengontrol nyeri punggung dan dapat membatasi gerakan punggung bawah. penggunaan lumbal korset pada penderita spondilosis lumbalis akan berfungsi mengontrol nyeri karena dapat membatasi atau menyangga gerakan lumbal. pemakaian lumbal korset akan mempertahankan titik berat tubuh tetap pada tempatnya sehingga beban kerja otot dalam keadaan seimbang antara group agonis dan antagonis. lumbal korset pada kondisi ini sangat perperan dalam mengurangi nyeri terutama saat beraktifi tas, disamping sebagai stabilisasi lumbal juga sebagai pengambil alih sebagian tumpuan berat badan (sujana 2013) faktor yang menyebabkan tidak adanya penurunan skala nyeri pada kelompok kontrol adalah tidak adanya alat bantu untuk melindungi punggung ketika bekerja dan aktivitas mengangkat yang salah pada saat responden bekerja, pemakaian lumbal korset merupakan alat pelindung diri pada region punggung bawah yang berfungsi membantu mengontrol nyeri punggung dan dapat membatasi gerakan punggung bawah (pratiwi 2009). aktivitas mengangkat pekerjaan manual handling dan lifting merupakan penyebab utama terjadinya cedera tulang belakang, disamping itu sekitar 25% kecelakaan kerja juga terjadi akibat pekerjaan material manual handling, sebelumnya dilaporkan bahwa pada penjual jamu gendong di kabupaten demak didapatkan sekitar 74% cedera tulang belakang disebabkan oleh aktivitas mengangkat (povovic et al 2009). hasil penelitian menunjukkan bahwa perbedaan rata-rata perubahan skala nyeri pada kelompok intervensi dan kelompok kontrol sebesar 4,13 point. perbedaan rata-rata perubahan penurunan skala nyeri antara kelompok intervensi dan kelompok kontrol dapat juga disebabkan karena penggunaan msb sehingga dapat membantu menghilangkan atau mengurangi nyeri yang dirasakan oleh responden, karena msb merupakan alat yang sederhana dan praktik yang dapat digunakan oleh responden intervensi, yang dapat mempertahankan posisi lumbal ketika bekerja sehingga mencegah pergeseran pada lumbal, mampu mengontrol pergerakan lumbal dan dapat mencehah pembengkakan pada lumbal, sehingga nyeri berkurang atau tidak dirasakan kembali oleh responden intervensi. faktor lain yang dapat menyebabkan perbedaan rata-rata skala nyeri antara responden 57 muhammadiyah journal of nursing intervensi dan kontrol adalah kepatuhan kelompok intervensi untuk menggunakan msb ketika bekerja, karena dirasakan sangat nyaman dan sangat efektif untuk mengurangi atau menghilangkan nyeri yang dirasakan oleh responden. stimbelt, sistem stimulasi listrik yang terdiri dari sabuk pinggang hingga delapan pasang elektroda tertanam dan stimulator elektronik delapan channel. stimbelt adalah sistem bantu untuk pengobatan nyeri punggung bawah. yang juga dapat mengurangi rasa sakit pada low back pain, dan dapat mengurangi kejang otot, karena alat ini juga dapat mempertahakn posisi dari lumbar itu sendiri (larivier et al 2014). nyeri punggung bawah juga dapat berkurang dengan lumbar belt (lb) merupakan alat yang sudah didesain untuk mengurangi nyeri pungung bawah, karena lb dapat memberikan beberapa manfaat biomekanik untuk pasien dengan gangguan punggung, didasarkan pada perlindungan yang dapat diberikan terhadap cedera yang dapat ditimbulkan akibat aktivitas pasien, dengn fungsi yang juga dapat mempertahankan posisi lumbar pada pasien (calmels et al 2009). sabuk lumbar yang digunkan pada orang dengan subakut nyeri pinggang yang berfungsi untuk meningkatkan secara signifi kan status fungsional, lumbar dan menurunkan nyeri, dengan efek daya tekan yang diberikan oleh sabuk lumbar tersebut19 dan banyak pasien dengan nyeri punggung bawah atau nyeri panggul dengan menggunakan korset mereka merasa lega setelah penggunaan sabuk panggul tersebut karena alat tersebut dapat memberikan efek tekan atau kompresi eksternal sehingga bisa memberikan perlindungan pada ligament, sendi dan struktur panggul secara keseluruhan (calmels et al 2009). dari beberapa teori diatas menjelaskan bahwa alat yang didesain oleh beberapa peneliti, memiliki fungsi yang hampir sama dengan msb pada penelitian ini, yaitu untuk memberikan kenyamanan pada orang yang merasakan nyeri punggung bawah, sehingga penelitian ini memberikan hasil bahwa ada perbedaan ratarata skala nyeri pada kelompok kontrol dan intervensi karena penggunaan dan kepatuhan responden dalam menggunakan msb, sehingga dapat menimbulkan kenyamanan pekerja pada saat mencetak batu bata dan memeberikan kenyamanan pada saat setelah responden bekerja. penambahan lumbal korset terhadap intervensi micro wave diathermy, ultra sound, dan william fl exion exercise sangat berpengaruh pada pengurangan nyeri kasus low back pain miogenik. hasil hipotesis i dengan menggunakan wilcoxon sign rank test dapat diketahui bahwa pada kelompok perlakuan terdapat penurunan nyeri yang signifi kan setelah hasil uji membuktikan bahwa nilai p=0,004 (p<0,05), maka dapat disimpulkan bahwa ada efek pemberian micro wave diatermy, ultra sound dan william fl exion exercise terhadap penurunan nyeri pada low back pain miogenik. hasil hipotesis ii dengan menggunakan wilcoxon sign rank test dapat diketahui bahwa pada kelompok kontrol terdapat penurunan nyeri yang signifi kan setelah hasil uji membuktikan bahwa nilai p= 0,004 (p<0.05), maka dapat disimpulkan bahwa ada efek pemberian micro wave diatermy, ultra sound dan william fl exion exercise dan lumbal korset terhadap penurunan nyeri pada low back pain miogenik. hasil hipotesis iii dengan menggunakan mann-whitney test dapat diketahui bahwa terdapat perbedaan efek penambahan lumbal korset pada intervensi micro wave diatermy, ultra sound dan dan william fl exion exercise terhadap penurunan nyeri pada low back pain miogenik yang signifi kan pada kelompok perlakuan dan kelompok kontrol setelah hasil uji membuktikan bahwa nilai p=0,000 (p<0,05) (oktaviyani 2010). terdapat hubungan atau tidak antara lama menggendong dengan nyeri punggung bawah hasil dari penelitiannya menunjukkan bahwa tidak ada hubungan yang signifi kan karena hasil yang didapat adalah (p=0,433, a=0,05). hal ini dikarenakan selama menggendong beban, 58 muhammadiyah journal of nursing responden menggunakan setagen atau korset yang membantu responden dalam mempertahankan posisi punggung dan tulang belakang agar tetap tegak sehingga dapat mengurangi risiko herniasi yang berdampak nyeri punggung bawah, dengan tegaknya tulang belakang maka tekanan pada diskus intervertebralis menjadi berkurang, sehingga risiko kerusakan diskus yang berdampak pada nyeri punggung bawah menjadi kecil (povovic et al 2009), karena sifat alat yang digunakan oleh responden penelitian pratiwi hampir sama dengan yang digunakan oleh peneliti sehingga hasil yang ditimbulkan tidak signifi kan analisis multivariat berdasarkan hasil analisis multivariat regresi linier menunjukkan intervensi dengan msb merupakan variabel yang paling berpengaruh terhadap penurunan skala nyeri. permasalahan kesehatan yang timbul berupa low back pain, secara teoritis dapat disebabkan oleh perilaku tidak sehat dan lingkungan sekitar yang tidak mendukung, juga perilaku tidak ergonomis, merokok, tidak berolah raga, lingkungan sekitar, yang penuh stres, dan umur tua. analisis ini sesuai dengan konsep teori precede-procede model dari l.green. gangguan pada salah satu aspek akan menimbulkan permasalah kesehatan (basuki 2009), sehingga dibutuhkan terapi konserpatif untuk mengatasi masalah tersebut, seperti msb. sejalan dengan penelitian yang yang menyatakan bahwa pemakaian lumbal korset merupakan alat pelindung diri pada region punggung bawah yang dibuat sedemikian rupa sehingga dapat berfungsi membantu mengontrol nyeri punggung dan dapat membatasi gerakan punggung bawah. penggunaan lumbal korset pada penderita spondilosis lumbalis akan berfungsi mengontrol nyeri karena dapat membatasi atau menyangga gerakan lumbal. pemakaian lumbal korset akan mempertahankan titik berat tubuh tetap pada tempatnya sehingga beban kerja otot dalam keadaan seimbang antara group agonis dan antagonis. lumbal korset pada kondisi ini sangat perperan dalam mengurangi nyeri (pratiwi et al 2009). umur dan jenis kelamin yang bisa menyebabkan timbulnya nyeri pada punggung bawah pekerja batu bata, sesuai dengan teori tesebut diatas, dari hasil pengamartan peneliti faktor lain yang dapat menjadi penyebab timbulnya nyeri pada responden penelitian ini adalah kebanyakan reponden laki-laki merokok ketika bekerja dan perilaku tidak ergonomis ketika mengangkat beban yang berat. kebiasaan merokok akan menurunkan kapasitas paru-paru, sehingga kemampuannya untuk mengkonsumsi oksigen akan menurun. akibatnya tingkat kebugaran tubuh juga menurun. bila orang tersebut dituntut untuk melakukan tugas yang menuntut pengerahan tenaga, maka akan mudah lelah karena kandungan oksigen dalam darah rendah, pembakaran karbohidrat terhambat, terjadi tumpukan asam laktat dan terjadilah nyeri otot. beberapa penelitian menunjukkan bahwah merokok berhubungan dengan peningkatan bahaya terjadinya nyeri punggung bawah. pada perokok bahaya terjadinya nyeri punggung bawah meningkat secara cepat sesuai dengan pajanan kumulatif dan dengan derajat pajanan harian maksimal (syahrul 2012). hal ini sesuai dengan penelitian yang menyatakan sebanyak 18 dari kelompok kasus mengaku merokok atau pernah merokok dan 16 sampel mengaku tidak merokok sama sekali. sedangkan pada kelompok kontrol yang mengaku merokok atau pernah merokok 6 orang dan tidak merokok 15 orang. setelah dilakukan uji hipotesis chi-square test dengan nilai p 0,04 berarti p < 0,05 disimpulkan ada hubungan antara merokok dengan lbp. berdasarkan hasil nilai odds didapatkan angka 2,813 ini artinya merokok berat memiliki risiko untuk terjadinya lbp (or > 1) (sepatadina 2002). pekerja yang bekerja mengangkat dan membawa beban berat setiap hari, maka tulang 59 muhammadiyah journal of nursing belakangnya akan terus mengalami penekanan sehingga lama kelamaan sikap tubuhnya akan berubah. perubahan ini terjadi sebagai akibat dari kebiasaan mereka bertumpu saat membawa beban. cara bekerja di dalam waktu lama dengan sikap yang salah, dapat menyebabkan nyeri pinggang yang kronis. jadi factor rokok dan cara kerja yang tidak ergonomis dan beratnya beban yang diangkat, merupakan hal yang menimmbulkan nyeri punggung bawah ada pekerja batu bata, karena semua aktivitas tersebut melibatkan berbagai kelompok otot terutama otot penyangga tulang belakang yang berfungsi untuk memelihara postur tubuh, keseimbangan dan koordinasi keseimbangan yang baik. sikap kerja tersebut memungkinkan para pekerja terkena nyeri punggung bawah, sedangkan rokok bisa menyebabkan timbulnya nyeri punggung bawah adalah karena kebiasaan merokok akan dapat menurunkan kapasitas paru-paru yang diakibatkan adanya kandungan karbonmonoksida sehingga kemampuan untuk mengkonsumsi oksigen menurun dan sebagai akibatnya tingkat kesegaran menurun. apabila yang bersangkutan melakukan tugas yang menuntut pengerahan tenaga maka akan mudah lelah karena kandungan oksigen dalam darah rendah, pembakaran karbohidrat terhambat, terjadi penumpukan asam laktat, dan akhirnya timbul nyeri otot, sehingga menimbulkan nyeri pada pekerja (povovic 2009). penutup simpulan terdapat penurunan rata-rata intensitas nyeri punggung bawah pada kelompok intervensi setelah menggunakan medula spinalis belt, dan terdapat peningkatan rata-rata intensitas nyeri punggung bawah pada kelompok kontrol setelah dilakukan post test. intervensi msb merupakan variabel yang paling berpengaruh terhadap penurunan nyeri setelah dibandingkan dengan variabel karakteristik usia dan jenis kelamin saran penelitian ini diharapkan dapat memberikan manfaat bagi responden dengan menggunakan alat msb ketika mengangkat beban yang berat dapat mengurangi atau menghilangkan nyeri yang dirasakan, pada pekerja batu bata. daftar pustaka basuki (2009). faktor risiko kejadian low back pain pada operator tambang sebuahperusahaan tambang nickel di sulawesi selatan. jurnal promosi kesehatan indonesia vol. 4 / no. 2 / agustus 2009. calmels et al (2009). eff ectiveness of a lumbar belt in subacute low back pain: an open, multicentric, and randomized clinical study. htt p://www.ncbi.nlm.nih.gov/ pubmed/19179915. dalichau (2000). eff ects of elastic lumbar belts on the eff ect of a muscle training program for patients with chronic back pain. e journal zeitschrift für orthopädie und unfallchirurgie. htt p://www.ncbi.nlm.nih. gov/pubmed/10730357. demoulin c, (2012). eff ectiveness of preventive back educational interventions for low back pain: a critical review of randomized controlled clinical trials. eur spine journal. http://www.ncbi.nlm.nih.gov/pubmed/ 00586-012-2445-2. erika et al (2012) pengaruh terapi dingin ice massage terhadap perubahan intensitas nyeri pada penderita low back pain. jurnal ners indonesia, vol. 2. ejournal.unri.ac.id/ index.php/jni/article garfi n. 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a small rna virus which is wrapped by fat, its diameter is around 30 to 60 nm. an acute hcv infection is generally asymptomatic or minimally symptomatic. there are fi ve basic guidelines according to the kdigo (kidney disease improving global outcomes) for the prevention, diagnosis, evaluation, and treatment of hepatitis c in chronic kidney disease (chronic kidney disease). methods: the design of this research was descriptive analytic design with cross sectional approach. the population was 18 haemodyalisis patients with hcv rapid test negative on assessment in march 2012 and the sampling technique was total sampling. this study consisted of 5 independent variable application of universal precautions (hand hygiene, the use of handscoen, the use of masks, the use goggle and the use of dress/ apron), and one dependent variable: the incident of hepatitis c. the instruments were: observation sheets (checklist) for universal precautions implementation and the results of eia (=elisa/ enzyme linked immuno assay) laboratory tests for hepatitis c incidents. data analysis was uniariat and multivariate analysis (nominal regression test). results: hand hygiene signifi cantly aff ected the incidence of hepatitis c with probability value 0.012, as well as the use of handscoen signifi cantly aff ected the incidence of hepatitis c with probability value 0.002, while the use of masks had no signifi cant eff ect on the incidence of hepatitis c due to probability value 1.000, while the statistical value of the use of goggle glasses and dress/apron weren’t found because none of the nurses wore goggle glasses and apron when caring hemodyalisis patient for both with isolation (positive hepatitis b) and without isolation (hepatitis c positive/negative). in general, the application of universal precautions had signifi cant eff ect in preventing the incident of hepatitis c with a probability value of 0.000. pengaruh penerapan universal precaution (hand higiene dan apd) dalam mencegah insiden hepatitis c pada pasien hemodialisa di rsu pku muhammadiyah yogyakarta mashuri, elsye maria rosa, yuni permatasari istanti universitas muhammadiyah yogyakarta conclusion: there was signifi cant eff ect of implementation of universal precautions (hand hygiene and ppe) in preventing the incident of hepatitis, especially for hand hygiene (hand wash) and the use of gloves (handscoen). keywords: universal precautions, the incidence of hepatitis c pendahuluan hepatitis c disebabkan oleh virus hepatitis c (hcv) yang merupakan virus rna kecil terbungkus lemak yang berdiameter sekitar 30 sampai 60 nm, penyakit infeksi ini bisa tak terdeteksi pada seseorang selama puluhan tahun dan perlahan-lahan tapi pasti merusak organ hati. umumnya infeksi akut hcv tidak memberi gejala atau hanya bergejala minimal; hanya 20-30% kasus saja yang menunjukkan tanda-tanda hepatitis akut 7-8 minggu (berkisar 2-26 minggu) setelah terjadi paparan. dari beberapa laporan yang berhasil mengidentifi kasi pasien dengan infeksi hepatitis c akut, didapatkan adanya gejala malaise, mual-mual dan ikterus seperti halnya hepatitis akut akibat infeksi virus hepatitis lainnya (sudoyo aru w, 2006). masa inkubasi virus tersebut berlangsung 2 minggu sampai 6 bulan dengan manifestasi klinis non spesifi k, dan proses penularannya dapat vertikal dan horizontal. penularan vertikal adalah penularan dari seorang ibu pengidap hepatitis c kepada bayinya sebelum persalinan, pada saat persalinan, atau beberapa saat setelah persalinan. sementara penularan horizontal adalah penularan yang terjadi melalui transfusi darah yang terkontaminasi oleh hcv dan pasien yang mendapat 158 muhammadiyah journal of nursing hemodialisa, selain itu dapat juga melalui luka pada kulit dan selaput lendir, misalnya tertusuk jarum, menggunakan jarum suntik yang kurang steril, menindik telinga, dan sebagainya (yusuf, 2010). infeksi virus hepatitis c (hcv) 10% akan menjadi kronik dan 20% penderita hepatitis kronik dalam waktu 25 tahun sejak tertular akan mengalami sirosis hati dan hepatoma. kondisi infeksi hcv dengan pajanan agen lain seperti alfatoksin dapat menyebabkan terjadinya hepatoma tanpa melalui sirosis hati. dari studi pendahuluan melalui wawancara peneliti dengan kepala ruang hemodialisa rumah sakit umum pku muhammadiyyah yogyakrta, diperoleh data bahwa jumlah pasien hemodialisa sebanyak 79 pasien, dari screaning pemeriksaan rapid test pada bulan maret 2012 diperoleh data : 58 pasien dengan hcv positif, 3 pasien dengan hbv dan hcv positif, 5 pasien dengan hbv positif dan hcv negatif, dan hanya 13 pasien saja dengan hbv dan hcv negatif. sementara treatmen yang dilakukan oleh petugas hanya sebatas tindakan preventif saja untuk mencegah dan mengendalikan penyebaran virus tersebut melalui penerapan universal precaution bekerjasama dengan program magister manajemen rumah sakit fakultas kedoteran dan ilmu kesehatan universitas muhammadiyah yogyakarta, dan pada tahun 2013 ini belum dilakukan screaning ulang untuk pemeriksaan hcv. universal precaution merupakan satu-satunya cara untuk mencegah dan mengendalikan penularan penyakit dari cairan tubuh, baik dari pasien ke petugas kesehatan dan sebaliknya juga dari pasien ke pasien lainnya. berdasarkan pedoman praktek kilinis menurut kdigo (kidney disease improving global outcomes) terdapat lima pedoman baku untuk pencegahan, diagnosis, evaluasi, dan pengobatan hepatitis c pada penyakit ginjal kronis (cronic kidney disease) yaitu : (1) deteksi dan evaluasi hepatitis c pada penyakit ginjal kronik, (2) terapi infeksi hcv pada pasien penyakit ginjal kronik, (3) mencegah transmisi hcv pada unit hemodialisis, (4) tatalaksana pasien terinfeksi hepatitis c sebelum dan sesudah tranplantasi ginjal, (5) diagnosis dan tatalaksana penyakit ginjal terkait dengan infeksi hepatitis c. pernefri juga memberikan empat rekomendasi untuk pengendalian infeksi virus hepatitis b, virus hepatitis c, dan hiv pada unit hemodialisis di indonesia sesuai dengan target yang diharapkan yaitu : (1) rekomendasi umum dan khusus untuk evaluasi diagnositik dan tatalaksana infeksi hepatitis c pada pasien pgk, (2. rekomendasi umum dan khusus bagi staf ruang ketika bekerja di ruang hd, (3) mesin hd, dialiser, ruang hd, peralatan lainnya dan tempat sampah, (4) saat kondisi pada rekomendasi 1-3 tidak bisa diterapkan. bahan dan cara desain penelitian ini menggunakan rancangan deskriptif analitik dengan pendekatan potong lintang (cross sectional) yaitu penelitian yang bertujuan mendeskripsikan atau menguraikan suatu keadaan dalam suatu komunitas (exploratory study) dan selanjutnya menjelaskan suatu keadaan tersebut melalui pengumpulan atau pengukuran variabel korelasi yang terjadi pada obyek penelitian secara simultan dan dalam waktu yang bersamaan (notoatmodjo, 2002). penelitian ini bertujuan mendeskripsikan tentang pengaruh penerapan universal precaution (hand hygiene dan apd) dalam mencegah insiden hepatitis c. populasi pada penelitian ini adalah seluruh pasien hd dengan hcv negatif pada pemeriksaan rapid test bulan maret 2012 yang berjumlah 18 orang di ruang hemodialisa rsu pku muhammadiyah yogyakarta. sedangkan sampelnya adalah seluruh pasien hd dengan hcv negatif pada pemeriksaan rapid test bulan maret 2012 yang berjumlah 18 pasien di ruang hemodialisa rsu pku muhammadiyah 159 muhammadiyah journal of nursing yogyakarta dengan kriteria inklusi sebagai berikut : 1. tidak pindah hd di tempat lain 2. bersedia menjadi responden 3. tidak meninggal dunia saat pengambilan sampel jadi tehnik sampling yang digunakan pada penelitian ini adalah total sampling. lokasi penelitian adalah ruang hd rsu pku muhammadiyah yogyakarta unit ii, jl. wates km. 5,5 gamping, sleman yogyakarta 55294 telpon (0274) 6499704-6499706 fax. (0274) 6499727, dan penelitian ini dilaksanakan pada tanggal 15 maret 2013 hingga 30 maret 2013. variabel pada penelitian terdiri dari: 1. variabel independen penerapan universal precaution (hand hygiene) (x1 ) penerapan universal precaution (apd): penggunaan handscoen (x2), penggunaan masker (x3), penggunaan gaun (x4), penggunaan goggle (x5) 2. variabel dependen insiden hepatitis c (y) instrumen pengumpulan data yang digunakan adalah lembar observasi (checklist) untuk penerapan universal precaution (hand hygiene dan apd) dan hasil pemeriksaan laboratorium eia (=elisa/enzyme linked immuno assay) untuk insiden hepatitis c. sedangkan langkah-langkah pengumpulan data yang dilakukan pada penelitian ini sebagai berikut : 1. tahap persiapan a. sebelum penelitian ini dilaksanakan oleh peneliti, terlebih dahulu peneliti mengajukan ijin untuk melakukan penelitian kepada direktur rsu pku muhammadiyah yogyakarta melalui bidang pendidikan dan penelitian. b. setelah mendapatkan ijin dari bidang pendidikan dan penelitian rsu pku muhammadiyah yogyakarta selanjutnya peneliti meminta ijin kepada penanggungjawab ruangan serta menjelaskan tujuan dan waktu penelitian yang akan dilakukan serta meminta bantuan untuk memberi tahu pasien hemodialisa yang bisa dijadikan responden pada penelitian ini sesuai dengan kriteria inklusi yang telah peneliti ditentukan. 2. tahap pelaksanaan a. mengidentifi kasi responden berdasarkan kriteria inklusi yang telah ditentukan dengan terlebih dahulu berdiskusi dengan kepala ruang hemodialisa. b. peneliti menemui, memperkenalkan diri, menjelaskan tujuan penelitian dan informed consent (lampiran 1 dan 2) serta menanyakan dan mencatat jadwal hd pada pasien yang dijadikan responden. c. peneliti menyerahkan jadwal hd pasien yang dijadikan responden pada petugas laboratorium untuk dilakukan pengambilan sampel darah pada pemeriksaan eia (=elisa/ enzyme linked immuno assay) guna mendeteksi virus hepatitis c. d. selanjutnya penelti mengobservasi penerapan universal precaution oleh perawat ruang hd terhadap pasien hd dengan hcv negatif pada pemeriksaan rapid test bulan maret 2012 di ruang hemodialisa rsu pku muhammadiyah yogyakarta. uji analisa data yang digunakan pada peneltian ini adalah: 1. analisis uniariat pada penelitian ini variabel yang dideskripsikan melalui analisis univariat adalah variabel dependen yaitu insiden 160 muhammadiyah journal of nursing hepatitis c pada pasien hd; dan variabel independen yaitu penerapan universal precaution meliputi: cuci tangan, penggunaan handscoen, masker, goggle dan gaun/apron. data yang diperoleh kemudian dihitung jumlah dan prosentase masing-masing kelompok dan disajikan dengan menggunakan tabel serta diinterprestasikan. 2. analisis multivariat analisis multivariat digunakan untuk mengetahui hubungan secara bersamasama variabel bebas terhadap variabel terikat, dan variabel bebas mana yang paling besar hubungannya terhadap variabel terikat dengan menggunakan uji nominal regresi karena skala datanya berbentuk kategorik. hasil penelitian ini menggunakan sample berjumlah 18 pasien hemodialisa yang dinyatakan negatif hepatitis c saat pemeriksaan rapid test pada bulan maret 2012. penyajian akan dimulai dari karakteristik responden meliputi : jenis kelamin, usia, dan status perkawinan, karakteristik hemodialisa pasien hd yang meliputi: frekuensi hd perminggu, durasi setiap hd, lama menjalani hd, penggunaan reuse dyalizer, ruangan yang digunakan saat hd, traveling dyalisis, riwayat opname 1 tahun terakhir, riwayat mendapatkan tindakan invasif, riwayat tranfusi darah 1 tahun terakhir, penyimpanan reuse dyalizer, dan pasien hd dengan hepatitis b. kemudian dilanjutkan dengan karakteristik kategori ketepatan penerapan komponen universal precaution dan insiden hepatitis c pada pasien hd di ruang hemodialisa rsu pku muhammadiyah yogyakarta tahun 2013 sesuai dengan tujuan khusus penelitian. 1. karakteristik responden tabel 1. frekuensi dan prosentasi karakteristik pasien hemodialisa di ruang hd rsu pku muhammadiyah yogyakarta tahun 2013. no. karakteristik frekuensi prosentase 1. jenis kelamin laki-laki perempuan 10 8 55,6 44,4 2. usia 21 – 30 tahun 31 – 40 tahun 41 – 50 tahun 51 – 60 tahun 4 4 5 5 22,2 22,2 27,6 27,6 3. status perkawinan kawin tidak kawin 16 2 88,9 11,1 sumber : checklist 2013 tabel 1 menunjukkan bahwa sebagian besar jenis kelamin pasien hd adalah laki-laki 55,6 %, sebagian besar usia pasien hd berkisar antara 4150 tahun dan 51-60 tahun masing-masing 27,6 %, dan sebagian besar status perkawinan pasien hd kawin (88,9 %) 2. karakteristik hemodialisa pasien hd tabel 2 frekuensi dan prosentasi karakteristik hemodialisa pasien di ruang hd rsu pku muhammadiyah yogyakarta tahun 2013. no. karakteristik hemodialisa pasien hd jumlah prosentase 1. frekuensi hd perminggu satu kali perminggu dua kali perminggu tiga kali perminggu 1 14 3 5,6 77,8 16,7 2. durasi setiap hd 3 jam >3 jam 18 0 100 0 3. lama menjalani hd =/>24 bulan < 24 bulan 8 10 44,4 55,6 4. penggunaan reuse dyalizer menggunakan reuse tidak menggunkan reuse 14 4 77,8 22,2 5. ruangan yang digunakan saat hd ruang non isolasi ruang isolasi 14 4 77,8 22,2 sumber : checklist 2013 161 muhammadiyah journal of nursing tabel 2 menunjukkan bahwa sebagian besar frekuensi hd perminggu pasien hemodialisa dua kali perminggu 77,8 %, mayoritas durasi setiap hd 3 jam 100%, sebagian besar pasien hd menjalani hemodialisa < 24 bulan 55,6%, sebagian besar pasien hd menggunakan reuse dyalizer 77,8 %, sebagian besar pasien hd dilakukan dialysis di ruang non isolasi 77,8 %. traveling dyalisis diagram pie 1 menunjukkan bahwa sebagian besar pasien hd menjalani traveling dyalisis 61,1%. riwayat opname 1 tahun terakhir diagram pie 2 menunjukkan bahwa separoh pasien hd mempunyai riwayat opname 1 tahun terakhir dan separohnya lagi tidak mempunyai riwayat opname 1 tahun terakhir riwayat mendapat tindakan invasif diagram pie 3 menunjukkan bahwa sebagian besar pasien hd mempunyai riwayat mendapatkan tindakan invasif 61,1 %, dan hanya 38,9 % yang tidak mempunyai riwayat mendapatkan tindakan invasif. riwayat transfusi darah 1 tahun terakhir diagram pie 4 menunjukkan bahwa sebagian besar pasien hd mempunyai riwayat tranfusi darah satu tahun terakhir 77,8 %, dan hanya 22,2 % saja yang tidak penyimpanan reuse dializer diagram pie 5 menunjukkan bahwa sebagian besar penyimpanan reuse dyalizer pasien hd dilakukan secara tidak terpisah 77,8 %. pasien hepatitis b positif diagram pie 6 menunjukkan bahwa sebagian besar pasien hd dinyatakan negative hepatitis b 77,8 % 162 muhammadiyah journal of nursing 3. gambaran ketepatan penerapan komponen universal precaution tabel 3 distribusi frekuensi responden berdasarkan kategori ketepatan penerapan komponen universal precaution di ruang hd rsu pku muhammadiyah yogyakarta tahun 2013. no. kategori ketepatan penerapan komponen universal precaution jumlah prosentase 1. hand higiene tepat tidak tepat 6 12 33,3 66,7 2. penggunaan handscoen tepat tidak tepat 8 10 44,4 55,6 3. penggunaan masker tepat tidak tepat 2 16 11,1 88,9 4. penggunaan kaca mata goggle tepat tidak tepat 0 18 0 100 5. penggunaan gaun tepat tidak tepat 0 18 0 100 sumber : checklist 2013 tabel 3 menunjukkan bahwa sebagian besar hand hygiene perawat pada saat merawat pasien hd tidak tepat 66,7%, sebagian besar penggunaan handscoen oleh perawat pada saat merawat pasien hd tidak tepat 55,6%, sebagian besar penggunaan masker oleh perawat pada saat merawat pasien hd tidak tepat 88,9%, mayoritas perawat tidak menggunakan kaca mata goggle dan gaun/apron pada saat merawat pasien hd 100%. 4. kategori ketepatan penerapan universal precaution dalam mencegah insiden hepatitis c tabel 4 menunjukkan bahwa ketepatan penerapan universal precaution oleh perawat pada saat merawat pasien hd tidak tepat 61,1%, sedangkan insiden hepatitis c pada pasien hd sebagian besar negative 55,6 %. tabel 4 distribusi frekuensi responden berdasarkan kategori ketepatan penerapan universal precaution dalam mencegah insiden hepatitis c di ruang hd rsu pku muhammadiyah yogyakarta tahun 2013. no. kategori ketepatan penerapan komponen universal precaution jumlah prosentase 1. ketepatan penerapan universal precaution tepat tidak tepat 7 11 38,9 61,1 2. pasien hepatitis c positif negatif 8 10 44,4 55,6 sumber : checklist 2013 5. hubungan ketepatan penerapan universal precaution dalam mencegah insiden hepatitis c di ruang hd rsu pku muhammadiyah yogyakarta tahun 2013. tabel 5 tabulasi silang hubungan ketepatan penerapan universal precaution dalam mencegah insiden hepatitis c di ruang hd rsu pku muhammadiyah yogyakarta tahun 2013. hepatitis c up positif negatif jumlah ya 0 7 7 tidak 8 3 11 jumlah 8 10 18 sumber : checklist 2013 tabel 5 menunjukkan bahwa dari 11 pasien hd yang tidak tepat penerapan universal precautionnya oleh perawat pada saat perawatan di ruang hd dinyatakan positif hepatitis c sebanyak 8 pasien, sedangkan yang 3 pasien lainnya dinyatakan negatif hepatitis c, sementara dari 7 pasien hd yang penerapan universal precautionnya tepat oleh perawat pada saat perawatan di ruang hd semuanya dinyatakan negatif hepatitis c tidak memiliki distribusi normal. 163 muhammadiyah journal of nursing 6. data hasil uji statistic nominal regresi untuk pengaruh hand hygiene, penggunaan handscoen, masker, kaca mata goggle dan gaun/apron terhadap insiden hepatitis c tabel 6 data hasil uji statistic nominal regresi untuk pengaruh hand hygiene, penggunaan handscoen, masker, kaca mata goggle dan gaun/apron terhadap insiden hepatitis c di ruang hd rsu pku muhammadiyah yogyakarta tahun 2013. variabel uji rasio kemungkinan chi-square derajat kebebasan kemaknaan hh 6.279 1 .012 handscoen 10.008 1 .002 masker .000 1 1.000 goggle .000 0 . gaun .000 0 . sumber : checklist 2013 tabel 6 menunjukkan bahwa nilai probabilitas pengaruh hand hygiene terhadap insiden hepatitis c sebesar 0.012, nilai probabilitas pengaruh penggunaan handscoen terhadap insiden hepatitis c sebesar 0.002, sehingga terdapat pengaruh yang signifi kan antara hand hygiene dan penggunaan handscoen terhadap insiden hepatitis c. sedangkan nilai probabilitas pengaruh penggunaan masker terhadap insiden hepatitis c sebesar 1.000 yang berarti tidak terdapat pengaruh yang signifi kan antara penggunaan masker terhadap insiden hepatitis c, sedangkan untuk pengaruh penggunaan kaca mata goggle dan gaun/apron terhadap insiden hepatitis c tidak ditemukan nilai hasil uji statistiknya, karena tidak ada satupun perawat yang menggunakan kaca mata goggle dan gaun/ apron pada saat merawat pasien hd baik pada pasien isolasi (positif hepatitis b) maupun pada pasien non isolasi (hepatitis c positif/negatif). 7. data hasil uji statistic nominal regresi untuk pengaruh penerapan universal precaution dalam mencegah insiden hepatitis c tabel 7 data hasil uji statistic nominal regresi untuk pengaruh penerapan universal precaution dalam mencegah insiden hepatitis c di ruang hd rsu pku muhammadiyah yogyakarta tahun 2013. variabel uji rasio kemungkinan chi-square derajat kebebasan kemaknaan universal precaution insiden hepatitis c 24.731 4 .000 sumber : checklist 2013 tabel 7 menunjukkan bahwa nilai probabilitas uji statistic nominal regresi untuk pengaruh penerapan universal precaution dalam mencegah insiden hepatitis c sebesar 0.000 sehingga terdapat pengaruh yang signifi kan penerapan universal precaution dalam mencegah insiden hepatitis c di ruang hd rsu pku muhammadiyah yogyakarta tahun 2013. diskusi 1. pengaruh hand hygiene/cuci tangan dalam mencegah insiden hepatitis c pada pasien hemodialisa di rsu pku muhammadiyah yogyakarta tahun 2013 berdasarkan tabel 6 didapatkan nilai probabilitas sebesar 0.012 kurang dari 0,05 yang berarti terdapat pengaruh yang signifi kan hand hygiene/cuci tangan dalam mencegah insiden hepatitis c mencuci tangan adalah prosedur kesehatan yang paling penting yang dapat dilakukan oleh semua orang untuk mencegah penyebaran kuman. cuci tangan harus selalu dilakukan dengan benar sebelum dan sesudah melakukan tindakan perawatan walaupun memakai sarung tangan atau 164 muhammadiyah journal of nursing alat pelindung lain untuk menghilangkan atau mengurangi mikroorganisme yang ada ditangan sehingga penyebaran penyakit dapat dikurangi dan lingkungan terjaga dari infeksi. cuci tangan tidak dapat digantikan oleh pemakaian sarung tangan (nursalam, 2007). karena tangan merupakan salah satu anggota tubuh yang memiliki peranan utama dalam penyebaran mikroorganisme patogenik baik dari petugas, lingkungan maupun pasien, oleh sebab itu dari beberapa indicator pencapaian pelaksanaan universal precaution hampir sebagian besar didominasi oleh hand hygiene (cuci tangan) untuk menghindari tranmisi kuman bahkan sebaik apapun jenis alat pelindung diri juga masih tidak mampu menggantikan cuci tangan. 2. pengaruh penggunaan handscoen dalam mencegah insiden hepatitis c pada pasien hemodialisa di rsu pku muhammadiyah yogyakarta tahun 2013 berdasarkan tabel 6, didapatkan nilai probabilitas sebesar 0.002 kurang dari 0,05 yang berarti terdapat pengaruh yang signifi kan penggunaan handscoen dalam mencegah insiden hepatitis c. sarung tangan atau istilahnya handscoon merupakan salah satu kunci dalam meminimalisasi penularan penyakit, merupakan alat yang mutlak harus dipergunakan oleh petugas kesehatan termasuk perawat. pemakaian sarung tangan bertujuan untuk melindungi tangan dari kontak dengan darah, semua jenis cairan tubuh, sekret, kulit yang tidak utuh, selaput lendir pasien dan benda yang terkontaminasi (jumata, 2010). menurut tietjen, dkk, 2004 sampai sekitar 15 tahun lalu, petugas kesehatan menggunakan sarung tangan untuk tiga alasan untuk mengurangi risiko petugas terkena infeksi bakterial dari pasien, mencegah penularan fl ora kulit petugas kepada pasien dan mengurangi kontaminasi tangan petugas kesehatan dengan mikroorganisme yang dapat berpindah dari satu pasien ke pasien lain. menurut tenosis (2001) yang dikutip tietjen (2004), walaupun sarung tangan telah berulang kali terbukti sangat efektif mencegah kontaminasi pada tangan petugas kesehatan, sarung tangan tidak dapat menggantikan perlunya cuci tangan. sarung tangan lateks kualitas terbaik pun mungkin mempunyai kerusakan kecil yang tidak tampak. selain itu sarung tangan juga dapat robek sehingga tangan dapat terkontaminasi sewaktu melepaskan sarung tangan. tergantung situasi, sarung tangan pemeriksaan atau sarung tangan rumah tangga harus dipakai bila akan terjadi kontak tangan pemeriksa dengan darah atau tubuh lainnya, selaput lendir, atau kulit yang terluka, akan melakukan tindakan medik invasif (misalnya pemasangan alat-alat vaskular seperti intravena perifer) dan akan membersihkan sampah terkontaminasi atau memegang permukaan yang terkontaminasi (tietjen, dkk, 2004). ketersediaan penggunaan handscoen steril masih terbatas pada tindakan pemasangan dan pelepasan akses vaskuler saat mengakhiri hd, sementara untuk tindakan preeming, pengukuran tanda-tanda vital, penanganan alarm, verbed dan reuse masih menggunakan sarung tangan bersih dengan jumlah yang terbatas, sehingga masing sering ditemukan pada saat tindakan tersebut perawat tindak menggunakan handscoen, lebihlebih pada saat proses reuse yang sepenuhnya dikerjakan oleh cleaning service dengan latarbelakang pendidikan dan pelatihan tentang managemen hd yang tidak dia miliki, sehingga penerapan universal precaution saat reuse masih sangat berpotensi untuk menyebar luaskan mikroorganisme patogenik seperti halnya virus hepatitis c. 165 muhammadiyah journal of nursing 3. pengaruh penggunaan masker dalam mencegah insiden hepatitis c pada pasien hemodialisa di rsu pku muhammadiyah yogyakarta tahun 2013 berdasarkan tabel 6 didapatkan nilai probabilitas sebesar 1.000 lebih besar dari 0,05 yang berarti tidak terdapat pengaruh yang signifi kan penggunaan masker dalam mencegah insiden hepatitis c masker berguna untuk melindungi alat pernapasan terhadap udara yang terkontaminasi di tempat kerja atau di rumah sakit yang bertujuan untuk melindungi dan mengurangi risiko tertular penyakit melalui udara (ramdayana, 2009). pemakaian pelindung wajah ini dimaksudkan untuk melindungi selaput lender hidung, mulut selama melakukan perawatan pasien yang memungkinkan terjadi percikan darah dan cairan tubuh lain. masker tanpa kaca mata hanya digunakan pada saat tertentu misalnya merawat pasien tuberkulosa terbuka tanpa luka bagian kulit atau perdarahan. masker kaca mata dan pelindung wajah secara bersamaan digunakan petugas yang melaksanakan atau membantu melaksanakan tindakan beresiko tinggi terpajan lama oleh darah dan cairan tubuh lainnya antara lain pembersihan luka, membalut luka, mengganti kateter atau dekontaminasi alat bekas pakai. bila ada indikasi untuk memakai ketiga macam alat pelindung tersebut, maka masker selalu dipasang dahulu sebelum memakai gaun pelindung atau sarung tangan, bahkan sebelum melakukan cuci tangan bedah. pada kondisi riil dilapangan hampir semua perawat tidak ada yang menggunakan masker, kalaupun ada hanya satu perawat saja yang menggunakan masker (satu masker untuk satu shift dinas). memang secara teori hepatitis c hanya ditularkan lewat darah (blood-borne), tidak ditularkan melalui: bersin, memeluk, batuk, makanan, air, menggunakan peralatan makanan atau kontak biasa 4. pengaruh penggunaan kaca mata goggle dalam mencegah insiden hepatitis c pada pasien hemodialisa di rsu pku muhammadiyah yogyakarta tahun 2013 berdasarkan tabel 6 tidak didapatkan nilai probabilitas sama sekali sebab tidak ada satupun perawat yang menggunakan kaca mata goggle pada saat merawat pasien hd baik pada pasien isolasi (positif hepatitis b) maupun pada pasien non isolasi (hepatitis c positif/negatif). pelindung mata dapat berupa goggles, glass polikarbonat dengan sisi-perisai, face-shield dan prescription glasses dengan side-shields sekali pakai. walaupun sudah memakai side-shields, masker harus tetap dipakai untuk mengkontrol paparan percikan dari side. kebanyakan kacamata setidaknya harus dibersihkan dengan sabun dan air pada akhir setiap sesi atau ketika tampak terkontaminasi. pada saat melakukan asuhan keperawatan khususnya pada pasien hd dengan posisitf hepatitis b dan c, penggunaan pelindung mata adalah suatu keharusan untuk mengurangi kemungkinan terpapar cairan tubuh berbahaya yang dapat mentransmisikan kuman patogenik melalui mata (siegel,j.d.,2007) 5. pengaruh penggunaan gaun/apron dalam mencegah insiden hepatitis c pada pasien hemodialisa di rsu pku muhammadiyah yogyakarta tahun 2013 berdasarkan tabel 6 tidak didapatkan nilai probabilitas sama sekali dikarenakan tidak ada satupun perawat yang menggunakan gaun/apron pada saat merawat pasien hd baik pada pasien isolasi (positif hepatitis b) maupun pada pasien non isolasi (hepatitis c positif/negatif) gaun pelindung merupakan salah satu jenis pakaian kerja. jenis bahan sedapat mungkin tidak tembus cairan. tujuan pemakaian gaun pelindung adalah untuk melindungi petugas dari kemungkinan genangan atau percikan darah atau cairan tubuh lain. gaun pelindung harus dipakai apabila ada indikasi seperti halnya pada 166 muhammadiyah journal of nursing saat membersihkan luka, melakukan irigasi, melakukan tindakan drainase, menuangkan cairan terkontaminasi ke dalam lubang wc, mengganti pembalut, menangani pasien dengan perdarahan masif. sebaiknya setiap kali dinas selalu memakai pakaian kerja yang bersih, termasuk gaun pelindung. gaun pelindung harus segera diganti bila terkena kotoran, darah atau cairan tubuh. pada saat pengambilan data oleh peneliti tidak ada satupun perawat yang menggunakan gaun/ apron saat melakukan perawatan pada pasien hd baik untuk pasien ruang isolasi (positif hepatitis b) maupun non isolasi (hepatitis c positif/negatif), gaun/apron hanya digunakan ketika melakukan proses reuse dyalizer saja, dan itu sepenuhnya dikerjakan oleh bagian cleaning service. 6. pengaruh penerapan universal precaution dalam mencegah insiden hepatitis c di ruang hd rsu pku muhammadiyah yogyakarta tahun 2013 berdasarkan tabel 7 didapatkan nilai probabilitas sebesar 0.000 kurang dari 0,05 yang berarti terdapat pengaruh yang signifi kan penerapan universal precaution dalam mencegah insiden hepatitis c. kewaspadaan umum tersebut ditujukan untuk melindungi setiap orang (pasien, klien, dan petugas kesehatan) apakah mereka terinfeksi atau tidak. kewaspadaan baku berlaku untuk darah, tubuh/semua cairan tubuh, sekresi dan ekskresi (kecuali keringat), luka pada kulit, dan selaput lendir, kulit dan membrane mukosa yang tidak utuh. penerapan ini adalah untuk mengurangi risiko penularan mikroorganisme yang berasal dari sumber infeksi yang diketahui atau yang tidak diketahui (misalnya si pasien, benda yang terkontaminasi, jarum suntik bekas pakai, dan spuit) di dalam sistem pelayanan kesehatan (tietjen, dkk, 2004). menurut nursalam (2007), kewaspadaan umum perlu diterapkan dengan tujuan: a. mengendalikan infeksi secara konsisten. b. memastikan standar adekuat bagi mereka yang tidak terdiagnosa atau tidak terlihat seperti risiko. c. mengurangi risiko bagi petugas kesehatan dan pasien. d. asumsi bahwa risiko atau infeksi berbahaya. dengan maksud dan tujuan penerapan universal precaution tersebut diatas sebenarnya sangat relevan dengan ditunjang oleh tabel 4.5 yang menunjukkan bahwa dari 11 pasien hd yang tidak tepat penerapan universal precautionnya oleh perawat pada saat perawatan di ruang hd dinyatakan positif hepatitis c sebanyak 8 pasien, sedangkan yang 3 pasien lainnya dinyatakan negatif hepatitis c, sementara dari 7 pasien hd yang penerapan universal precautionnya tepat oleh perawat pada saat perawatan di ruang hd semuanya dinyatakan negatif hepatitis c, dengan demikian penerapan universal precaution sangatlah efektif dan efi sien untuk mengurangi risiko penularan mikroorganisme yang berasal dari sumber infeksi, walaupun sebenarnya masih banyak factor lain yang turut berperan serta dalam mentransmisikan beberapa kuman patogenik seperti: tranfusi, tindakan invasif, dan traveling dyalisis, selain juga karena factor endogen seperti penurunan daya tahan tubuh (immunosupresi) pasien hd itu sendiri. simpulan terdapat pengaruh yang signifi kan penerapan universal precaution (hand hygiene dan apd) dalam mencegah insiden hepatitis, terutama untuk hand hygiene (cuci tangan ) dan penggunaan sarung tangan (handscoen). daftar pustaka brunner, suddart, 2002, buku ajar keperawatan medikal bedah. edisi 8 alih bahasa; agung waluyo, egc, jakarta. 167 muhammadiyah journal of nursing cdc, 2001, recommendations for preventing transmission of infections among chronic hemodialysis patients. mmwr. cdc, 1998, recommendations for prevention and control of hepatitis c virus (hcv) infection and hcv-related chronic disease, mmwr. consensus statement, 1999, easl international consensus conference on hepatitis c. european association for study of the liver, journal of hepatology, paris. d. cahyaningsih, niken, hemodialisis (cuci darah). cetakan ke 3, mitra cendikia press, jogjakarta. dame sheila sherlock, 1995, management of acute and chronic hepatitis due to hepatitis b virus or hepatitis c virus. review article. current opinion in gastroenterology. depkes ri, 2000, profi l kesehatan indonesia, jakarta. depkes ri. 2003, pedoman pelaksanaan kewaspadaan universal di pelayanan kesehatan. jakarta hastono, s.p., 2007, analisis data kesehatan, jakarta: fkm ui. hayes c. peter, mackay, thomas w, 1997, buku saku diagnosis dan terapi, cetakan i, egc, jakarta. jean-michel pawlotsky, 1999, diagnostic test for hepatitis c. easl international consensus conference on hepatitis c. european association for study of the liver, journal of hepatology, paris. joyce lefever k., 1997. buku saku pemeriksaan laboratorium & diagnostik dengan implikasi keperawatan edisi ke 2, egc, jakarta. kaplan, robert, m, dan saccuzo, dennis., 1993, phsycological testing, rineka cipta, jakarta. kidney disease improving global outcomes (kdigo), 2008, clinical practice guidelines for the prevention, diagnosis, evaluation, and treatment of hepatitis c in chronic kidney disease, kidney international. notoatmodjo., 2002, metodologi penelitian kesehatan, rineka cipta, jakarta. nursalam dan ninuk., 2007, asuhan keperawatn pada pasien terinfeksi, salemba medika, jakarta. patrick marcellin., 1999. hepatitis c: the clinical spectrum of disease, easl international consensus conference on hepatitis c. european association for study of the liver, journal of hepatology. perry & pott er., 2005. buku ajar fundamental keperawatan: konsep, proses dan praktek. edisi ke 4. egc, jakarta. price, sylvia anderson., (1995). patofi siologi konsep klinis proses-proses penyakit, buku 2, alih bahasa oleh lorraine m.wilson,, egc, jakarta. proyek impact (integrated management of prevention and care & treatment), 2007, upk unpad, bandung. siegel j.d., rhinehart e., jackson m., chiarello l, and the healthcare infection control practises advisory committ ee, 2007, guideline for isolation precautions: preventing transmission of infectious agents in healthcare sett ings accessed juni 20, 2013, htt p://www.cdc.gov/ncidod/ dhqp/pdf/isolation2007.pdf siregar charles j.p., 2000, pharmaceutical care, editor: lia amalia, diky mudhakir, tomi hendrayana, mipa farmasi itb, bandung. sopiyudin dahlan., 2009, besar sampel dan cara pengambilan sampel (dalam penelitian kedokteran dan kesehatan), edisi ke-2, salemba medika press, jakarta sudoyo, aru w., 2006, buku ajar ilmu penyakit dalam, departemen ilmu penyakit dalam fkui, jakarta. sugiyono., 2004, metode penelitian administrasi, alfabeta, bandung. tietjen, l., 2004, panduan pencegahan infeksi untuk fasilitas pelayanan kesehatan, 168 muhammadiyah journal of nursing yayasan bina pustaka sarwono prawirohardjo, jakarta. w. wibisono., 2000, aspek laboratorium infeksi virus hepatitis c. dalam: management of hepatitis c in the new millenium, informasi laboratorium prodia berkesinambungan, 30 september 2000, jakarta. walker roger, edwards clive., 2003, clinical pharmacytherapetics, third edition, churchill livingstone, london wells, barbara g., dipiro joseph t., 2003, schwinghammer terry l., hamilton cynthia w., pharmacotherapy hand book, fifth edition, mcgraw-hill companies, usa. white, heather m., 1995, penyakit-penyakit hati. dalam: woodley, michele & alison whelan (eds). pedoman pengobatan. edisi ke-27, terj. dari: manual of medical therapeutica, essentia medika. zuraida zulkarnaen, 2000, tinjauan multi aspek hepatitis virus c pada anak. dalam: tinjauan kompre-hensif hepatitis virus pada anak. naskah lengkap pendidikan kedokteran. ilmu kedokteran anak fkui. jakarta. blank page 128 muhammadiyah journal of nursing abstract background: one of the methods to control blood sugar level within 2 hours after eating in patients with diabetes mellitus is by providing proper insulin injection (proper dose, proper method, proper time and proper location) objective: to determine the eff ective location and time of insulin injection on the control of blood sugar level within 2 hours after eating in patients with diabetes mellitus. method: this is an experimental research with the design of randomized complete block design (rcbd). patients with iddm type of diabetes mellitus in bantul regency became the population in this research; meanwhile the samples used were 60 respondents taken by simple random sampling and they were divided into 4 blocks. the respondents were injected by using analogue type insulin with daily dose on four sites (abdominal, deltoid, thighs, gluteus) and time of the provision (0, 10, 20 and 30 minutes before eating). the blood sugar level within two hours after eating was measured by using a glucometer. result: the result of the analysis of two-way anova and tukey hsd indicates that there is a diff erence in blood sugar level within two hours after eating in patients with diabetes mellitus to whom insulin injection is performed on abdominal, deltoid, thigh and gluteus location (p= 0.000). there is a diff erence in blood sugar level within two hours after eating in patients with diabetes mellitus to whom insulin injection is performed within 0,10,20 and 30 minutes before eating (p= 0.000). the most eff ective location and time for insulin injection is in the abdomen in 0 minutes before eating. conclusion: insulin injection which is performed on abdominal location in 0 minute is eff ective to control blood sugar level within two hours after eating keywords: location, time, insulin injection efektifi vitas lokasi dan waktu injeksi insulin terhadap pengendalian kadar gula darah 2 jam setelah makan pada penderita diabetes melitus agus santosa, elsye maria rosa universitas muhammadiyah yogyakarta aguscakepp@gmail.com pendahuluan menurut survei yang dilakukan who, indonesia menempati urutan ke-4 dengan jumlah penderita terbesar di dunia setelah india, cina, dan amerika (maulana, 2012). menurut kementrian kesehatan ri (2012), jumlah penderita diabetes melitus di indonesia diperkirakan mengalami peningkatan dari 8,4 juta jiwa pada tahun 2000 menjadi sekitar 21,3 juta jiwa pada tahun 2030 mendatang. diabetes mellitus jika tidak dikelola dengan baik akan dapat mengakibatkan terjadinya berbagai penyulit menahun, seperti penyakit serebro-vaskuler, penyakit jantung coroner, penyakit pembuluh darah tungkai, penyulit pada mata, ginjal dan syaraf (suyono, et al, 2011). berbagai studi yang telah ada menemukan, bahwa penyandang diabetes tipe 1 dan tipe 2 yang menjaga kadar glukosa plasma rata-rata tetap rendah menunjukkan insiden komplikasi mikrovaskuler berupa timbulnya retinopati diabetik, nefropati, dan neuropati yang lebih rendah dibandingkan dengan penderita yang tidak menjaga kadar glukosa plasma rata-rata tetap rendah (perkumpulan endokrinologi indonesia, 2011). oleh karena itu mengendalikan kadar gula darah pada penderita diabetes sangat penting dilakukan, jika kadar gula darah dapat selalu dikendalikan dengan baik, diharapkan semua penyulit menahun tersebut dapat dicegah. salah satu cara mengendalikan kadar gula darah 2 jam setelah makan pada penderita diabetes melitus adalah dengan memberikan injeksi insulin yang benar: benar dosis, benar cara, benar waktu dan benar lokasi, (thahir, 2008). kesalahan dalam penyuntikan insulin 129 muhammadiyah journal of nursing oleh petugas medis ataupun oleh penderita itu sendiri seringkali dijumpai, studi mencatat kesalahan tersebut sebanyak 12-34% (hendrata, 2010). beberapa pendapat menyatakan, insulin diberikan sesaat sebelum makan, hal ini dilakukan karena insulin bekerja lebih baik ketika glukosa dari makanan mulai memasuki darah. para ahli menyarankan untuk menyuntik sebelum makan atau sekitar 20-30 menit sebelum makan (bararah, 2010). teori lain menyebutkan insulin akan bekerja paling cepat saat disuntikkan di perut, yaitu di atas atau daerah samping pusar, insulin akan masuk ke sistem tubuh sedikit lebih lama jika disuntikkan pada lengan atas, lebih lambat lagi jika disuntikkan di kaki atau paha dan paling lambat ketika disuntikkan di bokong (misnadiarly, 2006). perawat atau petugas kesehatan juga lebih sering melakukan penyuntikan pada dareah lengan, padahal tidak dianjurkan untuk menyuntikkan insulin di tempat yang sama setiap waktu, karena akan muncul jaringan parut yang dapat mempengaruhi penyerapan insulin (bararah, 2010). bila muncul jaringan parut maka penyerapan insulin terpengaruh, sehingga pengendalian kadar gula darah 2 jam setelah makan menjadi buruk dan komplikasi diabetes akan mungkin terjadi. berdasar uraian-uraian permasalahan pada latar belakang di atas, maka penting untuk melakukan penelitian terhadap lokasi dan waktu injeksi insulin yang efektif terhadap pengendalian kadar gula darah 2 jam setelah makan pada penderita diabetes mellitus. manfaat diketahuinya lokasi dan waktu yang efektif dalam mengendalikan kadar gula darah 2 jam setelah makan diharapkan dapat menjadi acuan standar operasional prosedur tentang pemberian injeksi insulin pada penderita diabetes melitus. metode penelitian ini merupakan eksperimental dengan desain randomized complete block design (rcbd). populasi dalam penelitian ini adalah penderita diabetes melitus tipe iddm di kabupaten bantul. sampel yang digunakan sampel yang digunakan berjumlah 60 responden diambil secara simple random sampling dan dibagi ke dalam 4 blok (dahlan, 2010 dan sugiyono 2007) variabel bebas dalam penelitian ini terdiri dari lokasi injeksi (abdomen, deltoid, paha, gluteus) dan waktu injeksi (0, 10, 20 dan 30 menit sebelum makan), sedangkan variabel terikatnya adalah kadar gula darah 2 jam setelah makan. setelah variabel peracu dikendalikan (diet, aktifi tas, terapi oral, jenis dan dosis insulin), kemudian responden diberikan perlakuan injeksi insulin dengan menggunkan jenis insulin rapid-acting sesuai dosis harian, di empat lokasi (abdomen, deltoid, paha, gluteus) dan waktu pemberian (0, 10, 20 dan 30 menit sebelum makan). variabel kadar gula darah 2 jam setelah makan diukur menggunakan glucometer. analisis yang digunakan untuk melihat nilai rata-rata (mean) dan distribusi frekuensi kadar gula darah 2 jam setelah makan pada tiap-tiap lokasi injeksi dan pada tiap-tiap waktu injeksi digunakan statistika deskriptif. analisis yang digunakan untuk mengetahuan adanya perbedaan kadar gula darah 2 jam setelah makan pada tiap lokasi dan waktu injeksi dalam penelitian ini menggunakan analisis statistik parametris two-way anova. sedangkan untuk mengetahui lokasi dan waktu mana yang paling efektif untuk pengendalian kadar gula darah 2 jam setelah makan, maka dilanjutkan dengan uji lanjut post hoc analysis dengan rumus tukey hsd (suwanda, 2011). hasil rata-rata kadar gula darah 2 jam setelah makan penderita diabetes mellitus yang dilakukan injeksi insulin di lokasi abdomen pada waktu 0 menit adalah 133.2 (±18.2), pada waktu 10 menit sebesar 141.4 (±12.5), pada waktu 20 menit adalah 166.5 (±10.2) dan pada waktu 30 menit sebelum makan sebesar 183.8 (±7.1) (tabel 1). distribusi frekuensi 130 muhammadiyah journal of nursing kadar gula darah terendah terdapat pada kelompok responden dengan waktu penyuntikan 0 menit sebelum makan, sebagian besar berkisar pada 120-140 mg/dl, dan distribusi frekuensi kadar gula darah tertinggi pada kelompok responden dengan waktu penyuntikan 30 menit sebelum makan, sebagian besar berkisar pada 180-200 mg/ dl. trenline pada grafi k menunjukkan adanya trend kenaikan kadar gula darah tiap kenaikan interval waktu penyuntikan (gambar 1). rata-rata kadar gula darah 2 jam setelah makan penderita diabetes mellitus yang dilakukan injeksi insulin di lokasi deltoid pada waktu 0 menit adalah 151.3 (±13.5), pada waktu 10 menit sebesar 161.5 (±12.9), pada waktu 20 menit adalah 184.8 (±11.6) dan pada waktu 30 menit sebelum makan sebesar 200.1 (±7.9) (tabel 1). distribusi frekuensi kadar gula darah terendah terdapat pada kelompok responden dengan waktu penyuntikan 0 menit sebelum makan, sebagian besar berkisar pada 140-160 mg/dl dan distribusi frekuensi kadar gula darah tertinggi tetap pada kelompok responden dengan waktu penyuntikan 30 menit sebelum makan, sebagian besar berkisar pada 200-220 mg/dl. trenline pada grafi k juga memperlihatkan adanya kenaikan kadar gula darah tiap kenaikan interval waktu penyuntikan (gambar 1). rata-rata kadar gula darah 2 jam setelah makan penderita diabetes mellitus yang dilakukan injeksi insulin di lokasi paha pada waktu 0 menit adalah 172.8 (±21.0), pada waktu 10 menit sebesar 179.2 (±15.5), pada waktu 20 menit adalah 205.6 (±14.3) dan pada waktu 30 menit sebelum makan sebesar 244.1 (±8.8) (tabel 1). distribusi frekuensi kadar gula darah terendah terdapat pada kelompok responden dengan waktu penyuntikan 0 menit sebelum makan, sebagian besar berkisar pada 160-180 mg/dl dan distribusi frekuensi kadar gula darah tertinggi tetap pada kelompok responden dengan waktu penyuntikan 30 menit sebelum makan, sebagian besar berkisar pada 240-260 mg/dl. trenline pada grafi k juga memperlihatkan adanya kenaikan kadar gula darah tiap kenaikan interval waktu penyuntikan (gambar 1). rata-rata kadar gula darah 2 jam setelah makan penderita diabetes mellitus yang dilakukan injeksi insulin di lokasi gluteus pada waktu 0 menit adalah 186.0 (±21.9), pada waktu 10 menit sebesar 197.5 (±14.8), pada waktu 20 menit adalah 228.6 (±15.2) dan pada waktu 30 menit sebelum makan sebesar 255.3 (±9.1) (tabel 1). distribusi frekuensi kadar gula darah terendah terdapat pada kelompok responden dengan waktu penyuntikan 0 menit sebelum makan, sebagian besar berkisar pada 180-200 mg/dl dan distribusi frekuensi kadar gula darah tertinggi tetap pada kelompok responden dengan waktu penyuntikan 30 menit sebelum makan, sebagian besar berkisar pada 250-270 mg/dl. trenline pada grafi k juga memperlihatkan adanya kenaikan kadar gula darah tiap kenaikan interval waktu penyuntikan (gambar 1). tabel 1. rata-rata kadar gula darah 2 jam setelah makan pada penderita diabetes mellitus pada lokasi injeksi abdomen, deltoid, paha dan gluteus pada waktu 0, 10, 20 dan 30 menit sebelum makan lokasi waktu kadar gula darah 2 jam n (60) mean (sd) abdomen 0 menit 133.2 18.2 15 10 menit 141.4 12.5 15 20 menit 166.5 10.2 15 30 menit 183.8 7.1 15 deltoid 0 menit 151.3 13.5 15 10 menit 161.5 12.9 15 20 menit 184.8 11.6 15 30 menit 200.1 7.9 15 paha 0 menit 172.8 21.0 15 10 menit 179.2 15.5 15 20 menit 205.6 14.3 15 30 menit 244.1 8.8 15 gluteus 0 menit 186.0 21.9 15 10 menit 197.5 14.8 15 20 menit 228.6 15.2 15 30 menit 255.3 9.1 15 131 muhammadiyah journal of nursing gambar 1. grafi k distribusi frekuensi dan trendline kadar gula darah 2 jam setelah makan penderita diabetes mellitus pada lokasi injeksi abdomen, deltoid, paha dan gluteus pada waktu 0, 10, 20 dan 30 menit sebelum makan analisis multivariat dalam penelitian ini menemukan ada perbedaan kadar gula darah 2 jam setelah makan penderita diabetes mellitus yang dilakukan injeksi insulin di lokasi abdomen, deltoid, paha dan gluteus (nilai p=0.000). (tabel 2). lokasi paling efektif untuk injeksi insulin adalah pada abdomen. (tabel 3) ada perbedaan kadar gula darah 2 jam setelah makan penderita diabetes mellitus yang dilakukan injeksi insulin pada waktu 0, 10, 20 dan 30 menit sebelum makan (nilai p=0.000). (tabel 4). waktu paling efektif untuk injeksi insulin adalah pada waktu 0 menit atau bersamaan dengan makan (tabel 5) tabel.2. perbedaan kadar gula darah 2 jam setelah makan pada lokasi injeksi abdomen, deltoid, paha dan gluteus lokasi n mean (sd) f nilai p abdomen 60 156.2 23.7 77.759 0.000 deltoid 60 174.4 22.4 paha 60 200.4 32.1 gluteus 60 216.8 31.4 ket: berdasar uji two-way anova test 132 muhammadiyah journal of nursing tabel.3. multiple comparison efektifi tas pengendalian kadar gula darah 2 jam setelah makan penderita diabetes mellitus pada lokasi injeksi abdomen, deltoid, paha dan gluteus variabel mean diff erence (i-j) nilai p(i) lokasi injeksi (j) lokasi injeksi abdomen deltoid -18.2167 0.000 paha -44.2167 0.000 gluteus -60.6167 0.000 deltoid abdomen 18.2167 0.000 paha -26.0000 0.000 gluteus -42.4000 0.000 paha abdomen 44.2167 0.000 deltoid 26.0000 0.000 gluteus -16.4000 0.000 gluteus abdomen 60.6167 0.000 deltoid 42.4000 0.000 paha 16.6167 0.000 ket: berdasar uji tukey hsd test tabel.4. perbedaan kadar gula darah 2 jam setelah makan pada waktu injeksi 0, 10, 20 dan 30 menit sebelum makan waktu n mean (sd) f nilai p 0 menit 60 160.8 27.5 79.023 0.000 10 menit 60 169.9 25.0 20 menit 60 196.4 26.5 30 menit 60 220.8 31.0 ket: berdasar uji two-way anova test tabel. 5. multiple comparison efektifi tas pengendalian kadar gula darah 2 jam setelah makan penderita diabetes mellitus pada waktu injeksi 0, 10, 20 dan 30 menit sebelum makan variabel mean diff erence (i-j) nilai p(i) waktu injeksi (j) waktu injeksi 0 menit 10 menit -9.1000 0.003 20 menit -35.5833 0.000 30 menit -60.0333 0.000 variabel mean diff erence (i-j) nilai p(i) waktu injeksi (j) waktu injeksi 10 menit 0 menit 9.1000 0.003 20 menit -26.4833 0.000 30 menit -50.9333 0.000 20 menit 0 menit 35. 5833 0.000 10 menit 26.4833 0.000 30 menit -24.4500 0.000 30 menit 0 menit 60.0333 0.000 10 menit 50.9333 0.000 20 menit 24.4500 0.000 ket: berdasar uji tukey hsd test pembahasan karakteristik responden dalam penelitian ini adalah pasien dengan insulin dependent diabetes mellitus (iddm) distribusi terbanyak adalah responden laki-laki yakni sebanyak 33 orang (55%) dan sisanya sebanyak 27 orang (45%) adalah perempuan, dengan usia seluruhnya di atas 40 tahun dan lama menderita penyakit diabetes mellitus sebagian besar >10 tahun (25.8%) dengan rata-rata 12.9 tahun. pasien dengan diabetes mellitus t2 yang telah 8 tahun lebih sejak terdiagnosa maka ia sudah masuk dalam diabetes mellitus t2 fase iii, diabetes mellitus t2 fase iii ini ditandai dengan fungsi sel beta pangkreas yang hanya <25% sehingga produksi insulin jauh sangat kurang sehingga untuk mencukupinya pasien harus menggunkan insulin dari luar, dengan kata lain pasien tersebut tergantung insulin atau insulin dependent diabetes mellitus (lebovitz , 2000). jenis insulin yang digunakan dalam penelitian ini adalah jenis rapid–acting insulin. sedangkan dosis insulin harian yang diperoleh responden dari dokter sebagian besar (65%) adalah < 8 unit, dengan rata-rata 8.3 unit. peneliti menggunakan insulin jenis rapid–acting insulin karena yang sekarang lebih banyak digunakan di masyarakat ataupun di rumah sakit. insulin analog merupakan jenis insulin yang baik karena memiliki profi l 133 muhammadiyah journal of nursing sekresi yang sangat mendekati pola sekresi insulin normal atau fi siologis (rismayanthi, 2011). hasil analisis univariat menunjukkan terjadi peningkatan kadar gula darah 2 jam setelah makan pada tiap-tiap lokasi dan waktu injeksi insulin. rata-rata kadar gula darah terendah yaitu pada lokasi injeksi di abdomen, kemudian diikuti pada lokasi injeksi deltoid, lebih meningkat lagi bila di injeksi dilokasi paha, dan kadar gula darah 2 jam tertinggi pada lokasi gluteus. pada variabel waktu injeksi menunjukkan rata-rata kadar gula darah terendah pada waktu injeksi 0 menit, kemudian diikuti pada waktu 10 menit, lebih meningkat lagi bila di pada waktu 20 menit, dan kadar gula darah 2 jam tertinggi pada waktu penyuntikan 30 menit sebelum makan. keadaan normal, insulin dalam tubuh akan meningkat seiring dengan konsumsi makanan dan akan kembali normal dalam 2 jam setelah makan (suckale dan solimena, 2008). insulin akan bekerja paling cepat saat disuntikkan ke perut. insulin akan masuk ke sistem tubuh sedikit lebih lama jika disuntikkan pada lengan atas. lebih lambat lagi jika disuntikkan di kaki atau paha dan paling lambat ketika disuntikkan di bokong (misnadiarly, 2006). responden yang dilakukan injeksi insulin di lokasi abdomen pada 0 menit atau bersamaan dengan makan, maka insulin akan cepat diserap oleh tubuh dan akan bekerja sejalan dengan meningkatnya kadar gula darah akibat proses metabolisme pencernaan tubuh serta akan sama-sama kembali normal 2 jam sesudahnya. bila dilakukan pengunduran penyuntikan akan menyebabkan insulin lebih dulu bekerja dan tidak sejalan dengan peningkatan kadar gula darah akibat proses metabolisme pencernaan tubuh, akibat lebih dulu insulin bekerja, maka ia akan lebih dulu pula akan kembali normal dibandingkan kadar gula darah, sehingga kadar gula darah akan sedikit lebih tinggi pada 2 jam setelah makan. peneliti menganalisis bukan hanya cepat atau lambatnya penyerapan insulin pada tiap lokasi, namun juga karena adanya “penurunan” penyerapan insulin oleh tubuh bila dengan 8.3 u insulin (rata-rata pengunaan insulin dalam penelitian ini) dapat menurunkan kadar gula darah tersebut ke normal yaitu 133,2 mg/dl saat penyuntikan di lokasi abdomen pada 0 menit yang masuk kategori “baik”, dan penyuntikan yang dilakukan di deltoid dengan waktu dan dosis yang sama menghasilkan nilai rata-rata kadar gula darah sebesar 151,3 mg/dl dan masuk dalam kategori “sedang”, sehingga ada kenaikan gula darah sebesar 18 mg/dl. peneliti menyimpulkan penyuntikan pada lokasi abdomen pada 0 menit, insulin dapat diserap sempurna atau 100% sehingga menghasilkan kadar gula darah yang “baik”, dan bila di suntikkan di deltoid maka dengan perhitungan peneliti menyimpulkan adanya penurunan penyerapan insulin sebesar ±23% (18/100x133) oleh tubuh, sehingga terjadi peningkatan kadar gula darah. begitu pula penyuntikan yang dilakukan di lokasi paha pada waktu 0 menit didapatkan nilai rata-rata kadar gula darah yang lebih tinggi yaitu 172,8 mg/dl yang masuk dalam kategori pengendalian diabetes mellitus “sedang”, sehingga terjadi peningkatan sebesar 41 mg/dl (172-133) bila dibandingkan dengan penyuntikan di abdomen pada waktu yang sama. peneliti menyimpulkan penyuntikan di lokasi paha, terjadi penurunan penyerapan insulin sebesar ±51% (41/100x133) oleh tubuh sehingga meningkatkan kadar gula darah 2 jam setelah makan. penyuntikan yang dilakukan di lokasi gluteus pada waktu 0 menit didapatkan nilai rata-rata kadar gula darah yang sangat tinggi yaitu 186,0 mg/dl yang masuk dalam kategori pengendalian diabetes mellitus “buruk”, sehingga ada peningkatan kadar gula darah sebesar 53 mg/dl (186-133) bila dibandingkan dengan penyuntikan di abdomen dengan waktu yang sama. peneliti menyimpulkan, penyuntikan di lokasi gluteus terjadi penurunan penyerapan insulin sebesar 134 muhammadiyah journal of nursing ±70% (53/100x133) dari tubuh sehingga meningkatkan kadar gula darah 2 jam setelah makan. analisis perbedaan pada variabel lokasi dalam penelitian ini menemukan adanya perbedaan yang signifi kan kadar gula darah 2 jam setelah makan penderita diabetes mellitus baik yang dilakukan injeksi insulin di lokasi abdomen, deltoid, paha maupun gluteus (f=77.759, p=0.000). pada hasil analisis multiple comparison menunjukkan penyuntikan di lokasi abdomen secara signifi kan lebih efektif mengendalikan kadar gula darah 2 jam setelah makan pada penderita diabetes mellitus dibandingkan dengan penyuntikan di lokasi deltoid, paha maupun gluteus. sebuah penelitian yang meneliti mengenai efek anatomi regional yang digunakan untuk injeksi insulin terhadap glukosa darah pada pasien diabetes tipe i yang menggunakan dua tempat injeksi yaitu perut dan paha, menyimpulkan injeksi insulin yang dilakukan di subkutan pada lokasi abdomen menghasilkan pengurangan substansial lebih besar pada glukosa plasma dibandingkan suntikan insulin di lokasi paha. mengubah tempat suntikan insulin dari perut ke paha itu efeknya setara dengan mengurangi dosis insulin yang diberikan (bantle, et al, 1993). hasil analisis perbedaan pada variabel waktu dalam penelitian ini juga menemukan adanya perbedaan yang signifi kan kadar gula darah 2 jam setelah makan penderita diabetes mellitus baik yang dilakukan injeksi insulin pada waktu 0, 10, 20 dan 30 menit sebelum makan (f=79.023, p=0.000). hasil analisis multiple comparasi menunjukkan penyuntikan pada waktu 0 menit atau bersamaan dengan makan secara signifi kan lebih efektif mengendalikan kadar gula darah 2 jam setelah makan penderita diabetes mellitus dibandingkan dengan penyuntikan pada waktu 10, 20 dan 30 menit sebelum makan. pemberian insulin eksogen diupayakan semaksimal mungkin menyerupai produksi insulin alamiah pada orang yang sehat (syam, 2008). insulin analog jenis rapid–acting insulin merupakan jenis insulin yang baik, karena memiliki profi l sekresi yang sangat mendekati pola sekresi insulin normal atau fi siologis (rismayanthi, 2011). insulin yang digunakan dalam penelitian ini adalah jenis insulin rapid– acting insulin yang disebut juga insulin analog, sehingga pemilihan insulin dalam penelitian ini dirasa tepat, karena jenis dan cara kerja insulin yang dipakai sangat mendekati pola sekresi insulin normal atau fi siologis. insulin jenis rapid–acting insulin memiliki penyerapan di subkutan yang lebih cepat, puncak kerja yang lebih singkat dan tinggi serta masa kerja yang juga lebih singkat, sehingga waktu pemberian menjadi lebih dekat dengan waktu makan, dan bahkan dapat diberikan saat makan. (suyono, et al, 2011 dan sucipto, 2008). teoriteori tersebut sesuai dengan temuan yang didapat dalam penelitian ini, di mana penyuntikan yang dilakukan bersamaan dengan makan atau 0 menit paling efektif untuk mengendalikan kadar gula darah 2 jam setelah makan, dibandingkan penyuntikan dengan waktu yang lain yaitu 10, 20 dan 30 menit sebelum makan. hasil penelitian ini sesuai dengan hasil penelitian yang dipublikasikan medsafe, menemukan, injeksi insulin jenis novorapid (0,15 u / kg) segera sebelum makan lebih efektif dalam penurunan kadar gula darah dibandingkan dengan penyuntikan 30 menit sebelum makan (medsafe, 2012). penelitian yang menggunakan variabel waktu untuk menyuntikan insulin sebagai pengendalian diabetes juga pernah dilakukan. penelitian tersebut bertujuan untuk mengetahui hubungan antara waktu penyuntikan insulin dengan pengendalian metabolik pada penderita diabetes tipe 2. sebanyak 74 pasien dilibatkan dalam penelitian, jenis insulin yang digunakan adalah insulin regular/nph insulin. hasil yang didapatkan adalah rata-rata pasien menyuntikkan insulin 24 menit sebelum makan (dengan rentang antara 1 sampai 95 menit). hasil analisis mendapatkan, 135 muhammadiyah journal of nursing pasien yang menyuntikkan insulin ≤15 menit sebelum makan (n=30) pengendalian metabolinya lebih baik dan signifi kan dibandingkan dengan pasien yang menyuntikkan insulin >15 menit sebelum makan (n=34) (hba1c 7.8±1.3% dan 9.8±1.6%, p<0.001) (czupryniak, et al, 2000). kesimpulan 1. lokasi injeksi insulin yang paling efektif untuk mengendalikan kadar gula darah 2 jam setalah makan pada penderita diabetes melitus adalah di lokasi abdomen. 2. waktu injeksi insulin yang paling efektif untuk mengendalikan kadar gula darah 2 jam setalah makan pada penderita diabetes melitus adalah pada waktu 0 menit atau bersamaan dengan makan. saran pemberian injeksi insulin agar memperhatikan lokasi penyuntikan. lokasi penyuntikan insulin disarankan dilakukan pada lokasi abdomen karena lebih efektif dalam mengendalikan kadar gula darah 2 jam setelah makan, mengubah lokasi injeksi insulin dari abdomen ke lokasi lain sama halnya dengan mengurangi dosis insulin yang diberikan. pemberian injeksi insulin agar memperhatikan dan mempertahankan waktu injeksi. waktu injeksi insulin sebaiknya diberikan pada 0 menit atau bersamaan dengan makan, menunda waktu penyuntikan (10, 20, 30 menit sebelum makan atau lebih) akan menyebabkan kerja insulin tidak bersamaan dengan metabolisme tubuh. daftar pustaka bantle, j.p., neal, l., frankamp, l.m., 1993, eff ects of the anatomical region used for insulin injections on glycemia in type i diabetes subjects. diabetes case, volume 16, number 12, december 1993 czupryniak, l., ruxer, j., wolska, m.s., kropiwnicka, a., drzewoski, j.,at all. 2000, eff ect of time interval between insulin injection and meal ingestion on metabolic control in type 2 diabetes mellitus. department of metabolic diseasesand gastroenterology, medical university of lodz, l.odz, poland. abstrak. diakses tanggal 11 juli 2012 dari: htt p://hinari-gw. who.int dahlan, s. 2010, besar sampel dan cara pengambilan sampel dalam penelitian kedoteran dan kesehatan, salemba medika, jakarta. bararah, v.f. 2010, cara suntik insulin diabetes yang tepat. detik health. jakarta. diakses tanggal 11 juli 2012 dari: htt p://health. detik.com/read/2010/08/31/151759/143205 9/766/cara-suntik-insulin-diabetes-yangtepat hendrata, m.i. 2010, injection technique workshop on the 19th jakarta diabetes meeting. jakarta. diakses tanggal 17 juli 2012 dari: htt p://www.tanyadok. com/acara/2010/11/injection-techniqueworkshop-on-the-19th-jakarta-diabetesmeeting/ kementerian kesehatan republik indonesia. 2012, tahun 2030 prevalensi diabetes melitus di indonesia mencapai 21,3 juta orang. jakarta. diakses tanggal 14 febuari 2013 dari: htt p://www.depkes.go.id/index. php/berita/press-release/414-tahun-2030prevalensi-diabetes-melitus-di-indonesiamencapai-213-juta-orang.html lebovitz , h.e. 2000, insulin resistance: defi nition and consequence. exp. clin. endocrinology diabetes maulana, m. 2012, mengenal diabetes melitus panduan praktis menangani penyakit kencing manis, kata hati, jogjakarta. misnadiarly, 2006, diabetes mellitus, gangren, ulcer, infeksi, mengenali gejala menanggulangi mencegah komplikasi. 136 muhammadiyah journal of nursing pustaka populer obor, jakarta. perkumpulan endokrinologi indonesia, 2011, konsensus pengelolaan dan pencegahan diabetes melitus tipe 2, jakarta. rismayanthi, c., 2011, terapi insulin sebagai alternatif pengobatan bagi penderita diabetes. abstrak. diakses tanggal 3 febuari 2014 dari: htt p://staff .uny. a c . i d / s i t e s / d e f a u l t / f i l e s / p e n e l i t i a n / c e r i k a % 2 0 r i s m a y a n t h i , % 2 0 s . o r . / terapi%20insulin%20sebagai%20 alternatif%20pengobatan.pdf suckale, j., & solimena, m., 2008, pancreas islets in metabolic signaling focus on the β-cell. precedings nature. diakses tanggal 5 desember 2012 dari: htt p://precedings. nature.com/documents/1724/version/2/ fi les/npre20081724-2.pdf sugiyono, 2007, statistika untuk penelitian, alfabeta, bandung suwanda. 2011, desain eksperimen untuk penelitian ilmiyah, alfabeta, bandung suyono, s., waspadji, s., soegondo, s., soewondo, p., subekti, i., semiardji, g., edi, t.j., dkk. 2011, penatalaksanaan penyakit diabetes melitus terpadu. edisi kedua, fkui, jakarta. thahir, m.r., 2008, pompa insulin, alat mutakhir untuk penderita diabetes mellitus, demedia, jakarta. syam a. f. 2008, pemberian insulinyang tepat, terhindar dari komplikasi. fakultas kedokteran universitas indonesia, jakarta. sucipto, k.w. 2008, jenis, kerja dan pemakaian insulin. fakultas kedokteran unsyiah, banda aceh. medsafe . 2012, novorapid novomix injection presentation. new zaeland data sheet. cas no: 116094-23-6. diakses tanggal 3 febuari 2014 dari htt p://www. m e d s a f e . g o v t . n z / p r o f s / d a t a s h e e t / n / novorapidnovomixinj.pdf blank page 66 muhammadiyah journal of nursing abstract general appearance of weakness, skinny, high blood pressure, anemia, itches, darkness skin color and nausea showing inadequate hemodialysis clinically. based on literature review there are some factors directly infl uencing on adequate hemodialysis, one of them is dialyzer surface area. the research aimed to study the eff ect of dialyzer surface area on dialysis adequacy on hemodialysis patient in pku muhammadiyah hospital yogyakarta from may until june 2013. cross sectional study was done involving 90 respondents through purposive sampling method. the hemodialysis adequacy counted by kt/v formula. data was taken during the second session of hemodialysis. the data were examined with kruskal wallis. mean dialysis adequacy was 1,36±0,377. the statistic test result revealed no signifi cant correlation on dialyzer surface area with dialysis adequacy (p=0.880). key words: adequacy, dialyzer, hemodialysis nur chayati,1 kusman ibrahim,2 maria komariah2 1program studi ilmu keperawatan, universitas muhammadiyah yogyakarta email: n_cha_klt@yahoo.com 2fakultas keperawatan, universitas padjadjaran, bandung pendahuluan pada tahun 1998 jumlah pasien hemodialisis di indonesia sekitar 3000 orang dan di tahun 2007 jumlah penderita naik menjadi 10.000 orang (gatot, 2003; kresnawan, 2007). terapi dialisis tidak bertujuan untuk menyembuhkan pasien tetapi untuk memperpanjang harapan hidup pasien (convenor, 2005; zadeh sebagaimana dikutip dalam abbas et al, 2009). untuk mencapai tujuan tersebut, maka proses dialisis yang dilakukan harus efektif (borzou et al, 2009). evaluasi terhadap keefektifan terapi dialysis dinyatakan sebagai adekuasi dialysis yang dihitung dengan rumus kt/v atau urr. dialisis yang adekuat berdampak pada kualitas hidup dan rata-rata kelangsungan hidup pasien, tingkat morbiditas dan mortalitas pasien, besarnya biaya perawatan serta frekuensi hospitalisasi pasien (gorman et al, 2006; maoujud et al, 2012). tingkat morbiditas, mortalitas, frekuensi hospitalisasi, lama rawat di rumah sakit dan kualitas hidup menjadi indikator mutu pelayanan ruang hemodialysis, yang termasuk ruang perawatan intensif dan pasien dengan kondisi kritis. amini et al (2011) menyatakan bahwa faktor yang paling berpengaruh terhadap nilai kt/v dan urr adalah luas permukaan dialyzer. penelitiannya dilakukan secara multicenter study di iran terhadap penggunaan dua jenis dialyzer, yaitu low fl ux dialyzer sebanyak 97,6% pasien dan sisanya 2,4% dengan dialyzer high fl ux. pada pasien hemodialysis 3 kali seminggu selama 4 jam. diperoleh hasil bahwa 56,7% pasien nilai kt/v nya <1,2 (tidak adekuat). nilai kt/v pada pasien dengan low pengaruh luas permukaan dializer terhadap capaian adekuasi dialisis pada penderita haemodialisis di rumah sakit pku muhammadiyah yogyakarta 67 muhammadiyah journal of nursing fl ux dialyzer adalah 1,17 dan kt/v pada high fl ux dialyzer sebesar 1,36. terdapat perbedaan kt/v pada kedua jenis dialyzer yang berbeda tersebut (p<0,05). penelitian ini didukung oleh reid et al (2005) di australia yang meneliti penggunaan dialyzer low fl ux (luas permukaan 1,3 m2-1,8 m2) dan dialyzer high fl ux (luas permukaan 1,8 m2) pada 9 pasien nocturnal hemodialysis terhadap tingkat bersihan β2 mikroglobulin yang diukur pada bulan ke enam, ke dua belas dan ke lima belas. hasilnya menunjukkan bahwa pada penggunaan dialyzer low fl ux, terjadi peningkatan kadar β2 mikroglobulin di bulan ke enam sampai ke lima belas, sedangkan pada dialyzer high fl ux kadar β2 mikroglobulin cenderung menurun pada bulan ke enam dan konstan pada bulan ke dua belas. rumah sakit pku muhammadiyah adalah rumah sakit tipe b. pasien hemodialisis di rumah sakit ini menggunakan beberapa tipe dialyzer yaitu dializer dengan low fl ux low effi ciency dan high fl ux high effi ciency, masing-masing dengan luas permukaan dialyzer yang berbeda yaitu 1,1 m2, 1,3 m2, 1,5 m2 dan 1,8 m2. mengingat pentingnya penilaian adekuasi dialysis, maka peran perawat hemodialisis adalah mengevaluasi efektifi tas proses hemodialisis pada penggunaan keempat jenis luas hemodializer tersebut. penelitian ini bertujuan untuk menganalisis pengaruh luas permukaan dialyzer (1,1 m2, 1,3 m2, 1,5 m2 dan 1,8 m2) terhadap pencapaian adekuasi dialisis pada pasien di unit hemodialisis rumah sakit pku muhammadiyah yogyakarta. secara teoritis, hasil penelitian ini diharapkan dapat menambah pengetahuan tentang hubungan luas permukaan dializer terhadap adekuasi dialysis yang harus menjadi perhatian tenaga kesehatan dalam terapi hemodialysis. dalam aplikasi praktis klinis, penelitian ini dapat meningkatkan pengetahuan dan aplikasi dalam praktik klinik penatalaksanaan pasien hemodialysis melalui sosialisasi kepada perawat ruangan dan pihak rumah sakit guna mencapai adekuasi dialysis yang optimal, meningkatkan peran perawat khususnya perawat hemodialisis sebagai advokasi bagi pasien dengan memberikan saran dan pertimbangan kepada pasien tentang faktor yang harus dioptimalkan untuk mencapai adekuasi dialisis dan peran kolaborasi antara perawat dan dokter dengan memberikan masukan dan saran kepada tim medis tentang kondisi pasien dan upaya yang bisa dilakukan untuk memberikan pelayanan yang lebih berkualitas bagi pasien. hasil penelitian ini diharapkan pula dapat menjadi masukan bagi pembuat kebijakan di rumah sakit dengan mensosialisasikan hasil temuan penelitian yang sudah dilakukan untuk menentukan standar operating prosedure yang tetap guna melakukan pengukuran adekuasi dialisis secara rutin di unit hemodialisis. tinjauan pustaka hemodialisis merupakan salah satu terapi pengganti ginjal buatan yang bertujuan untuk membuang sisa-sisa produk metabolisme (protein) dan mengoreksi gangguan keseimbangan cairan dan elektrolit antara kompartemen darah dan cairan dialisat melalui membran semipermeabel dalam dializer yang berperan sebagai ginjal buatan melalui proses difusi (o’callaghan, 2009; thomas, 2009; yeun et al, 2012). adekuasi dialisis adalah kecukupan jumlah proses dialisis untuk menjaga dan menjamin kondisi optimal dan terbaik pada pasien uremik untuk mencegah komplikasi akibat penumpukan toksin uremik (djarwoto, 2009). ringoir dan vanholder (1992) mendefi nisikan adekuasi adalah kemampuan untuk membersihkan darah dan menyeimbangkan jumlah cairan guna mendekati fungsi ginjal secara normal. adekuasi adalah parameter yang menunjukkan hasil yang optimal pada pasien hemodialisis dengan memaksimalkan sumber-sumber yang tersedia (leypoldt, culleton & cheung, 2010). 68 muhammadiyah journal of nursing berdasarkan yeun et al (2012), beberapa hal yang mempengaruhi bersihan solute selama proses hemodialisis adalah faktor dari membran, faktor dari solute, faktor dari darah dan faktor dari dialisat. faktor dari membran yang diduga mampu meningkatkan bersihan solute adalah dengan meningkatkan porositas membran, meningkatkan luas permukaan membran dan menurunkan ketebalan membran. faktor dari solute terdiri dari berat molekul dan ukuran molekul. faktor dari darah meliputi area dializer yang dialiri darah, serta kecepatan aliran darah, dan faktor dari cairan dialisat, antara lain area dializer yang dialiri cairan dialisat, kecepatan aliran dialisat dan aliran countercurrent dialisat. reid et al (2005) meneliti di australia tentang penggunaan dializer low fl ux (luas permukaan 1,3 m2-1,8 m2) dan dializer high fl ux (luas permukaan 1,8 m2) pada 9 pasien nocturnal hemodialisis terhadap tingkat bersihan β2 mikroglobulin yang diukur pada bulan ke enam, ke dua belas dan ke lima belas. pada penggunaan dializer low fl ux, terjadi peningkatan kadar β2 mikroglobulin di bulan ke enam sampai ke lima belas, sedangkan pada dializer high fl ux kadar β2 mikroglobulin cenderung menurun pada bulan ke enam dan konstan pada bulan ke dua belas. penelitian fritz , doss, mccann, dan wrone (2003), guna meningkatkan luas permukaan dializer digunakan dializer dengan luas permukaan 1,8 m2 yang dirangkai secara single, dirangkai seri dan di rangkai paralel terhadap pencapaian nilai kt/v. hasilnya menunjukkan bahwa dializer yang dirangkai seri atau paralel mampu meningkatkan nilai kt/v sebesar 83% dibanding dializer yang single. antara dializer seri dan paralel, peningkatan nilai kt/v tidak menunjukkan perbedaan yang signifi kan. penggunaan dual dializer juga mampu meningkatkan bersihan molekul dengan ukuran sedang seperti β2 mikroglobulin yang ditunjukkan dengan penurunan kadar β2 mikroglobulin sebesar 34%. hasil tersebut didukung oleh penelitian gatot (2003) yang menggabungkan secara seri dializer dengan luas permukaan 0,9 m2 dan 1,2 m2, dibandingkan dengan dializer 0,9 m2 dan dializer 2,1 m2 secara tunggal. dibuktikan bahwa terdapat perbedaan urr yang bermakna pada dializer 0,90 dibanding dializer 2,10 dan dializer 0,90 dibanding 2 dializer seri 0,90 dengan 1,20. dua dializer seri 0,90 dengan 1,20 dapat meningkatkan adekuasi hemodialisis 26,3% dibanding pemakaian dializer 0,90, dan pemakaian 2 dializer seri 0,90 dengan 1,20 dapat meningkatkan adekuasi sebesar 10,5% dibanding pemakaian dializer 2,10 tunggal. hasil ini menyimpulkan bahwa penggunaan 2 dializer luas permukaan kecil secara seri dapat dipergunakan sebagai pengganti dializer luas permukaan besar tunggal dan lebih menguntungkan untuk meningkatkan keefektifan dialisis. hal serupa dilakukan oleh eloots, de vos, hombrouckx, dan verdonck (2005) yang menggabungkan secara seri dan paralel dializer low fl ux (f6hps) terhadap nilai urr dan clearance vitamin b12 ( middle molecule) pada dua kelompok. diperoleh hasil bahwa penggunaan dializer secara seri dan paralel terbukti mampu meningkatkan clearance dan urr pada kedua kelompok. dari empat penelitian di atas dapat diambil kesimpulan bahwa luas permukaan dializer berkontribusi terhadap pencapaian adekuasi pasien. sukandar (2006) menyatakan bahwa dializer dengan luas permukaan besar (high fl ux) memiliki resistensi terhadap solute dengan berat molekul tinggi lebih rendah dibanding dengan solute berat molekul rendah. dialyzer dengan high effi ciency atau high fl ux memiliki pori-pori yang lebih besar, permeabilitas terhadap air yang lebih tinggi, tingkat absorpsi solute yang lebih besar, dan resistensi terhadap solute rendah (gatot, 2003). dengan ukuran pori-pori yang besar, maka akan lebih banyak 69 muhammadiyah journal of nursing solute dengan berat molekul tinggi yang mampu dieliminasi seperti vitamin b12, β2 mikroglobulin dan lebih banyak air yang mampu dipaksa keluar dari dalam tubuh melalui proses ultrafi ltrasi (nkf-k/doqi, 2000). liangos et al (2002) menyatakan bahwa semakin luas permukaan dializer, maka semakin besar volume fi ber yang ada di dalamnya dan clearance yang dihasilkan akan semakin tinggi. hasil penelitiannya dengan menggunakan dializer sekali pakai menyatakan bahwa volume dializer tidak selalu tetap seperti pertama kali dibuat. rata-rata penurunan volume fi ber tiap jamnya adalah 0,84 ml/h untuk dializer tipe f4 dan 0,67 ml/h untuk dialyzer tipe pan 03 atau 24% (f4) dan 26% (pan 03) untuk keseluruhan sesi dialisis, tetapi berdasarkan hasil analisa data, penurunan volume fi ber ini tidak berhubungan signifi kan dengan penurunan kemampuan dalam membersihkan zat terlarut (small solute clearance). 1) tidak didapatkan komplikasi akibat uremia menurut yeun et al (2012) akibat penumpukan urea di dalam tubuh menyebabkan terganggunya semua sistem organ tubuh. komplikasi yang ditumbulkan antara lain terlihat pada kondisi umum pasien yang lemah, badan kurus, tekanan darah tinggi, anemia, gatal-gatal di kulit, warna kulit menjadi lebih gelap, mual. 2) rehabilitasi optimal yang berhubungan dengan aspek kehidupan pribadi, keluarga dan profesi menurut martin dan thomps (2001) bahwa perhatian dan pengkajian pada status psikososial menjadi bagian integral pada pengobatan pasien gagal ginjal. mekanisme pertahanan diri seperti denial atau menolak berpengaruh negatif pada persepsi pasien tentang penyakitnya sehingga memperlama proses adaptasi pasien terhadap penyakit kronis yang dideritanya. 3) kualitas hidup optimal kualitas hidup menurut who adalah suatu kondisi kesempurnaan baik fi sik, mental dan kesejahteraan dan tidak hanya terbebas dari penyakit atau kelemahan. kualitas hidup yang berhubungan dengan kesehatan secara spesifi k berfokus pada pengaruh kesehatan, penyakit dan pengobatan medis terhadap kualitas hidup. pengkajian kualitas hidup bermanfaat dalam meningkatkan komunikasi antara pasien dan tenaga kesehatan dan mengkaji kebutuhan pasien seperti memahami kebutuhan pasien akan perawatan secara mandiri sehingga kita bisa menyediakan alat bantu, penggunaan struktur program rehabilitasi atau merujuk ke tempat lain yang sesuai. manfaat lain adalah mampu meningkatkan kepuasan pasien (chang & tamura, 2009). menurut sukandar (2006) kriteria klinik adekuasi dialisis diatas sulit untuk dicapai karena banyak faktor yang mempengaruhi seperti integrated hemodialysis prescription dan status sosial. integrated hemodialysis prescription adalah peresepan hemodialisis yang terintergrasi pada semua aspek guna menjamin eliminasi toksin selama terapi hemodialisis. hal ini sulit dilakukan pada pasien hemodialisis di indonesia karena biaya yang cukup besar dan adanya faktor penyulit lain. faktor penyulit tersebut antara lain adanya penyakit kardiovaskuler yang menyertai, amyloidosis, anemia, osteodistrofi azotemik, gangguan imunologi dan sindrom malnutrisi. rekomendasi nkf-k/doqi (2000) bahwa penilaian adekuasi dialisis dapat dilakukan dengan menghitung volume penghilangan urea. ada dua rumus yang dapat dipakai, yaitu urr (urea reduction ratio) dan kt/v. kt/v adalah pengukuran standar dan paling terkenal untuk menilai adekuasi dialisis. geddes, traynor, walbaum, fox, dan mactier (2000) menyatakan bahwa kt/v menjadi metode pilihan untuk 70 muhammadiyah journal of nursing mengukur dosis dialisis karena lebih akurat menunjukkan bersihan urea, bisa dipakai untuk mengkaji status nutrisi pasien dengan memungkinkan penghitungan katabolisme protein yang dinormalisir, dan dapat digunakan untuk pendosisan dialisis bagi pasien yang memiliki fungsi sisa ginjal. untuk penilaian adekuasi hemodialisis, rumus yang dianjurkan oleh nkf-k/doqi adalah single-pool kt/v (sp kt/v). kt/v = -ln (r0,008 x t) + (4-3,5 x r) x uf/w dimana: ln : adalah logaritma natural r : adalah bun (blood ureum nitrogen) post dialisis dibagi bun pre dialysis t : adalah lama waktu dialisis dalam jam uf : adalah volume ultrafi ltrasi dalam liter w : adalah berat badan pasien dalam kilogram post dialisis kt/v minimum yang harus dicapai adalah 1,2 dengan urr 65%, tetapi nilai urr 65% belum tentu mencerminkan kt/v 1,2 karena dipengaruhi oleh proses ultrafi ltrasi (nkf-k/doqi, 2000). depner (2005) menyatakan target sp kt/v adalah >1,3 atau minimal 1,2 per dialisis bagi pasien yang menjalani cuci darah tiga kali seminggu. nilai kt/v 2,0 atau lebih dianggap sebagai level tercapainya adekuasi dialisis (martin & thompson, 2001). department of health and human services and national institute of diabetes and digestive and kidney disease (2009) menyatakan bahwa untuk mengetahui proses dialisis membuang cukup urea, maka sebaiknya pengukuran kt/v dilakukan setiap sebulan sekali. metode penelitian penelitian ini merupakan penelitian kuantitatif non eksperimental dengan desain analitik korelasional dan dengan pendekatan cross sectional. populasi target dalam penelitian ini adalah seluruh pasien yang menjalani hemodialisis rutin di yogyakarta sedangkan populasi terjangkau adalah pasien yang menjalani hemodialisis rutin di unit hemodialisis rumah sakit pku muhammadiyah 1 yogyakarta sebanyak 108 pasien. sampel dalam penelitian ini adalah setiap pasien yang menjalani hemodialisis rutin di unit hemodialisis rumah sakit pku muhammadiyah 1 yogyakarta yang memenuhi kriteria inklusi dan eksklusi. teknik pengambilan sampel dalam penelitian ini dengan purposive sampling. ukuran sampel dihitung menggunakan rumus estimasi besar sampel. diperoleh besar sampel sebanyak 90 orang. jumlah sampel ini ditambah 20% dari total sampel sebagai faktor koreksi = 18 sampel, sehingga besar sampel keseluruhan adalah 108. kriteria inklusi sampel dalam penelitian ini adalah pasien gagal ginjal terminal yang menjalani hemodialisis rutin dengan frekuensi cuci darah 2 dan 3 kali perminggu serta bersedia ikut dalam penelitian. kriteria eksklusi sampel penelitian meliputi pasien yang mengalami komplikasi intradialisis yang menyebabkan dialisis harus dihentikan, terjadi resirkulasi darah selama pengambilan data dan pasien tidak datang sesuai jadwal hemodialysis yang sudah ditentukan penelitian ini menggunakan instrumen berupa kuesioner dan lembar observasi. kuesioner berisi karakteristik demografi responden yang terdiri dari nomor responden, inisial responden, umur, jenis kelamin, alamat rumah, pekerjaan dan lama menjalani hemodialisis yang nantinya akan ditanyakan langsung kepada pasien dengan metode wawancara terpimpin. lembar observasi berupa lembar untuk melakukan pencatatan luas permukaan dialyzer yang dipakai oleh responden. semua observasi ini dilakukan pada saat responden sedang dilakukan hemodialysis pada sesi kedua proses hemodialysis dalam satu minggu. prosedur teknis penelitian yang dilakukan digambarkan dalam alur penelitian berikut. 71 muhammadiyah journal of nursing analisis data terdiri dari analisis univariat dan bivariat. analisis univariat bertujuan untuk menjelaskan/ mendiskripsikan karakteristik masing-masing variabel yang diteliti. analisis univariat untuk data luas permukaan dialyzer dan adekuasi hemodialysis digunakan nilai tendensi sentral (mean, median, modus), standar deviasi, range, interkuartil range, minimal dan maksimal. analisis bivariat yang digunakan untuk menguji hubungan antara luas permukaan dializer dengan adekuasi dialisis digunakan uji kruskal wallis. tingkat kemaknaan yang digunakan adalah 5% (α=0,05) dan nilai confi dence interval yang ditetapkan sebesar 95%. penelitian dilakukan di unit hemodialisis rumah sakit pku muhammadiyah i yogyakarta, daerah istimewa yogyakarta pada bulan november 2012-juni 2013. hasil penelitian dan pembahasan distribusi responden menurut jenis kelamin, alamat, pekerjaan, luas permukaan dializer yang digunakan, dalam penelitian ini disajikan dalam tabel 1. 72 muhammadiyah journal of nursing tabel 1 distribusi responden menurut karakteristik responden dan perlakuan hemodialisis di rumah sakit pku muhammadiyah yogyakarta bulan april 2013 (n=90) variabel jumlah persentase jenis kelamin laki-laki perempuan 49 41 54,4 45,6 alamat sleman (± 8-10 km dari rumah sakit) kota jogja (± 1-5 km dari rumah sakit) bantul (± 8-10 km dari rumah sakit) gunung kidul (± 40-45 km dari rumah sakit) kulon progo (± 25-30 km dari rumah sakit) 35 24 18 7 6 38,9 26,7 20 7,8 6,7 pekerjaan tidak bekerja wiraswasta irt (ibu rumah tangga) supir petani pensiunan pns guru perangkat desa dosen 18 28 26 2 3 8 2 1 1 1 20 31,1 28,9 2,2 3,3 8,9 2,2 1,1 1,1 1,1 luas permukaan dializer 1,1 m2 (fb 110) 1,3 m2 (surflux 130) 1,3 m2 (elisio 130) 1,5 m2 (surflux 150) 1,8 m2 (f8hps) 3 31 6 5 45 3,3 34,4 6,7 5,6 50 dari tabel 1 di atas, tampak bahwa berdasarkan jenis kelamin sebagian besar responden adalah laki-laki. menurut alamat tempat tinggal, lebih banyak responden tinggal di kabupaten sleman yang berjarak 8-10 km dari rumah sakit, dan dari jenis pekerjaan yang dimiliki, sebagian besar responden bekerja sebagai wiraswasta, ibu rumah tangga dan tidak bekerja. sebagian besar pasien menggunakan dializer dengan luas permukaan 1,8 m2 (f8hps) yaitu ada 45 orang (50%) dan sisanya menggunakan luas permukaan dializer 1,3 m2 (surflux 130), 1,3 m2 (elisio 1,3 m2) 1,5 m2 (surflux 150) dan 1,1 m2 (fb 110). distribusi responden menurut umur dan nilai adekuasi dialisis tertera dalam tabel 2 di bawah ini. 73 muhammadiyah journal of nursing tabel 2 distribusi rata-rata responden menurut karakteristik responden dan perlakuan hemodialisis di rumah sakit pku muhammadiyah yogyakarta bulan april 2013 (n=90) variabel mean sd min-mak 95% ci umur (tahun) ureum pre hemodialisis (mg/dl) ureum post hemodialisis (mg/dl) adekuasi dialisis 47,44 119,84 39,59 1,36 12,02 34,92 16,50 0,38 28-77 211-220,5 15,9-121,6 0,30 2,05 44,92 s/d 49,97 112,53 s/d 127,16 36,13 s/d 43,04 1,28 s/d 1,44 dari tabel 2 di atas, rata-rata umur responden yang menjalani hemodialisis adalah 47,44 tahun dengan standar deviasi 12,02 tahun. usia termuda adalah 28 tahun dan yang paling tua 77 tahun. hasil estimasi menunjukkan bahwa 95% diyakini umur responden berkisar antara 44,92 tahun hingga 59,97 tahun. rata-rata kadar ureum pre hemodialisis adalah 119,84 mg/dl dengan standar deviasi 34,92 mg/dl. kadar ureum pre hemodialisis terendah adalah 211 mg/dl dan yang paling tinggi 220,5 mg/dl. hasil estimasi menunjukkan bahwa 95% diyakini kadar ureum pre hemodialisis berkisar antara 112,53 mg/dl hingga 127,16 mg/dl. rata-rata kadar ureum post hemodialisis adalah 39,59 mg/dl dengan standar deviasi 16,50 mg/dl. kadar ureum post hemodialisis terendah adalah 15,9 mg/dl dan tertinggi adalah 121,6 mg/dl. berdasarkan nilai estimasi, dipercaya bahwa 95% kadar ureum post hemodialisis antara 36,13 mg/dl sampai 43,04 mg/dl. hasil analisis didapatkan rata-rata adekuasi dialisis pada pasien hemodialisis adalah 1,36 dengan standar deviasi 0,38. adekuasi dialisis terendah adalah 0,30 dan tertinggi adalah 2,05. dari hasil estimasi dapat disimpulkan bahwa 95% diyakini bahwa rata-rata adekuasi dialisis antara 1,28 sampai dengan 1,44. hasil uji normalitas data adekuasi dialisis diperoleh p value=0,200 yang berarti data terdistribusi normal. hasil analisis bivariat antara adekuasi dialisis dengan luas permukaan dializer disajikan pada tabel 3. tabel 3. signifi kansi antara luas permukaan dializer terhadap adekuasi dialisis responden di rumah sakit pku muhammadiyah yogyakarta bulan april 2013 (n=90) variabel p value luas permukaan dializer f8hps (1,8 m2) surflux 130 (1,3 m2) elisio 130 (1,3 m2) surflux 150 (1,5 m2) fb 110 (1,1 m2) 0,880 hasil analisis bivariat kruskal wallis pada tabel 3 tampak bahwa p value untuk luas permukaan dialyzer adalah 0,880. dapat disimpulkan bahwa tidak ada perbedaan adekuasi dialisis diantara keempat jenis luas permukaan dializer. pembahasan proses dialisis dikatakan baik apabila cukup membuang urea di dalam tubuh. ringoir dan vanholder (1992) mendefi nisikan adekuasi dialisis adalah kemampuan proses dialisis untuk membersihkan darah dan menyeimbangkan jumlah cairan dalam tubuh guna mendekati fungsi ginjal secara normal. djarwoto (2009) menyatakan bahwa adekuasi dialisis adalah tercukupinya jumlah proses dialisis untuk menjaga dan menjamin kondisi yang optimal pada pasien dari timbulnya komplikasi akibat penumpukan toksin uremik. dalam penelitian ini untuk mendapatkan data tentang adekuasi 74 muhammadiyah journal of nursing dialisis dengan cara memeriksakan ureum darah pasien sebelum dan setelah hemodialisis pada sesi kedua proses hemodialisis yang diambil dari fi stula arteri. hasil analisis pencapaian adekuasi dialisis dalam penelitian ini, diperoleh nilai rata-rata adekuasi dialisis adalah 1,36. nilai ini sudah memenuhi standar adekuasi dialisis (kt/v) minimal yang di tetapkan nkf-k/doqi yaitu 1,2 untuk sekali sesi hemodialisis. nilai rata-rata ini menunjukkan bahwa sebagian besar responden baik di pku muhammadiyah i maupun di pku muhammadiyah ii telah mencapai dialisis yang adekuat. hal ini karena berdasarkan pendosisan hemodialisis, kedua unit hemodialisis tersebut telah memenuhi standar yang telah ditetapkan dari nkf-k/doqi, yaitu 50% responden telah menjalani hemodialisis 3 kali seminggu dengan waktu dialisis antara 10 sampai 12 jam perminggu. nilai rata-rata adekuasi dialisis yang sudah cukup baik dalam penelitian ini dapat juga diakibatkan oleh telah lamanya pasien menjalani hemodialisis. diperoleh data bahwa responden rata-rata telah menjalani hemodialisis selama 48,11 bulan atau 4 tahun-an. menurut hasil penelitian rocco et al. (2001) menyebutkan bahwa lama menjalani hemodialisis berhubungan dengan tingkat adekuasi. pasien yang menjalani hemodialisis lebih dari dua (2) tahun, adekuasi dialisis yang dicapai 20 kali lebih tinggi dibanding pasien yang kurang dari setengah (0,5) tahun, dan 42 sampai 63 kali kali lebih tinggi dibanding pasien yang telah menjalani hemodialisis setengah (0,5) sampai satu (1) tahun. hasil penelitian ini sejalan dengan penemuan dewi (2010) yang menganalisis pencapaian adekuasi dialisis pada pasien hemodialysis di bali. rata-rata adekuasi dialisis pasien adalah 1,22 dari sejumlah 38 responden, yang artinya dialisis yang dijalani pasien telah adekuat. meskipun diperoleh hasil nilai adekuasi yang sudah bagus, namun dalam penelitian ini penilaian adekuasi dialisis masih sebatas pada satu parameter saja yaitu keefektifan dalam membuang urea dengan menggunakan rumus kt/v. menurut palma dan pitt ard (2002) adekuasi tidak hanya kecukupan dalam membuang ureum, akan tetapi juga keberhasilan dalam mengontrol hipertensi dan nutrisi. gatot (2003), ringoir dan vanholder (1992) dan sukandar (2006) menambahkan bahwa pasien dinyatakan dialisisnya adekuat apabila keadaan umum dan status nutrisinya baik, tekanan darah dalam nilai normal/ normotensi, tidak ada gejala-gejala klinis terkait anemia, tercapai keseimbangan cairan, elektrolit dan asam basa, metabolisme fosfor dan kalsium yang terkontrol tanpa osteodistrofi renal, tidak timbul komplikasi akibat uremia, rehabilitasi yang optimal berhubungan dengan aspek kehidupan pribadi, keluarga dan profesi serta menunjukkan kualitas hidup yang baik. dalam penelitian ini penentuan adekuat tidaknya hemodialisis baru berdasar pada pemeriksaan secara laboratorium, belum memadukan kembali hasil nilai laboratorium dengan kondisi klinis pasien. nilai rata-rata adekuasi dialisis yang sangat kurang dari nilai minimal yang direkomendasikan nkf-k/doqi dalam penelitian ini ditunjukkan oleh kondisi klinis pasien yang tidak semuanya buruk. terdapat dua (2) responden dengan nilai adekuasi dialisis 0,30 dan satu (1) responden dengan nilai adekuasi 0,4. nilai ini sangat jauh sekali dari nilai minimal yang direkomendasikan, yaitu 1,2. kondisi klinis responden pertama dengan nilai adekuasi 0,30 adalah kadar hematokritnya 39%, ureum pre hemodialisis 54,9 mg/dl, ureum post hemodialisis masih 43 mg/dl berat badan post hemodialisis tergolong obesitas serta rata-rata ultrafi ltrasi adalah 16,67 ml/mnt, sedangkan faktor yang lain normal. responden kedua dengan kondisi klinis ureum pre hemodialisis 21,1 mg/dl, ureum post hemodialisis masih 16,8 mg/dl, sedangkan variabel yang lain normal. 75 muhammadiyah journal of nursing responden ketiga (3) dengan kondisi ureum pre hemodialisis 168,2 mg/dl, ureum post hemodialisis masih 121,6 mg/dl, menggunakan free heparin serta frekuensi hemodialisis hanya 2 kali seminggu. untuk variabel yang lain dari responden ketiga ini semua normal. responden yang lain meskipun nilai adekuasinya bagus, ternyata tidak semua kondisi yang diteliti menunjukkan hasil yang baik pula, sehingga dalam menentukan tingkat adekuasi dialisis harus memperhatikan dua aspek yaitu hasil pemeriksaan laborotorium yang didasarkan tidak hanya pada bersihan ureum saja (kt/v) tetapi diharapkan dengan menggunakan lebih dari satu parameter dan ditunjang dengan kondisi klinis pasien itu sendiri. dializer merupakan ginjal buatan tempat dimana proses pencucian darah terjadi. aliran darah dan aliran dialisat yang berjalan berlawanan arah di dalam dializer memungkinkan darah lebih lama dibersihkan karena lebih lama kontak dengan cairan dialisat. kemampuan pembersihan toksin urea dan solute lain oleh dializer salah satunya dipengaruhi oleh luas permukaan dializer. setiap jenis dializer memiliki luas permukaan yang berbeda, yang akan menentuan koefi sien transfer urea. terdapat lima (jenis dializer) yang digunakan oleh pasien hemodialisis di rumah sakit pku muhammadiyah yogyakarta, yaitu 1) f8hps dengan luas permukaan 1,8 m2 yang termasuk high fl ux dan high effi ciency dializer, 2) surfl ux 130 yang memiliki luas permukaan 1,3 m2 termasuk low fl ux dan high effi ciency dializer, 3) elisio 130 dengan luas permukaan 1,3 m2 tergolong high fl ux dan high effi ciency dializer, 4) surfl ux 150 yang mempunyai luas permukaan 1,5 m2 termasuk low fl ux dan high effi ciency dializer, dan 5) fb 110 dengan luas permukaan 1,1 m2 tergolong low fl ux dan low effi ciency dializer. dalam penelitian ini, lebih dari separuh jumlah responden telah menggunakan dializer tipe high efi siensi dan hanya 3 responden yang menggunakan low efi siensi dializer. tipe dializer high efi siensi ini memiliki kemampuan tinggi dalam membersihkan urea, sedangkan kemampuan dializer dalam membersihkan solute dengan berat molekul besar seperti β2 mikroglobulin ditentukan oleh tipe fl ux dari dializer. locatelli et al. (2009) membuktikan bahwa nilai kt/v tidak menunjukkan perbedaan yang bermakna pada penggunaan dializer high fl ux dan low fl ux. pada analisis secara sub group diperoleh hasil bahwa pasien yang menggunakan high fl ux dializer kemampuan bertahan hidupnya lebih lama dengan kadar serum albumin ≤ 4 gr/dl. hasil analisa data ternyata tidak terbukti adanya perbedaan antara jenis luas permukaan dializer dengan adekuasi dialisis (p=0,880). dalam penelitian ini karena penentuan adekuasi dialisis berdasarkan kemampuan dalam membersihkan ureum, maka menurut telaah teori diatas, peneliti menyimpulkan bahwa penyebab tidak adanya hubungan antara luas permukaan dializer karena 96,6% responden telah menggunakan dializer high efi siensi. simpulan dan saran kesimpulan yang dapat diambil dari penelitian ini, adalah sebagai berikut: 1) pencapaian rata-rata adekuasi dialisis responden di rumah sakit pku muhammadiyah adalah 1,36, yang berarti responden telah mencapai nilai adekuasi minimal yang ditetapkan oleh nkf-k/doqi 2) tidak ada hubungan yang bermakna antara adekuasi dialisis pada pasien hemodialisis dengan luas permukaan dializer saran 1) pengukuran adekuasi dialisis dilakukan secara komprehensif dengan mempertimbangkan data hasil laboratorium dengan kondisi klinis pasien 76 muhammadiyah journal of nursing 2) hasil penelitian ini bisa menjadi data awal di lingkup keparawatan kritis khususnya di area hemodialisis, baik di institusi pelayanan maupun institusi pendidikan untuk dapat melanjutkan penelitian dengan melakukan pengukuran adekuasi dialisis dengan menggunakan lebih dari satu parameter seperti pengukuran kt/v dan bersihan solute total daftar pustaka abbas hn, rabbani ma, safdar n, murtaza g, maria q, ahamd a, 2009, biochemical nutritional parameters and their impact on hemodialysis effi ciency, saudi journal of kidney diseases and transplantation, 20 (6), pp.1105-1109. amini m, aghighi m, masoudkabir f, zamyadi m, norouzi s, rajolani h, et al, 2011, hemodialysis adequacy and treatment in iranian patients, a national multicenter study. iranian journal of kidney diseases, 5 (2), pp.103-109. borzou, s.r., gholyaf, m., zandiha, m., amini, r., goodarzi, m.t., & torkaman, b. 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adequacy, anemia management, and serum albumin level, american journal of kidney diseases, 38 (4), pp.813823 sukandar e, 2006, gagal ginjal dan panduan terapi dialisis. bandung: pusat informasi ilmiah bagian ilmu penyakit dalam fakultas kedokteran unpad rs.dr. hasan sadikin, bandung. thomas n, 2009, haemodialysis, dalam yayasan de’lima sehat-i (penyunting). “pelatihan hemodialisis”, yayasan de’lima sehat-i, jakarta. yeun jy, ornt db, & depner ta, 2012, hemodialysis, in taal mw, chertow gm, et al (eds.), “brenner and rector’s the kidney, 9th edition”, saunders elsevier, philadelphia. 9 muhammadiyah journal of nursing abstract background. diabetes mellitus (dm) is a chronic metabolic disease characterized by elevated levels of glucose in the blood. poor adherence to treatment of patients with type 2 diabetes causes uncontrolled blood glucose so increasing the risk of various complications. one major factor is the failure of a treatment non compliance to therapy is planned. counseling is one way to improve the knowledge , attitudes and patient compliance. objective. this study aimed to evaluate the eff ectiveness of counseling in improving compliance and diabetes control blood sugar in patients with type 2 diabetes. research design. this study is an experimental study with a quasi experiment design with pre and post test control group design prospectively performed in dr soeradji tirtonegoro klaten from march to december 2014. the sample consisted of 44 respondents, with 22 intervention and 22 control group. the measurement results were analyzed using the paired t test to test blood sugar levels 2 hours postprandial ( gdpp ) and mac nemar test for levels of patient compliance. results. the analysis showed there are signifi cant diff erence before and after adherence counseling in the intervention group (p diet = 0.001; p control = 0.002; p = 0.000 pill count ; gdpp p = 0.000 ) and have not signifi cant diff erence in the exercise group (p value = 0.549) conclusions. this study indicates that counseling is very eff ective in improving diabetes diet compliance, control and pill count and post prandial blood sugar compliance (gdpp) and are not eff ective in improving exercise compliance of patients . keywords: counseling, compliance, diabetes mellitus adi sucipto1, elsye maria rosa2 1) universitas respati yogyakarta 2) universitas muhammadiyah yogyakarta universitas muhammadiyah yogyakarta, jl. lingkar selatan, kasihan, bantul, yogyakarta email: adisuc2410@gmail.com efektivitas konseling dm dalam meningkatkan kepatuhan dan pengendalian gula darah pada diabetes melitus tipe 2 a. pendahuluan diabetes melitus (dm) merupakan penyakit degeneratif yang banyak diderita penduduk dunia. angka insiden dan prevalensi diabetes melitus (dm), diseluruh penjuru dunia dari berbagai penelitian epidemiologi cenderung menunjukkan adanya peningkatan dari tahun ketahun 1. tanpa upaya pencegahan dan program pengendalian yang efektif prevalensi tersebut akan terus meningkat 2. suatu jumlah yang sangat besar mengingat bahwa dm akan memberikan dampak terhadap kualitas sumber daya manusia, sosial dan tingginya biaya kesehatan. pasien diabetes perlu diberikan beberapa perawatan agar tidak semakin parah dan tidak mengalami komplikasi yang dapat menimbulkan masalah kesehatan baik makroangiopati maupun mikroangiopati. jika kadar gula darah dapat selalu dikendalikan dengan baik, diharapkan semua penyulit menahun tersebut dapat dicegah sehingga pasien dapat menjalani kehidupannya secara normal 3. salah satu faktor utama kegagalan sebuah terapi adalah ketidakpatuhan terhadap terapi yang telah direncanakan, maka salah satu upaya penting untuk meningkatkan kepatuhan pasien terhadap terapi adalah dengan edukasi atau pemberian konseling yang lengkap, akurat serta secara terstruktur tentang terapi tersebut 4. adanya pemberian edukasi dan konseling ini sangat penting karena penyakit diabetes merupakan penyakit yang berhubungan dengan gaya hidup pasien. dengan pemberian edukasi dan konseling inilah pasien 10 muhammadiyah journal of nursing diharapkan memiliki pengetahuan yang cukup tentang diabetes, yang selanjutnya dapat merubah sikap dan perilakunya sehingga diharapkan dapat mengendalikan kondisi penyakit dan kadar gula darahnya dan dapat meningkatkan kualitas hidupnya. b. metode penelitian ini merupakan metode penelitian eksperimental, dengan menggunakan quasi experiment, dengan rancangan yang digunakan adalah pre dan post control group design. penelitian ini bertujuan untuk mengetahui efektivitas konseling dm dalam meningkatkan kepatuhan dan pengendalian gula darah pada diabetes melitus tipe 2. populasi dalam penelitian ini adalah pasien diabetes mellitus tipe 2 yang menjalani rawat jalan di rumah sakit dr soeradji tirtonegoro klaten yang memenuhi kriteria inklusi dan eklusi dengan jumlah sampel sebanyak 44 responden, yang terdiri dari 22 responden kelompok intervensi dan 22 responden kelompok kontrol. c. hasil dan pembahasan 1. karakteristik responden tabel 1. perbedaan karakteristik proporsi kelompok intervensi dan kontrol penelitian kelompok penelitian variabel kontrol intervensi f (%) f (%) total (%) jenis kelamin perempuan 12 27,3 14 31,8 26 59,1 laki-laki 10 22,7 8 18,2 18 40,9 total 22 50 22 50 44 100 kategori usia dewasa akhir (36-45 thn) 1 2,3 3 6,8 4 9,1 lansia awal (46-55 thn) 10 22,7 12 27,3 22 50 lansia akhir (56-65 thn) 11 25 7 15,9 18 40,9 total 22 50 22 50 44 100 tingkat pendidikan tidak sekolah 1 2,3 1 2,3 2 4,5 sd 6 13,6 5 11,4 11 25 smp/ sltp 8 18,2 4 9,1 12 27,3 sma/ smu 6 13,6 10 22,7 16 36,4 perguruan tinggi (pt) 1 2,3 2 4,5 3 6,8 total 22 50 22 50 44 100 pekerjaan responden pensiun/ tidak bekerja 7 15,9 3 6,8 10 22,7 pns/ tni/ polri 3 6,8 3 6,8 6 13,6 wiraswasta 3 6,8 4 9,1 7 15,9 pegawai swasta 1 2,3 3 6,8 4 9,1 irt 8 18,2 9 20,5 17 38,6 total 22 50 22 50 100 11 muhammadiyah journal of nursing kelompok penelitian variabel kontrol intervensi f (%) f (%) total (%) lama menderita dm e 1 tahun 1 2,3 2 4,5 3 6,8 2 5 tahun 11 25 10 22,7 21 47,7 6 9 tahun 6 13,6 7 15,9 13 29,5 10 14 tahun 3 6,8 2 4,5 5 11,4 f 15 tahun 1 2,3 1 2,3 2 4,5 total 22 50 22 50 44 100 karakteristik sosio-demografi res-ponden berdasarkan jenis kelamin menunjukkan bahwa sebagian besar responden, yaitu 26 responden (59,1%) berjenis kelamin wanita dibandingkan dengan jumlah laki-laki sebanyak 18 responden (40,9%). belum ditemukan literatur yang menyatakan bahwa jenis kelamin merupakan faktor resiko terhadap penyakit diabetes melitus tipe 2. hasil penelitian ini hampir sama dengan hasil penelitian yang pernah dilakukan oleh rsud koja yang menyatakan bahwa prevalensi diabetes melitus tipe 2 yang terjadi pada wanita sebesar 62%, lebih besar dibandingkan dengan prevalensi pada laki-laki 5. menurut joshlin (1985) bahwa wanita lebih rentan mengidap dm tipe2 dengan ratio perempuan dan laki-laki 1,8 : 1. hal ini sejalan juga dengan penelitian yang disampaikan oleh azrul azwar yang menyatakan bahwa terdapat variasi prevalensi penyakit dm tipe 2 antara laki-laki dan perempuan di sejumlah daerah 6. pasien dm mengalami peningkatan jumlah kasusnya paling banyak terjadi pada rentang usia lansia awal menurut penggolongan usia berdasarkan depkes ri (2009) yang berkisar antara 46 tahun sampai dengan 55 tahun sebanyak 22 orang reponden (50%) 7. data ini sesuai dengan pernyataan dari american diabetes association (ada), bahwa usia diatas 45 tahun merupakan salah satu faktor resiko terjadinya dm tipe 2 8. menurut perkeni (2006) resiko berkembang penyakit dm tipe 2 meningkat seiring dengan bertambahnya usia 9. selain itu juga, sejumlah perubahan akan terjadi dengan bertambahnya usia, termasuk anatomi, fi siologi, psikologi dan sosiologi 10. califano mengemukakan bahwa umur merupakan salah satu faktor resiko terjadinya masalah kesehatan seperti penyakit dm. insiden penyakit dm meningkat seiring dengan pertambahan umur 3. rochmah, (2006) menjelaskan bahwa prevalensi penyakit dm lebih banyak didapatkan pada usia dewasa, dimana pada usia dewasa (30 tahun) kadar glukosa darah mengalami kenaikan 1 – 2 mg/ tahun pada saat puasa dan akan naik sekitar 5,6 – 13 mg pada 2 jam setelah makan. pasien dm di indonesia kebanyakan berumur antara 45 sampai 64 tahun 11. tingkat pendidikan responden pada penelitian ini bervariasi dari rendah hingga tinggi. tingkat pendidikan responden terbanyak pada tingkat pendidikan menengah atas (sma/ smu) sebanyak 16 reponden (36,4%). tidak ditemukan literatur yang mengatakan adanya hubungan antara tingkat pendidikan sebagai salah satu resiko terhadap penyakit diabetes mellitus tipe 2. tingginya jumlah responden pada tingkat pendidikan ini hanya menunjukkan bahwa kondisi pendidikan di indonesia sudah jauh lebih baik. semakin tinggi tingkat pendidikan seseorang, semakin tinggi kesadarannya terhadap upaya menjaga kesehatan dirinya. hal ini juga mungkin 12 muhammadiyah journal of nursing menjadi penyebab jumlah responden terbanyak ada pada tingkat pendidikan ini. hal ini ditemui pada mrcos, g dkk bahwa dm tipe2 dapat saja diderita pada semua lapisan pendidikan, namun kepatuhan berobat ternyata lebih berhasil pada penyandang dengan pendidikan yang cukup tinggi dari pada mereka yang berpendidikan rendah 12. gambaran sosio-demografi respon-den yang lain berdasarkan status pekerjaan menyatakan bahwa sebanyak 27 responden (61,3%) tidak bekerja. hal ini dikarenakan sebagian besar responden adalah wanita yang merupakan ibu rumah tangga dan sebagian lainnya adalah pensiunan/ tidak bekerja. 2. kepatuhan diit, olahraga, kontrol dan pill count sebelum dan setelah dilakukan konseling a. kepatuhan diit tabel 2. efektivitas konseling terhadap kepatuhan diit pada kelompok kontrol dan intervensi variabel p value diet sebelum dan setelah konseling pada kelompok kontrol diet sebelum dan setelah konseling pada kelompok intervensi diet antara kelompok kontrol dan intervensi sebelum konseling diet antara kelompok kontrol dan intervensi setelah konseling 1,000 0,001 1,000 0,000 13 muhammadiyah journal of nursing prinsip pengaturan diit pada pasien diabetes hampir sama dengan anjuran makan untuk masyarakat umum, yaitu makanan yang seimbang dan sesuai dengan kebutuhan kalori dan zat gizi masing-masing individu. kebutuhan kalori dihitung berdasarkan berat badan, jenis kelamin, umur, dan aktivitas fisik pasien dm yang pada dasarnya ditujukan untuk mencapai atau mempertahankan berat badan ideal. jika modifikasi diet diaplikasikan secara benar, dapat mengontrol glukosa darah pada penderita dm tipe 2 9. edukasi pasien merupakan salah satu pilar penting dalam pengelolaan dm untuk mengoptimalkan terapi pengobatan. jika edukasi dapat dijalankan secara efektif, dapat meningkatkan kepatuhan dan pengelolaan diri sendiri oleh pasien terhadap penyakitnya 13. who pada tahun 2006 menyatakan bahwa perawat memegang peranan yang cukup penting untuk membantu mengatasi masalah kepatuhan yang rendah terhadap diit jangka panjang pada penyakit kronik, seperti dm. perawat adalah posisi yang tepat untuk memberikan edukasi kepada pasien tentang diit yang benar, menjelaskan pentingnya pengontrolan gula darah untuk untuk meningkatkan kepatuhan dan meminimalisir timbulnya komplikasi jangka panjang karena perawat yang senantiasa berhubungan dengan pasien selama 24 jam dan lebih memahami kondisi pasien 13,14. berbagai penelitian mengenai intervensi dengan konseling oleh perawat telah terbukti dapat meningkatkan kontrol dan kepatuhan pasien dengan dm tipe 2. penelitian yang dilakukan oleh lindenmeyer menyatakan bahwa ada manfaat potensial dari intervensi yang diberikan perawat untuk meningkatkan efektivitas kepatuhan diit, terutama intervensi edukasi dengan konseling kepada pasien 13. intervensi edukasi dengan konseling yang diberikan oleh perawat juga dapat meningkatkan kontrol glukosa darah dan kepatuhan pasien dm tipe 2 15. pada penelitian ini edukasi diberikan dengan cara konseling tentang 4 pilar penatalaksanaan dm yang meliputi edukasi penyakit, diit, olahraga dan farmakologi. umumnya pemberian edukasi yang dilakukan di pelayanan kesehatan dasar di luar negeri dilakukan langsung oleh perawat dengan memberikan edukasi langsung baik secara individual, kelompok, melalui telepon atau datang ke rumah pasien. penggunaan edukasi dengan konseling di sarana pelayanan kesehatan di luar negeri umumnya dapat membantu atau mempermudah pasien dalam menerima suatu informasi karena menurut penelitian yang dilakukan oleh sperlhillen melaporkan bahwa pemberian edukasi secara individu lebih baik dalam meningkatkan kontrol glukosa darah pada pasien dm tipe 2 dibandingkan dengan edukasi secara kelompok dan perawatan standar biasa (12,8%) 16. berbeda dengan hasil penelitian yang dilakukan oleh kravitz yang menyatakan bahwa tingkat ketidakpatuhan pasien dm terhadap program modifi kasi diet ternyata masih tinggi. hasil penelitian ini menyatakan bahwa tingkat kepatuhan pasien dm tipe 2 terhadap modifi kasi diet berkisar antara 3087%. begitu pula dengan hasil penelitian yang dilakukan oleh hernández ronquillo juga dilaporkan hanya sebesar 38% responden yang patuh mengikuti program modifi kasi diet 17. penelitian yang dilakukan di india dan amerika juga menunjukkan sebesar 37 dan 52% penderita dm tipe 2 yang melaksanakan program pengaturan pola makan 18. alasan paling umum yang berkaitan dengan ketidakpatuhan pasien dm tipe 2 terhadap diet atau pengaturan pola makan adalah faktor situasi jika pasien makan di luar rumah, seperti makan di restoran atau saat menghadiri acara undangan tertentu 19. 14 muhammadiyah journal of nursing 3. kepatuhan olahraga tabel 3. efektivitas konseling terhadap kepatuhan olahraga pada kelompok kontrol dan intervensi variabel p value olahraga sebelum dan setelah konseling pada kelp. kontrol olahraga sebelum dan setelah konseling pada kelp. intervensi olahraga antara kelp. kontrol dan intervensi sebelum konseling olahraga antara kelp. kontrol dan intervensi setelah konseling 0,375 0,549 0,731 0,001 pada penelitian ini responden yang melaksanakan olahraga sesuai dengan anjuran perkeni, yang meliputi jenis dan durasi/ takaran waktu yang dianjurkan yakni paling sedikit 2-3 kali seminggu dengan durasi 20-30 menit 2. pelaksanaan olahraga diharapkan dapat menurunkan atau mempertahankan berat badan yang ideal. penurunan berat badan telah dibuktikan dapat mengurangi resistensi insulin dan memperbaiki respon sel-sel j terhadap stimulus glukosa. salah satu penelitian dilaporkan bahwa penurunan 5% berat badan dapat mengurangi kadar hba1c sebanyak 0,6% dan setiap kilogram penurunan berat badan dihubungkan dengan 3-4 bulan tambahan waktu harapan hidup 20. manfaat potensial lain dari olahraga pada pasien dm tipe 2 telah dilaporkan dapat meningkatkan kontrol glukosa dan fungsi kardiovaskuler, menurunkan berat badan, memberikan efek psikologis yang positif, dan mencegah timbulnya penyakit lain 17. penelitian yang dilakukan oleh kravitz juga melaporkan bahwa tingkat kepatuhan pasien dm terhadap pelaksanaan olahraga, yaitu sebesar 19%. sama halnya dengan hasil penelitian hernández-ronquillo yang menyatakan bahwa tingkat ketidakpatuhan pasien dm tipe 2 terhadap olahraga adalah sebesar 85% 17. secara umum, berdasarkan hasil penelitian survei secara random juga dinyatakan bahwa kepatuhan terhadap diet dan olahraga pada pasien dm tipe 2 umumnya suboptimal13. umumnya responden pada penelitian ini tidak melakukan olahraga karena alasan malas atau tidak terbiasa dengan kebiasaan untuk berolahraga. alasan ini serupa dengan hasil survey yang dilakukan oleh kamiya terhadap 570 pasien diabetes yang menyatakan bahwa alasan utama pasien tidak melakukan olahraga adalah pasien tidak punya waktu untuk olahraga, pasien tidak memiliki kebiasaan berolah raga, dan pasien tidak memiliki keinginan untuk berolahraga 17. secara umum, berdasarkan hasil penelitian survei secara random juga dinyatakan bahwa kepatuhan terhadap diet dan olahraga pada pasien dm tipe 2 umumnya suboptimal 13, 17. kocurek juga menyatakan bahwa ketidakpatuhan dalam melakukan olahraga dapat terjadi pada setiap orang. suatu penelitian telah menunjukkan bahwa ketidakpatuhan dapat terjadi pada laki-laki atau wanita di semua umur, di semua tingkat pendidikan, dan di semua lapisan ekonomi 21. selain itu, faktor lain yang ikut berpengaruh pada penelitian ini berdasarkan karakteristik usia responden dimana usia responden paling banyak ditemukan pada kategori usia lansia awal (46 – 55 tahun) sebanyak 22 responden (50%) dan lansia akhir (56 – 65 tahun) sebanyak 20 responden (40,9%) sedangkan lainnya ditemukan pada dewasa akhir (36 – 45 tahun) sebanyak 4 responden (9,1%). pada kategori usia lansia awal maupun akhir ini fungsi dan integrasi mulai mengalami penurunan, kemampuan untuk mobilisasi dan aktivitas sudah mulai berkurang, dan muncul beberapa penyakit yang menyebabkan status kesehatan menurun 22. kondisi ini mengakibatkan penurunan motivasi dalam melakukan kegiatan olahraga. rendahnya status kesehatan merupakan salah satu faktor yang mempengaruhi penuranan aktivitas usia lanjut 23. hal ini di dukung oleh 15 muhammadiyah journal of nursing hasil penelitian brawley, rajeski, dan king (2003), mengemukakan faktor yang mempengaruhi penurunan aktivitas pada orang usia lanjut adalah kehadiran penyakit kronis, keterbatasan gerak, dan kekuatiran terhadap munculnya nyeri 22, 23 4. kepatuhan kontrol tabel 4. efektivitas konseling terhadap kepatuhan kontrol pada kelompok kontrol dan intervensi variabel p value kontrol sebelum dan setelah konseling pada kelp. kontrol kontrol sebelum dan setelah konseling pada kelp. intervensi kontrol antara kelp. kontrol dan intervensi sebelum konseling kontrol antara kelp. kontrol dan intervensi setelah konseling 0,453 0,002 0,536 0,000 hasil penelitian ini sama dengan hasil penelitian yang dilakukan oleh farsaei, 2011 yang menyatakan bahwa konseling dm sangat efektif dalam meningkatkan pengetahuan dan sikap yang akan membentuk perilaku seseorang dalam meningkatkan kepatuhan. kepatuhan kontrol pada pasien dm terlihat dari responden yang datang berobat sesuai dengan jadwal maupun anjuran tenaga kesehatan 13. hasil penelitian adisa (2009) yang menyatakan bahwa laki-laki cenderung lupa untuk kontrol dan meminum obat dan pasien yang bekerja dengan tingkat pendidikan yang tinggi memiliki kecenderungan untuk lebih ingat untuk kontrol dan meminum obat dibandingkan dengan pasien tanpa pekerjaan 13, 24. hal ini sesuai dengan karakteristik responden dalam penelitian ini dimana jumlah reponden perempuan lebih banyak 59,1% jika dibandingkan dengan responden laki-laki yang berjumlah 18 responden (40,9%). selain itu juga ditemukan tingkat pendidikan responden terbanyak adalah menengah keatas sebanyak 36,4% jika dibandingkan dengan tingkat pendidikan yang lain. beberapa penelitian lain menyatakan bahwa pasien dengan umur yang lebih tua lebih patuh terhadap kontrol berobat dibandingkan pasien muda. penelitian lain juga menyatakan bahwa pasien geriatri lebih beresiko tidak patuh kontrol karena mereka tidak mengerti regimen obat dan sering kali lupa serta memiliki masalah penglihatan, pendengaran, dan kognitif dengan prevalensi yang lebih besar dibandingkan pasien dengan umur yang lebih muda 25. faktor lain yang berperan dalam kepatuhan kontrol adalah durasi menderita dm. penderita dm yang mengalami sakit lama mengalami kejenuhan dan beresiko terjadinya komplikasi. diabetes melitus (dm) selain dikenal sebagai penyakit, juga dikenal sebagai faktor resiko. penderita dengan durasi menderita penyakit dm lebih dari 6 bulan mengalami kecenderungan komplikasi baik akut yaitu hipoglikemi dan kronis yaitu penyakit jantung, pembuluh darah, gagal ginjal gangguan penglihatan, impotensi, ulkus pada kaki, dan gangren 7. hasil penelitian ini sejalan dengan peneliti sebelumnya yang menyatakan bahwa rata-rata responden menderita penyakit lebih dari 6 bulan, artinya sebagian besar responden mengalami masalah kesehatan kronis. horner, (1997) mengemukakan bahwa keberadaan penyakit kronis pada keluarga merupakan sumber stressor keluarga, sehingga keluarga ikut berperan dalam mengatasi hal tersebut. keluarga menjadi sangat penting terutama memberikan dukungan bila salah satu anggota mengalami penyakit kronis. model perawatan penyakit kronik pada keluarga memandang bahwa kondisi kronik merupakan suatu kondisi yang membutuhkan dukungan untuk mencapai manajemen diri penderita dengan baik 26. 16 muhammadiyah journal of nursing 5. kepatuhan pill count tabel 5. efektivitas konseling terhadap kepatuhan pill count pada kelompok kontrol dan intervensi variabel p value pill count sebelum dan setelah konseling pada kelp. kontrol pill count sebelum dan setelah konseling pada kelp. intervensi pill count antara kelp. kontrol dan intervensi sebelum konseling pill count antara kelp. kontrol dan intervensi setelah konseling 1,00 0,00 0,032 0,009 pada penelitian ini tingkat kepatuhan yang kurang sebelum dilakukan konseling adalah dalam pemakaian obat yang kuensinya banyak (3 x sehari) seperti metformin. alasan pasien ini bermacam-macam tidak meminum obat sesuai anjuran dokter, ada yang karena tidak sempat minum obat dengan alasan sibuk bekerja pada siang hari dan obat ditinggal di rumah, ada yang karena alasan efek samping obat dimana pasien merasa mual atau mengalami gangguan pencernaan setelah minum obat tersebut, dan juga ada pasien beranggapan bahwa obat itu racun (zat kimia), jadi tidak baik diminum seringkali. jadi pada umumnya pasien lebih menyukai minum obat yang frekuensi minumnya 1 kali dalam sehari. untuk glucobay, ada pasien yang tidak meminumnya karena alasan efek samping obat yang menyebabkan pasien sering buang angin, sehingga kadangkala mengganggu dalam aktivitasnya sehari-hari. begitu juga dengan glibenklamid, dimana ada pasien yang langsung merasa lemas, pusing dan berkeringat dingin setelah meminumnya (gejala hipoglikemi). banyak cara yang dapat dilakukan untuk dapat meningkatkan kepatuhan pasien seperti memberikan obat dengan jadwal minum obat satu kali sehari, memberikan obat sesuai dengan kemampuan pasien untuk membelinya, tidak mengubah jenis obat dari yang biasanya dikonsumsi oleh pasien apabila tidak dibutuhkan. selain itu juga bisa dengan memberikan alat bantu seperti kartu pengingat obat yang bisa ditandai apabila pasien sudah minum obat, memberikan dukungan kepada anggota keluarga untuk mengingatkan pasien minum obat, dan lain sebagainya 27. hasil penelitian ini sama dengan hasil penelitian yang dilakukan oleh linda yang menyatakan bahwa faktor sosio-demografi , seperti umur dan jenis kelamin berpengaruh terhadap kepatuhan pasien terhadap pengobatannya. penelitian yang dilakukan oleh adisa juga melaporkan bahwa jenis kelamin dan pekerjaan berpengaruh terhadap kepatuhan pasien. hasil penelitian adisa menyatakan bahwa laki-laki cenderung lupa untuk meminum obat dan pasien yang bekerja dengan tingkat pendidikan yang tinggi memiliki kecenderungan untuk lebih ingat meminum obat dibandingkan dengan pasien tanpa pekerjaan 13, 24. hal ini sesuai dengan karakteristik responden dalam penelitian ini dimana jumlah reponden perempuan lebih banyak 59,1% jika dibandingkan dengan responden lakilaki yang berjumlah 18 responden (40,9%). selain itu, rata-rata tingkat pendidikan responden paling banyak adalah menengah atas sebanyak 16 responden (36,4%) responden pada penelitian ini menunjukkan bahwa mereka yang memiliki tingkat pendidikan yang tinggi, memahami kondisi penyakitnya atau percaya akan pentingnya manfaat pengobatan terhadap penyakitnya sehingga menyebabkan pasien patuh. dengan demikian, pada penelitian ini tingkat pendidikan berpengaruh terhadap tingkat kepatuhan terhadap pengobatan. beberapa penelitian juga melaporkan hasil yang sama bahwa ditemukan korelasi antara tingkat pendidikan dengan tingkat kepatuhan25. 17 muhammadiyah journal of nursing 6. keterkendalian gula darah tabel 6. perbedaan tingkat kadar gula darah sebelum dan setelah dilakukan konseling variabel mean sd min mak 95% ci gula darah pp sebelum konseling 279,73 55,09 172 413 262,98 296,48 gula darah pp setelah konseling 252,95 63,63 126 372 233,61 272,30 tabel 7. efektivitas konseling terhadap keterkendalian gula darah 2 jam post prandial pada kelompok kontrol dan intervensi variabel p value gdpp antara kelompok kontrol dan intervensi sebelum konseling gdpp antara kelompok kontrol dan intervensi setelah konseling gdpp sebelum dan setelah konseling pada kelp. kontrol gdpp sebelum dan setelah konseling pada kelp. intervensi 0,094 0,045 0,012 0,000 hasil penelitian ini sesuai dengan literatur yang menyatakan bahwa konseling oleh tenaga kesehatan seperti perawat merupakan salah satu upaya yang dapat dilakukan untuk meningkatkan kepatuhan pasien dan mengontrol kadar gula darah pasien dm. dari rerata kadar glukosa darah post prandial pasien sebelum dan setelah konseling terdapat perbedaan yang bermakna, berdasarkan hasil pengujian statistik dengan menggunakan uji t berpasangan dengan tingkat signifi kansinya 0,000 (p< 0,05). penurunan kadar glukosa darah 2 jam setelah makan (post prandial) setelah konseling menunjukkan bahwa konseling yang diberikan berpengaruh terhadap pengetahuan dan sikap pasien sehingga akan menimbulkan tindakan untuk patuh terhadap penatalaksanaan dm yang meliputi diit, olahraga dan pengobatan. hasil ini sesuai dengan penelitian yang dilakukan oleh malathy r, dkk yang meneliti tentang efektivitas konseling dm terhadap pengetahuan dan sikap pasien diabetes di erode kabupaten india selatan. penelitian tersebut memperoleh hasil yang signifi kan yaitu bahwa pasien yang mendapat konseling tentang dm dapat mengurangi komplikasi dan mengontrol kadar gula darahnya. skor dari kelompok uji pasien meningkat secara signifi kan (p <0,0001), sedangkan tidak ada perubahan signifi kan yang diamati pada pasien kelompok kontrol. glucosa postprandial tingkat darah menurun secara signifi kan pada kelompok uji, begitu juga kolesterol total, trigliserida (tgl), dan tingkat low density lipoprotein (ldl) juga menunjukkan penurunan pada kelompok uji. dengan demikian, penelitian mengungkapkan bahwa konseling yang dilakukan oleh perawat mungkin menjadi elemen penting dalam program manajemen diabetes 28. pemberian edukasi dengan konseling merupakan bagian integral dan penting dalam pemberian asuhan perawatan pada pasien diabetes. konseling diabetes adalah pemberian pendidikan, pemahaman dan latihan mengenai pengetahuan dan ketrampilan dalam pengelolaan diabetes yang diberikan kepada setiap pasien diabetes untuk mengatasi setiap masalahnya. edukasi dan konseling kesehatan pada pasien dm merupakan suatu hal yang sangat penting dalam pengontrolan kadar gula darah pasien. selain itu, edukasi dan konseling pada penderita dm juga diharapkan dapat mencegah atau setidaknya menghambat munculnya penyulit kronik ataupun penyulit akut yang ditakuti oleh penderita dm. dalam melakukan edukasi dan konseling kepada pasien, seorang konselor mempunyai tujuan untuk mengubah pengetahuan (knowledge), sikap (attitude), dan perilaku (behaviour). perubahan perilaku inilah yang paling sukar dilaksanakan. adanya pemberian edukasi 18 muhammadiyah journal of nursing dan konseling ini sangat penting karena penyakit diabetes merupakan penyakit yang berhubungan dengan gaya hidup pasien. oleh karenanya untuk mencapai keberhasilan terapi diabetes perlu adanya kerjasama antara pasien, keluarga dan petugas kesehatan dalam hal ini perawat yang memberikan edukasi dan konseling kepada pasien. dengan pemberian edukasi dan konseling inilah pasien diharapkan memiliki pengetahuan yang cukup tentang diabetes, yang selanjutnya dapat merubah sikap dan perilakunya sehingga diharapkan dapat mengendalikan kondisi penyakit dan kadar gula darahnya dan dapat meningkatkan kualitas hidupnya. d. simpulan 1. responden pada penelitian ini terdiri dari 59,1% berjenis kelamin perempuan, 50% berusia diantara 46-55 tahun (lansia awal), 36,4% berpendidikan menengah atas, 38,6% % sebagai irt, 47,7% telah menderita dm tipe 2 selama 2-5 tahun 2. ada perbedaan yang signifikan kepatuhan diit, kontrol dan pill count sebelum dan setelah dilakukan konseling pada kelompok intervensi dan tidak ada perbedaan yang signifikan kepatuhan diit, kontrol dan pill count sebelum dan setelah dilakukan konseling pada kelompok kontrol 3. tidak ada perbedaan yang signifikan kepatuhan olahraga sebelum dan setelah dilakukan konseling pada kelompok intervensi, dan tidak ada perbedaan yang signifikan kepatuhan olahraga sebelum dan setelah dilakukan konseling pada kelompok kontrol. 4. ada perbedaan yang signifikan keterkendalian gula darah post prandial (gdpp) sebelum dan setelah dilakukan konseling pada kelompok intervensi, dan ada perbedaan yang signifikan kepatuhan gdpp sebelum dan setelah dilakukan konseling pada kelompok kontrol 5. ada perbedaan yang signifikan pada diit, olahraga, kontrol, pill count, dan keterkendalian gdpp antara kelompok kontrol dengan intervensi setelah dilakukan konseling. e. saran perlu dilakukan penelitian lebih lanjut dengan menggunakan hba1c sebagai salah satu indikator kepatuhan pasien dalam pengontrolan kadar gula darah secara tepat dan juga perlu dilakukan edukasi pada setiap pasien dm dengan menggunakan pendekatan konseling dalam penyelesaian masalah pasien dm baik diruang rawat inap maupun rawat jalan sehingga dapat membantu meningkatkan pengetahuan, sikap dan perilaku kepatuhan pasien dm tipe 2 dalam mengontrol kadar gula darah pasien. daftar pustaka 1. wild, s., dkk (2004). global prevalence of diabetes: estimates for the year 2000 and projections for care: epidemiology/health services/psychosocial research. 2. perkeni (perkumpulan endokrinologi indonesia). 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(2007). komunikasi apotekerpasien : panduan konseling pasien (edisi 2). penerjemah : a.n. sani. jakarta : penerbit buku kedokteran egc 20 muhammadiyah journal of nursing 28. malathy r, dkk (2011). effect of a diabetes counseling programme on knowledge, attitude and practice among diabetic patients in erode district of south india. journal of young pharmacists vol 3 / no 1. diakses tanggal 16 juli 2013 dari: http://proquest.com jurnal mjn vol. 1 no. 2 revisi fix.indd 185 muhammadiyah journal of nursing abstract background: reporting of patient safety incidents are the basis for building a system of patient care safer, more awareness in implementing patient safety reporting culture will require knowledge, awareness to change attitudes and behaviors become habits. eff orts to improve the knowledge, attitudes and behaviors with training demonstrations. objective: the study is aimed to determine the risk of an incident, determine the level of knowledge, attitudes and behavior as well as provide recommendations to improve patient safety reporting culture in ibs rsst klaten. methods: action research, with purposive sampling, the population is nurses ibs rsst klaten, validity triangulation, with content analysis. results: cycle i know the level of knowledge and ideology. change of attitude: cognitive, all participants have no intention to make a report. aff ective changes seen from the discussion/ refl ection, participants begin to understand these the type of incidents and how to create reports using the internal incident report form. cycle ii increased knowledge on the application and analysis, report formats charging 88.94 value. change of attitude: cognitive, each participant had the courage to report the incident and presented 1, reporting the presence of behavioral change: of fi ve incident. cycle iii: the level of knowledge on the application, analysis and syntesis, charging value increased to 93.09 report format. attitude: cognitive, aff ective, conative. according to the intensity at the level of respect and respondents reported (dare report all incidents). changes in the number of reports the existence of 17 incidents. (22 reporting in 3 cycles). data obtained ktd types of incidents: 7, kpc: 8, knc: 4, and ktc: 3 conclusion: action research with three cycles of training demonstrations, an increase in knowledge, change attitudes and behavior of all participants. there is a plan to followup and reporting of patient safety culture recommendations and unknown risk grading matrixs. keywords: cultural reporting, patient safety, demonstration training sri suparti, elsye maria rosa, yuni permatasari i universitas muhammadiyah yogyakarta suparti2464@yahoo.com action research: pelaporan insiden keselamatan pasien di ibs rsup dr. soeradji tirtonegoro klaten pendahuluan keselamatan pasien rumah sakit adalah suatu sistem dalam membuat asuhan pasien lebih aman yang meliputi pengkajian risiko, identifi kasi dan pengelolaan hal yang berhubungan dengan risiko pasien, pelaporan dan analisis insiden. insiden keselamatan pasien adalah setiap kejadian yang tidak disengaja dan kondisi yang mengakibatkan atau berpotensi mengakibatkan cedera yang dapat dicegah pada pasien yaitu ktd, knc, ktc, kpc. ktd adalah insiden yang mengakibatkan cedera pada pasien. knc adalah terjadinya insiden yang belum sampai terpapar ke pasien, ktc adalah insiden yang sudah terpapar tapi tidak cedera, kpc adalah kondisi potensial cedera (permenkes ri no 1691, 2011). ktd tahun 2000 menurut penelitian di rs utah dan colorado: 2,9%, yang meninggal: 6,6%. di new york: 3,7%, angka kematian 13,6%. angka kematian akibat ktd/adverse event rawat inap diseluruh amerika serikat 33,6 juta/tahun: 44.000-98.000/tahun. who pada tahun 2004 mengumpulkan angka penelitian rumah sakit di berbagai negara: amerika, inggris, denmark, dan australia, ditemukan ktd dengan rentang 3,2– 16,6 %, dengan data tersebut akhirnya berbagai negara mengembangkan sistem keselamatan pasien (depkes ri, 2008). laporan insiden keselamatan pasien di indonesia berdasarkan propinsi menemukan dari 145 insiden yang dilaporkan sebanyak 55 kasus (37,9%) di wilayah dki jakarta. berdasarkan jenisnya dari 145 insiden yang dilaporkan tersebut didapatkan knc: 69 kasus (47,6%), ktd: 67 kasus (46,2%) dan lain-lain: 9 kasus (6,2%) (lumenta, 2008). 186 muhammadiyah journal of nursing tujuh langkah dalam program keselamatan pasien, langkah yang ke 4: kembangkan sistem pelaporan, pastikan staf anda agar dengan mudah dapat melaporkan insiden, serta rs mengatur pelaporan kepada kkp-rs4. pelaporan merupakan dasar untuk mendeteksi masalah keselamatan pasien, sumber informasi lain yang dapat digunakan oleh pelayanan kesehatan dan nasional (who, 2005). pelaporan ikp merupakan dasar untuk membangun suatu sistem asuhan pasien yg lebih aman, 3 kegiatan penting adalah: 1) mendorong seluruh staf untuk melaporkan masalah keselamatan pasien, khususnya kelompok yg tingkat pelaporannya rendah. tingkatan pelaporan yg tinggi biasanya ada pada suatu rumah sakit yg lebih aman, 2) pelaporan agar disalurkan ke tingkat nasional yaitu kkprs utnuk proses pembelajaran bersama, 3) upaya kurangi tingkat keparahan insiden: manajer risiko harus melihat semua laporan dari kematian pada ktd sebelum dikirim ke kkprs. pimpinan rs harus menerima laporan & rencana kegiatan dari semua kematian yg secara langsung berhubungan dgn ikp (lumenta, 2008). pelaporan yang baik dapat meningkatkan mutu keselamatan pasien, apabila terdokumentasi dengan baik, dan semua menerapkan budaya pelaporan setiap ada ikp. budaya merupakan suatu kebiasaan yang bisa dilakukan oleh seseorang tanpa menunggu perintah, agar budaya bisa diterapkan dengan baik, maka seseorang harus mempunyai pengetahuan, kesadaran, untuk merubah sikap dan perilaku menjadi suatu kebiasaan. mutu merupakan gambaran total sifat dari suatu jasa pelayanan yang berhubungan dengan kemampuannya untuk memberikan kebutuhan kepuasan. mutu dalam pelayanan di rumah sakit berguna untuk mengurangi tingkat kecacatan atau kesalahan (wijono, 1999). upaya yang dilakukan untuk membudayakan pelaporan ikp perlu dilakukan peningkatan pengetahuan, pemahaman tentang manfaat pelaporan bagi mutu pelayanan rumah sakit maupun keselamtan pasien, perlu diberikan pelatihan tentang konsep patient safety, jenis insiden, cara pengisian format pelaporan insiden internal, dan alur pelaporannya. tujuannya adalah agar perawat memahami, dan mengetahui manfaat dari pelaporan jika terjadi ktd/knc/ ktc/kpc (ariyani, 2008). pelatihan adalah proses membantu orang lain dalam memperoleh skill dan pengetahuan (marzuki, 1992). pelatihan adalah proses memberikan bantuan para pekerja untuk menguasai ketrampilan khusus, membantu memperbaiki kekurangannya dalam melaksanakan pekerjaan (notoadmojo, 2003). metode pelatihan demonstrasi menguraikan dan memperagakan melalui contoh-contoh, dan sangat efektif, karena lebih mudah menunjukkan cara mengerjakan suatu tugas, karena dikombinasikan dengan alat bantu belajar: gambar, teks materi, ceramah, diskusi (wibawa, 2007). metode demonstrasi lebih efektif dibandingkan video untuk meningkatkan sikap dan pengetahuan (wibawa, 2007). di rsst telah dibentuk tim patient safety sejak tahun 2007, kemudian dilakukan revisi tim patient safety pada tahun 2011, sudah ada program kegiatan tim patient safety namun belum dilaksanakan secara optimal terutama dokumentasi pelaporannya. pengisian format laporan insiden internal belum disosialisakan secara optimal keseluruh unit pelayanan terutama di ibs, sehingga perawat di ibs belum memahami cara pelaporan menggunakan format tersebut, selama ini setiap ada insiden atau beberapa hari setelah ada insiden, mereka melaporkan secara lisan, baik dari ruangan, tim medis, perawat supervisor, karyawan lain, atau komplain dari keluarga. insiden yang terjadi tersebut oleh ruangan melaporkan kepada atasannya/kepala ruang, kemudian kepala ruang menulis kronologis kejadian secara singkat dibuku permasalahan ruangan, dan dilanjutkan melaporkan kepada ke 187 muhammadiyah journal of nursing tim patient safety, kemudian tim patient safety melacak, dan melakukan klarifi kasi keruangan yang terjadi insiden kemudian membuat laporan dengan menggunakan format insiden internal rs dan dilakukan pembahasan/audit medik maupun keperawatan untuk mengetahui kronologis terjadinya insiden, kemudian ada pembahasan dan tindak lanjut berupa pembuatan sop, tapi belum dilakukan rca (bidang pelayanan keperawatan, 2013) jumlah pelaporan insiden pada tahun 2013: 3. di ibs pada bulan januari – agustus 2013: 31 insiden dengan nol laporan. menurut hasil wawancara dari beberapa perawat di rsst ada beberapa insiden yang tidak dilaporkan antara lain: keliru obat tapi diketahui kekeliruannya ketika diruang pelayanan dilakukan pengecekan obat dan obat belum sampai diberikan kepada pasien, pasien jatuh, salah menyebutkan indentitas kelamin, operasi salah sisi, salah pasien saat mengantar pasien akan dilakukan tindakan penunjang. belum semua perwawat berani melaporkan insiden kepada tim patient safety, berdasarkan wawancara kepada beberapa perawat terhadap permasalahan tersebut karena perasaan takut disalahkan, kurang faham manfaat dari pelaporan tersebut, tidak tahu cara melaporkan. dari studi pendahuluan yang peneliti lakukan didapatkan data pelaporan insiden belum optimal dilakukan oleh perawat, sehingga peneliti ingin melakukan action research pelaporan keselamatan pasien dengan metode pelatihan demonstrasi di rsup dr. soeradji titrtonegoro klaten. metode penelitian jenis penelitian kualitatif dengan desain action research. action research, adalah proses spiral tiga siklus yang terdiri dari perencanaan, aksi, observasi, dan refl eksi10. setiap siklus terdiri dari 4 tahap, tahap 1adalah plan, tahap ke 2 action, tahap ke 3 observation, tahap ke 4 refl ection. gambar 3.1. a cycle of action research (adapted from kemmis & mctaggart.1992) tabel 4.2. karakteristik responden di ibs rsup dr. soeradji tirtonegoro klaten bulan september s.d november 2013 no. karakteristik jumlah 1 jenis kelamin laki-laki 5 perempuan 0 total 5 2 usia 40-50 tahun 4 51-60 tahun 1 total 5 3 tingkat pendidikan d3 keperawatan 4 d4 keperawatan 1 total 5 4 lama kerja 20-25 tahun 2 26-30 tahun 3 total 5 5 jabatan kepala ruang 1 koordinator kamar operasi 4 total 5 sumber data primer, september 2013 188 muhammadiyah journal of nursing dari tabel 4.2 diatas dapat diketahui bahwa berdasarkan jenis kelamin, semua partisipan adalah laki–laki, usianya sebagian besar 40 sampai 50 tahun: 4 orang. pendidikan sebagian besar d.iii keperawatan: 4 orang, lama kerja sebagian besar 26 sampai 30 tahun, jabatan sebagian besar partisipan sebagai koordinator: 4 orang. hasil penelitian siklus i (pertama) perencanaan siklus 1, narasumber berasal dari universitas muhammadiyah yogyakarta, dengan materi tentang root causes of sentinel events, wrong site surgeries, jenis insiden patient safety, konsep patient safety, multi causal teory, type insiden, 6 sasaran patient safety, safe surgery, bundles of care in surgical site infection, pentingnya pelaporan insiden, organisational incident model, identifi kasi risiko, blaming. siapa yang bertanggung jawab dalam pelaporan insiden, apa yang boleh dan tidak boleh dilaporkan, contoh contoh kasus. model pelatihannya adalah ceramah, diskusi dan tanya jawab. narasumber yang kedua adalah peneliti sendiri dengan materi pengisian format laporan insiden internal di rumah sakit serta alur pelaporan jika terjadi insiden keselamatan pasien, metode ceramah, diskusi dan demonstrasi. action/pelaksanaan, penjelasan materi pelatihan sesuai dengan perencanaan, model pelatihannya ceramah, diskusi tanya jawab, demonstrasi. lama pelatihan 120 menit, di ruang rapat direktur medik dan keperawatan rsst, pada hari rabu tanggal 25 september 2013 pukul 12.30– 14.30 wib, yang diikuti oleh 5 partisipan dari ibs. materi pelatihan pada siklus 1 dijelaskan sesuai perencanaan. monitoring/observasi proses pelaksanaan pelatihan, dilakukan oleh peneliti bersamaan dengan pemberian materi pelatihan, selama pelatihan dari awal sampai selesai penyampaian materi, semua partisipan terdiam karena belum tahu tentang patient safety dan bagaimana cara membuat laporan jika terjadi insiden, sambil sekali sekali merubah posisi duduknya serta memperhatikan dengan serius. dari 5 partisipan, ada 4 partisipan yang aktif bertanya, dan mulai mengerti, dilihat dari evaluasi/pengamatan selama berlangsungnya pelatihan. refl eksi/evaluasi, setelah diberikan materi pelatihan dengan metode demonstrasi tersebut, semua partisipan awalnya belum tahu tentang patient safety, jenis insiden, cara pelaporan dengan format laporan insiden internal rumah sakit serta alur pelaporannya, maka setelah mengikuti pelatihan sekitar 120 menit, semua partisipan memperhatikan dengan serius, dan aktif diskusi. siklus ii (kedua), rencana dijelaskan kembali yang terkait dengan insiden keselamatan pasien (ktd, knc, ktc, kpc), cara pengisian format laporan insiden internal. action/pelaksanaan menjelaskan kembali tentang cara pengisian format laporan insiden internal, jenis insiden tentang knc, ktc, ktd dan kpc. masing–masing partisipan memaparkan hasil pengisian format laporan insiden internal. monitoring/observasi. tabel. 4.3. hasil skor penilaian format insiden internal di ibs rsup dr. soeradji tirtonegoro klaten pada siklus ii tahun 2013 no siklus ii jumlah skor nilai 1 partisipan i 1 20 82.75 2 partisipan ii 1 20 89.65 3 partisipan iii 1 20 96.55 4 partisipan iv 1 20 93.00 5 partisipan v 1 20 82.75 jumlah rata-rata 5 88.94 berdasarkan tabel 4.3 diatas dapat diketahui bahwa hasil skor pelaksanaan laporan pada insiden keselamatan pasien di ibs pada siklus kedua adalah masing-masing partisipan memaparkan 1 insiden dengan skor 20, penilaian pengisian format laporan insiden internal yang paling tinggi adalah partisipan 3 yaitu 96.55. 189 muhammadiyah journal of nursing tabel 4.4. data insiden di ibs pada siklus ii tahun 2013 no jenis insiden jumlah ket 1 rencana operasi tertunda karena persediaan darah belum ada/belum diambil. 1 kpc 2 operasi ditunda karena pasien panas 39oc. 1 kpc 3 tindakan operasi dibatalkan karena tensi tinggi 200/110 mmhg. 1 knc 4 salah menulis rencana tindakan operasi rencana orif fr. acetabulum tetapi ditulis orif fraktur clavicula. 1 knc 5 insiden memasukkan antibiotik tidak di skin test terlebih dahulu (tidak sesuai prosedur). 1 ktc jumlah 5 grafi k. 4.1. jumlah insiden di ibs rsup dr. soeradji tirtonegoro klaten pada siklus ii tahun 2013 dari hasil penilaian format laporan insiden internal tersebut diketahui bahwa jenis insidennya adalah: kpc, ktc, dan knc, yang paling banyak adalah kpc dan knc, masing-masing 2 insiden. diskusi refl eksi. setelah dijelaskan ulang tentang pengisian format pelaporan insiden internal dan jenis insiden serta pemaparan insiden tersebut, ke 5 partisipan mulai memahami cara pengisian format laporan tersebut, tetapi masih ada beberapa yang belum faham yaitu: tindakan yang dilakukan apabila kejadian yang semula telah terjadi pada unit lain, unit terkait, penyamaan persepsi tentang lokasi insiden (pra, intra dan pasca operasi). siklus iii (tiga). rencana tindak lanjut untuk semua partisipan untuk memaparkan insiden tahap ke 2. action/pelaksanaan masing masing partisipan memaparkan hasil pengisian format laporan insiden internal. monitor/evaluasi dengan mencocokkan kesesuaian pengisian format laporan insiden internal dari masingmasing partisipan dengan standar/juknis yang telah ditentukan, hasil skor penilaiannya adalah tertera pada tabel berikut ini: tabel. 4.5. hasil skor penilaian format insiden internal di ibs rsup dr. soeradji tirtonegoro klaten pada siklus iii tahun 2013 no siklus iii jumlah skor nilai 1 partisipan i 2 11.76 89.65 2 partisipan ii 4 23.52 95.17 3 partisipan iii 5 29.41 94.48 4 partisipan iv 2 11.76 94.82 5 partisipan v 4 23.52 91.37 jumlah rata-rata 17 93.09 berdasarkan tabel 4.5 diatas dapat diketahui bahwa hasil skor pelaksanaan laporan pada insiden keselamatan pasien di ibs pada siklus ketiga ini, hasil paling tinggi yang dibuat pelaporan ada: 5 insiden yang dilaporkan oleh partisipan 3 dengan skor 29.41 dengan penilaian format laporan insiden internal: 94.48, sedangkan hasil penilaian format laporan insiden internal yang paling tinggi dilakukan oleh partisipan 2 dengan jumlah insiden yang dilaporkan 4 dengan skor 23.52 dan total nilai format laporan insiden internal adalah: 95.17. tabel 4.6. data insiden di ibs pada siklus iii tahun 2013 no jenis insiden jumlah ket 1 pengambilan darah prp tidak kena, berulang lasi, pembuluh darah pecah 1 ktd 2 rencana operasi tertunda karena darah tinggi (210/120 mmhg) 1 knc 3 spo (surat persetujuan operasi) belum ada 1 kpc 4 penggunaan instrumen yang kurang 1 kpc 5 pasien terjadi prolong karena operator belum siap tetapi anestesi sudah melakukan pembiusan 1 ktd 190 muhammadiyah journal of nursing no jenis insiden jumlah ket 6 saturasi turun setelah pemasangan et (30) 1 ktd 7 saat di rr perdarahan dan stosel dari hidung sekitar 25 cc. 1 ktd 8 desaturasi sampai spo2-nya 0% selama 5 menit teratasi 1 ktd 9 hbsag (+) tidak dioperkan 1 kpc 10 kekeliruaan penulisan blangko pengiriman frozen dengan nama pasien, cm dan dx medis yang sama dengan pasien yang pertama. 1 ktd 11 memasang laringeal mask airway (lma) lebih dari 1x gagal. 1 ktc 12 penderita dengan hbsag (+) tanpa pemberitahuan ke ibs. 1 kpc 13 tidak ada tanda pada lokasi operasi. 1 kpc 14 terjadi trauma pada usus deodenum. 1 ktd 15 pasien ditunda operasinya karena tekanan darah rendah (td 80/40 mmhg) 1 knc 16 penderita ortho tidak bisa dipasang dc. 1 ktc 17 pasien rencana operasi laparatomi ditunda karena mengalami penurunan saturasi hingga 45 menit. 1 kpc jumlah 17 grafi k. 4.2. jumlah insiden di ibs rsup dr. soeradji tirtonegoro klaten pada siklus iii tahun 2013 berdasarkan jumlah pelaporan insiden keselamatan pasien yang dilakukan oleh 5 partisipan pada siklus 3 ini ada: 17 laporan insiden dengan jenis insiden terbanyak adalah ktd: 7, kpc: 6. refl eksi pada siklus iii, semua partisipan sudah mulai memahami cara pengisian format insiden internal tersebut, tapi untuk menentukan jenis insiden masih agak bingung (dilihat dari ekspresi wajah kelima partisipan ketika melakukan refl eksi/diskusi), dalam penentuan jenis insiden masih menjadi perdebatan saat partisipan 1 presentasi kasus temuannya, maka partisipan 5 menanggapi pemaparan yang disampaikan oleh partisipan 1 terkait kekeliruan dalam menulis nama, no rm serta diagnose pada format pemeriksaan pa. evaluasi dengan observasi keberhasilan pengisian format laporan insiden internal yang dilakuka selama tindakan serta jumlah kejadian insiden keselamatan pasien yang terjadi dan jumlah pelaporan yang di buat oleh responden selama tiga siklus adalah lihat grafi k berikut. grafi k. 4. hasil penilaian format insiden pada siklus i,ii,iii di ibs rsup dr. soeradji tirtonegoro klaten bulan september s.d november 2013 dari hasil pelaporan yang dilakukan oleh partisipan selama tiga siklus didapatkan data peningkatan skor pelaporan yang signifi kan yaitu dari 0 menjadi 20 dan pada siklus 3 menjadi 23.52. peningkatan nilai pengisian format laporan insiden internal dari semua partisipan dari siklus 1: 0, siklus 2: 88,04 dan siklus 3: 29.41. berdasarkan jumlah pelaporan insiden keselamatan pasien yang dilakukan oleh 5 partisipan pada siklus 1sampai 3 ini terdapat 22 laporan insiden dengan jenis insiden terbanyak adalah kpc: 8, ktd: 7, adapun insiden tersebut paling banyak ditemui pada fase intra operasi yaitu ada 14 dari 22 insiden, baik itu ktd, knc, ktc maupun kpc. seperti pada grafi k dibawah 191 muhammadiyah journal of nursing ini: tabel. 4.7. data insiden pada siklus i,ii,iii di ibs rsup dr. soeradji tirtonegoro klaten bulan september s.d november 2013 no jenis insiden jumlah ket a. pra 1 rencana operasi tertunda karena persediaan darah belum ada/ belum diambil 1 kpc 2 operasi ditunda karena pasien panas 39.8c 1 kpc 3 rencana operasi tertunda karena tekanan darah tinggi (210/120 mmhg) 1 knc 4 penderita dengan hbsag (+) tanpa pemberitahuan ke ibs 1 kpc 5 salah menulis rencana tindakan operasi rencana orif clavicula, tapi pasiennya fr. acetabulum 1 knc 6 spo (surat persetujuan operasi) belum ada 1 kpc 7 tidak ada tanda pada lokasi operasi 1 kpc b. intra 8 insiden memasukkan antibiotik tidak di skin test terlebih dahulu oleh tim sirkulasi (tidak sesuai prosedur) 1 ktc 9 pengambilan darah prp (platclct rich plasma) tidak kena/berulang kali, terjadi pembuluh darah pecah 1 ktd 10 penggunaan instrumen yang kurang 1 kpc 11 tindakan operasi dibatalkan karena tensi tinggi 200/110 mmhg, setelah dipasang monitor 1 knc 12 pasien terjadi prolong karena operator belum siap tetapi anestesi sudah melakukan pembiusan 1 ktd 13 saturasi turun setelah pemasangan et (30) 1 ktd 14 terjadi desaturasi, spo2 menjadi nol 1 ktd* 15 hbsag (+) tidak dioperkan, diketahui setelah masuk di ok vii 1 kpc 16 kekeliruan penulisan blangko pengiriman frozen (nama pasien, cm, diagnosa medis) sama dengan pasien yang pertama 1 ktd 17 terjadi trauma pada usus deodenum 1 ktd* no jenis insiden jumlah ket 18 pasien ditunda operasinya karena td rendah (td 80/40 mmhg) 1 knc 19 pasien rencana operasi laparatomi ditunda karena mengalami penurunan saturasi hingga 45 menit 1 kpc 20 memasang laringeal mask airway (lma) > 1x gagal 1 ktc 21 penderita ortho tidak bisa dipasang dc 1 ktc c. post 22 saat di rr perdarahan dan stosel dari hidung sekitar 25 cc 1 ktd* jumlah 22 sumber data primer: pelaporan perawat ibs tanda * dilakukan audit medik oleh tim patient safety rs grafi k. 4.4. jumlah jenis insiden pada siklus i,ii,iii di ibs rsup dr. soeradji tirtonegoro klaten bulan september s.d november 2013. grafi k. 4.5. jumlah jenis insiden pada tiga siklus di ibs rsup dr. soeradji tirtonegoro klaten bulan september s.d november 2013. 192 muhammadiyah journal of nursing setelah action research tiga siklus wawancara dengan kepala ruang dan ketua tim patient safety. gambar 4.6 hasil wawancara mendalam tentang budaya pelaporan patient safety dengan kepala ruang ibs dan ketua patient safety rsup dr. soeradji tirtonegoro klaten diskusi setelah dilakukan pelatihan 3 siklus kepada 5 partisipan, dengan melihat peningkatan pengetahuan, perubahan sikap dan perilaku, dapat dilihat pada pembahasan berikut: 1. peningkatan pengetahuan siklus i, partisipan 1 baru pada tingkat tahu (knowledge level), partisipan 2, 3, 4, 5 sudah mengalami peningkatan pengetahuan pada tingkat memahami (comprehension level), partisipan 3, peningkatan pengetahuan pada tingkat memahami (comprehension level). siklus ii: partisipan 1 pada tingkat menggunakan/ application, partisipan 2, 3, 4, dan 5 pada tingkat menguraikan (analysis. penilaian format pelaporan insiden partisipan 1: 82,75. masuk kategori baik, partisipan 2: 89,65. masuk kategori baik, partisipan 3: 96,55. masuk kategori baik, partisipan 4: 93,00. masuk kategori baik, partisipan 5: 82,75. masuk kategori baik. siklus iii, partisipan 1, pada tingkat menggunakan/aplication, partisipan 2 dan 5 berada pada tingkat menyimpulkan/sintesis, partisipan 3 dan 4, mampu menguraikan/analisis. penilaian format pelaporan insiden partisipan 1: 88,65. masuk kategori baik, partisipan 2: 95,17. masuk kategori baik, partisipan 3: 94,48. masuk kategori baik, partisipan 4: 94,82. masuk kategori baik, partisipan 5: 91,37. masuk kategori baik. ariyani (2009), tentang analisis pengetahuan dan motivasi perawat yang mempengaruhi sikap mendukung penerapan program patient safety sikap mendukung tinggi (76,3%), pengetahuan perawat baik (76,3%) motivasi perawat baik (7 1,1%). wibawa (2007), dalam perbedaan efektifi tas metode demonstrasi dengan pemutaran video terhadap peningkatan pengetahuan, hasil penelitian menunjukkan ada perbedaan antara metode demonstrasi dan metode video dalam meningkatkan pengetahuan yang menunjukkan peningkatan pengetahuan 58,97% lebih tinggi pada kelompok perlakuan demonstrasi (wibawa, 2007). kalau penelitian yang dilakukan oleh peneliti, partisipan setelah diberikan pelatihan menggunakan metode demonstrasi dengan action research, pada 3 siklus mengalami peningkatan pengetahuan, 1 partisipan pada level aplikasi, 2 partisipan pada level analisis, dan 2 partisipan pada level sintesis. penilaian tingkat pengetahuan dilihat pada hasil penilaiaan format laporan insiden internal, semua nilai dari 5 partisipan masuk kategori baik, siklus 1: 0, siklus ii: 88,94 dan siklus iii: 93,09. jadi pada penelitian ini terjadi peningkatan pengetahuan partisipan yang signifi kan dalam membuat penggunaan format laporan insiden internal rumah sakit, dari 0 menjadi 93,09. menurut bloom kognitif manusia ada 6 tingkatan: knowledge, 193 muhammadiyah journal of nursing comprehension, application, analythical, synthesis level, valuation. sesuai dengan penelitian ini bahwa setelah dilakukan pelatihan pada 5 partisipan, masing–masing partisipan terjadi peningkatan pengetahuan pada level aplikasi sampai sintesis, hasil penelitian ini dengan pendapat para peneliti maupun referensi yang peneliti dapatkan hampir sama, bahwa penelitian demonstrasi sangat berpengaruh untuk peningkatan pengetahuan baik dilihat dari level maupun penilaian format laporan insiden internal yang dilakukan oleh semua partisipan. 2. perubahan sikap pada siklus i. kognitif: semua partisipan ada niat untuk membuat pelaporan, afektif dilihat dari diskusi/refl eksi, dalam diskusi sudah mulai faham jenis insiden dan cara membuat laporan menggunakan format laporan insiden internal. siklus ii, kognitif: semua partisipan sudah berani melaporkan insiden masing-masing melaporkan 1 insiden dan dipresentasikan. didalam diskusi refl eksi saling mendiskusikan tentang jenis insiden, lokasi kejadian yang menurut partisipan hal tersebut diyakini benar pemahamnnya. konatif mempunyai kecenderungan berperilaku untuk membuat laporan insiden yang terjadi di kamar operasi. dilihat dari tingkatan sikap, partisipan 1, pada tingkat menanggapi, partisipan 3, dan 4, sikapnya sudah pada tingkat menanggapi, partisipan 2 dan 5 sudah sampai pada tingkat menghargai. siklus iii, sikap kognitif, semua partisipan sudah berani melaporkan insiden dari masing-masing partisipan yairtu partisipan 1: 2, partisipan 2: 4, partisipan 3: 5, partisipan 4: 2 dan partisipan 5: 4 insiden. pada siklus 3 ini perubahan sikap dari partisipan menurut intensitasnya pada tingkat menghargai dan bertanggungjawab. sesuai james a (2004), dalam penelitiannya, perawat secara signifi kan melaporkan > 80% dari medical error. alasan tidak dilaporkan termasuk kurangnya kepastian tentang apa yang dianggap sebagai kesalahan pada tabel 3 (40,7%) dan kekhawatiran tentang orang lain berimplikasi (37%). intervensi yang akan mengarah pada peningkatan pelaporan termasuk pendidikan tentang kesalahan yang harus dilaporkan pada tabel 4 (65,4%), umpan balik secara teratur tentang error dilaporkan (63,8%) dan tentang peristiwa individu (51,2%), bukti-bukti perubahan sistem karena laporan kesalahan (55,4%), dan format elektronik untuk laporan (44,9%). josé d jansma (2011), dalam penelitiannya yang mengikuti pelatihan 2 x hasilnya: 25 orang (57%) mengalami perubahan positif dalam pengetahuan, ketrampilan dan sikap yang ditemukan setelah pelatihan. pelatihan keselamatan pasien memiliki efek positif jangka panjang pada pengetahuan, ketrampilan dan sikap, dan mempengaruhi perilaku pelaporan responden. menurut robbins (2001) ada tiga komponen struktur sikap yang penting dan saling menunjang yaitu komponen :kognitif, afektif, konatif. sikap mempunyai tingkatan berdasarkan intensitasnya yaitu: menerima, menanggapi. menghargai (robins, 2001). hampir sama dengan hasil penelitian ini, bahwa dengan pelatihan ternyata dapat merubah sikap dari semua partisipan, yang awalnya sebelum dilakukan pelatihan semua partisipan takut untuk untuk melaporkan, takut disalahkan, tidak tahu bagaimana cara melaporkan, tidak tahu manfaat pelaporan insiden, setelah dilakukan pelatihan tiga siklus dari tanggal 25 september sampai 15 november 2013, ternyata semua partisipan sudah berani melaporkan insiden yang terjadi di ibs sejumlah 22 insiden. sesuai dengan penelitian ini untuk perubahan sikap dilihat dari intensitasnya bahwa semua responden sudah terjadi perubahan sikap dilihat dari kognitif, afektif serta intensitasnya. partisipan 1 pada tingkat menanggapi, partisipan 2 dan 5 pada tingkat menghargai, partisipan 3 dan 4, 194 muhammadiyah journal of nursing pada tingkat menanggapi. 3. perubahan perilaku. pada siklus i, belum ada perubahan perilaku, sebelum pelatihan ada 31 insiden dengan nol pelaporan. siklus ii, perubahan perilaku dari masingmasing partisipan melaporkan 1 insiden, total pelaporan adalah 5 insiden. dilihat dari factor predisposisi, pemungkin dan penguat ke 5 partisipan. siklus iii perubahan perilaku, semua partisipan sudah mempunyai kesadaran untuk melaporkan setiap ada insiden, pada siklus 3: 17 laporan insiden, total pelaporan selama 3 siklus: ada 22 laporan dari 22 insiden yang dilakukan oleh 5 partisipan, hal ini telah membuktikan bahwa setelah dilakukan tindakan pelatihan dengan metode demonstrasi ternyata sudah ada peningkatan/perubahan perilaku. dilihat dari faktor predisposisi, pemungkin dan penguat, sangat baik sekali pengaruh pelatihan terhadap perubahan perilaku partisipan dalam penelitian ini. faktor predisposisi adalah adanya kepercayaan responden untuk membuat pelaporan, faktor pemungkin yaitu responden melakukan pelaporan insiden dengan menggunakan format insiden internal yang telah disediakan, faktor penguat yaitu semua responden telah membuat pelaporan setiap ada insiden sesuai aturan yaitu menggunakan format laporan dan dilaporkan dalam waktu 2x24 jam sesuai dengan aturan yang ada di rsst. perubahan perilaku pada semua partisipan setelah dilakukan pelatihan menggunakan metode demonstrasi ini ternyata mengalami perubahan yang lebih baik, yang awalnya sebelum diberikan pelatihan, belum ada perilaku partisipan untuk melaporkan setiap ada kejadian, tetapi setelah dilakukan pelatihan terjadi peningkatan yang luar biasa dari 0 menjadi 22 pelaporan selama tiga siklus. pelatihan akan meningkatkan pengetahuan, sikap dan perilaku sehingga akan terjadi peningkatan budaya pelaporan patient safety, sesuai dengan pendapat para peneliti dan teori, dengan action research dengan tiga siklus didapatkan peningkatan pengetahuan, perubahan sikap dan perilaku serta berdasarkan dari hasil wawancara dengan kepala ruang maupun ketua tim patient safety bahwa budaya pelaporan patient safety perlu adanya pelatihan, demonstrasi dan campurtangan manajemen/pimpinan. sesuai penelitian fadi el-jardali (2011), pelaporan advest event, komunikasi, kepemimpinan keselamatan pasien dan manajemen, staf, dan akreditasi diidentifi kasi sebagai prediktor utama budaya keselamatan pasien. natasha j verbakel (2013), dengan cluster acak, dengan 3 uji control trial, yang dilakukan di 30 praktek umum di nederland. hasil mencakup jumlah insiden yang dilaporkan dan indikator beberapa kualitas dan budaya keselamatan pasien. serta wawancara dilakukan tindak lanjut untuk mengevaluasi proses pelaksanaan intervensi. hasil penelitian ini akan memberikan wawasan dalam efek pemberian kuesioner budaya atau kuesioner dengan lokakarya yang saling melengkapi. 4. dalam penelitian ini partisipan yang peneliti teliti adalah perawat, karena perawat yang cenderung berkonstribusi lebih besar mengetahui adanya kejadian/insiden di kamar operasi, sehingga perawat cenderung berkonstribusi untuk lebih besar melaporkan insiden, seuai peneliti james a (2004), perawat signifi kan melaporkan > 80% dari mr, alasan tidak dilaporkan pd tb 3 (40,7% r),khawatir tentang orang lain berimplikasi (37%). intervensi yang mengarah pada peningkatan pelaporan/pendidikan tentang kesalahan yang harus dilaporkan pada tb 4 (65,4% r). agar partisipan tahu dan akan merubah sikap dan perilaku maka perlu dilakukan pelatihanpelatihan tentang patient safety, seperti peneliti josé d jansma (2011), pelatihan sangat mempengaruhi pengetahuan, ketrampilan dan 195 muhammadiyah journal of nursing sikap seseorang untuk penanganan insiden patient safety, trampil untuk memperhatikan dan menganalisa insiden, mampu menilai jenis insiden yg layak dilaporkan, menyadari pentingnya pelaporan insiden & memiliki niat untuk melaporkan, memiliki efek positif pada pelaporan insiden. pelatihan patient safety memiliki efek positif jangka panjang pada pengetahuan, ketrampilan dan sikap, dan mempengaruhi perilaku pelapaporan. 5. persamaan dengan penelitian ini setelah dilakukan pelatihan tiga siklus juga dilakukan wawancara dengan kepala ruang maupun tim patient safety untuk rencana tindak lanjut dan rekomendasi terhadap manajmen/ pimpinan rumah sakit untuk optimalisasi budaya pelaporan patient safety. kalau dibandingkan denga peneliti sebelumnya yaitu joel s, (2008), wawancara dilakukan oleh dokter secara langsung dan parallel kepada pasien sehinggadidapatkan hasil: dari 998 studi pasien, 23% memiliki 1 adverse events terdeteksi oleh wawancara dan 11% memiliki 1 adverse events yang teridentifi kasi oleh medical record. grading, berdasarkan hasil penelitian dengan action research, didapatkan jenis insiden ktd yang tidak terjadi cedera ada: 3, mengalami cedera ringan ada: 2, dan cedera sedang ada: 2. berikut hasil grading matrixnya dilihat pada setiap insiden ktd. frekwensi dampak potensial konsekwensi tindakan sangat sering terjadi (tiap mgg/bln) 2x sebulan tidak cedera (tidak signifi kan) moderat (risiko sedang) 1. salah menulis blangko pemeriksaan pa 2. pendarahan di rr, setelah post operasi 3. saturasi turun setelah pasang et 1. dilakuan investigasi sederhana paling lama 2 minggu. 2. manajer/pimpinan klinis menilai dampak terhadap biaya dan kelola risiko. sangat sering terjadi (tiap mgg/bln) 2x sebulan cedera ringan (minor) moderat (risiko sedang) 1. pengambilan darah prp > 1 kali, pembuluh darah pecah 2. disaturasi 1. dilakukan investigasi sederhana paling lama 2 minggu. 2. manajer/pimpinan klinis menilai dampak terhadap biaya dan kelola risiko. sangat sering terjadi (tiap mgg/bln) 2x sebulan cedera sedang (moderat) high (risiko tinggi) 1. trauma usus duodenum 2. prolong karena operator masih mengerjakan pasien lain, pasien sudah dibius 1. dilakukan rca paling lama 45 hari. 2. kaji dengan detail dan perlu tindakan segera. 3. membutuhkan perhatian top manajer. gambar 4.8. risk grading matrix pada setiap insiden dan tindakan yang dilakukan pada gambar diatas dapat dilihat grading maupun tindakan yang seharusnya dilakukan oleh tim patient safety, grading dilaksanakan pada awal sebelum terjadi ktd, sehingga tahu apa yang akan dilakukan oleh rumah sakit. dari 7 insiden tersebut, yang masuk dalam potesial konsekuensi moderat adalah 5 insiden, dan yang masuk dalam potesial konsekuensi high risk ada 2 insiden. tindakan pada high risiko dilakukan tindakan pembahasan kasus dengan rca dalam waktu 45 hari dan di lakukan identifi kasi secara mendetail serta perlu untuk segera ada tindakan dari top manajer. kekuatan dan kelemahan penelitian 1. kekuatan a. sudah adanya program dari tim pasien safety. b. metode action research sehingga insiden yang selama ini tidak terlaporkan bisa digali permasalahannya/alasannya 196 muhammadiyah journal of nursing c. sampelnya dengan menggunakan perawat coordinator kamar operasi dan penanggung jawab ibs sudah sesuai d. instrumen pelaporan insiden internal rumah sakit sesuai standar depkes e. materi pelatihan yang digunakan sudah baku. 2. kelemahan a. metode penelitian action research harus dilakukan beberapa kali tindakan sehingga membutuhkan kejelian. b. sampelnya 5 responden sehingga tidak bisa digereralisir untuk satu rumah sakit, hanya sesuai untuk ibs saja. c. ujivaliditas transferbility tidak bisa digunakan untuk ruang lain selain ibs. d. instrumen untuk wawancara belum standard karena berdasarkan hasil dari penilaian action research (siklus i,ii,iii). kesimpulan berdasarkan hasil penelitian dengan action research dengan tiga siklus serta pembahasan maka bisa diambil kesimpulan sebagai berikut: 1. penilaian grading risiko pada jenis insiden ktd yang tidak ada cedera dan yang cedera ringan, pada matrik grading risiko moderat/ warna hijau, dengan risiko sedang, dilakukan investigasi sederhana. ktd dengan cedera sedang, matrik grading risiko masuk moderat/ warna kuning, risiko tinggi, dilakukan rca paling lama 45 hari, kaji dengan detail dan perlu tindakan segera serta membutuhkan perhatian top manajer 2. pengetahuan partisipan meningkat dari siklus i sampai dengan siklus iii. a. pada siklus i terjadi peningkatan pengetahuan pada knowledge level and comprehension level. b. siklus ii terjadi peningkatan pengetahuan pada application and analysi level. c. siklus iii terjadi peningkatan pengetahuan analysis and syntesis level. d. penilaian format laporan insiden internal mengalami peningkatan, dari siklus i: 0, siklus ii: 88,94 dan siklus iii: 93,09. 3. perubahan sikap pada siklus i sampai siklus iii a. siklus i: perubahan sikap kognitif ada niat untuk membuat pelaporan insiden. perubahan afektif mulai faham tentang jenis insiden dan cara membuat laporan menggunakan format laporan insiden internal. b. siklus ii, sikap kognitif, semua partisipan sudah berani melaporkan insiden pasien safety dari 0 menjadi 5 laporan. sikap afektif semua partisipan memahami jenis insiden, lokasi. konatif mempunyai kecenderungan berperilaku untuk membuat laporan insiden. dilihat dari tingkatan sikap: pada tingkat menanggapi, dan menghargai. c. siklus iii sudah berani melaporkan insiden pasien safety sebanyak 17 pelaporan. tingkat perubahan sikap pada tingkat konatif yaitu cenderung berperilaku untuk melaporkan insiden sesuai sikap yang dimiliki oleh partisipan yang berkaitan dengan adanya insiden di ibs. sikap dilihat dari intensitasnya pada tingkat menghargai dan bertanggungjawab untuk berani melaporkan semua insiden untuk pembenahan sistem di kamar operasi. 4. perubahan perilaku dengan adanya kesadaran melakukan pelaporan selama tiga siklus ada 22 pelaporan dari 22 insiden. perubahan perilaku baik dilihat dari faktor predisposisi yaitu adanya kepercayaan responden untuk melaporkan insiden, pemungkin yaitu responden melakukan pelaporan insiden dengan menggunakan format insiden internal yang telah disediakan, penguat yaitu adanya pelaporan yang dilakukan oleh partisipan sesuai dengan aturan yang ada di rsst tersebut. 197 muhammadiyah journal of nursing 5. adanya rencana tindak lanjut dan optimalisasi pelaporan insiden patient safety: sosialisasi, motivasi, observasi secara periodic, bimbingan untuk menindaklanjuti, pelatihan,demonstrasi, revisi protap, pembakuan adanya sign in, time out, dan sign out, sk tim investigasi, investigasi dan grading, dokumentasi, rca. 6. ada rekomendasi dari ketua tim patient safety kepada manajemen: inhouse training, demonstrasi dengan meniru, optimalisasi pelaporan yang baik sistematis dan ada peran manajemen. 7. didapatkan data insiden sebanyak 22 insiden, dan jenis insidennya ktd: 7, kpc: 8, knc: 4, dan ktc: 3 saran 1. merealisasi program tim patient safety secara optimal dan kejadian-kejadian yang mengakomodasi semua unit di rumah sakit. 2. perlunya dilakukan inhouse training di rsup dr. soeradji tirtonegoro klaten untuk peningkatan pengetahuan dengan metode pelatihan demonstrasi. 3. perlunya recording, reporting, pendokumentasian, setiap ada insiden patient safety. 4. perlunya semua perawat memahami tentang jenis insiden patient safety dan cara pencegahan insiden patient safety. 5. perlunya sosialisasi dan motivasi serta pemberian reward dalam implementasi pembuatan laporan. 6. ada evaluasi pencatatan dan observasi secara periodik terhadap insiden patient safety. 7. perlunya pembakuan/adanya sop tentang pelaksanaan sign in, time out, dan sign out di ibs oleh manajemen rumah sakit. 8. perlunya ada sk tim investigasi patient safety. 9. perlunya tim patient safety melakukan investigasi dan grading serta rca setiap ada insiden patient safety yang berat dan tindak lanjutnya. 10. perlunya revisi protap terkait dengan pelayanan, fasilitas dan sarana prasarana. 11. perlunya tim patient safety melakukan evaluasi pelaporan insiden patient safety untuk semua pemberi pelayanan. 12. untuk peneliti selanjutnya perlu dilakukan penilaian kepatuhan melaksanakan safe surgery ceklist secara rutin. 13. perlu dilakukan investigasi yang mendalam dan melakukan rca untuk kasus high daftar pustaka ariyani, 2008, analisis pengetahuan dan motivasi perawat yang mempengaruhi sikap mendukung penerapan program patient safety di instalasi perawatan intensif rsud dr moewardi surakarta, diakses 20 mei 2012, dari htt p://www.search-results.com /web bidang pelayanan keperawatan, 2013, data rsup dr. soeradji tirtonegoro klaten bloom b,1956, taxonomy of educational objectives. handbook i:cognitive domain, diterbitkan oleh mckey new york. diunduh 17 desember 2013 htt p:// penelitiantindakankelas.com/2013/04/ p e m b a g i a n r a n a h d o m a i n k o g n i t i f bloom.html departemen kesehatan republik indonesia, 2008, panduan keselamatan pasien rumah sakit patient safety, edisi 2, jakarta. hal 7 fadi el et al., 2011, predictors and outcomes of patient safety culture in hospitals. bmc health services research, htt p://www. biomedcentral. com/ 1472-6963/11/45 james a. taylor, md, 2004, use of incident reports by physicians and nurses to document medical errors in pediatric patients, from the developmental center for evaluation and research in pediatric patient safety and ‡department of pediatrics, university of washington and children’s hospital 198 muhammadiyah journal of nursing and regional medical center, seatt le, washington; §university of washington school of nursing, seatt le, washington; and _children’s hospital and regional medical center, seatt le, washington. accepted for publication apr 26, 2004. joel s. weissman, phd; eric c. schneider, md, msc, etall, 2008, comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not. ann intern med. 2008;149:100-108. downloaded from: htt p://annals.org/ by a radboud universiteit nijmegen user on 12/04/2013 josé d jansma, cordula wagner, 2011, eff ects on incident reporting after educating residents in patient safety: a controlled study, bmc health services research kaufman g, 2013, dalam the eff ect of organisational culture on patient safety, nursing standard. 27, 43, 50-56. date of submission: december 1 2012; date of acceptance: march 11 2013. kemmis, s. & mctaggart, r.,1992. the action research planner 3rd edition,. victoria: deakin university press. lumenta.a, 2008, pedoman pelaporan iinsiden keselamatan pasien ikp, patient safety incident report, komite keselamatan pasien rumah sakit kkp-rs, edisi 2,hal;9-11, jakarta marzuki, m.s,1992, strategi dan model pelatihan, malang : ikip malang. natasha j verbakel, 2013, cluster randomized, controlled trial on patient safety improvement in general practice: a study protocol. verbakel et al. bmc family practice 2013, 14:127 http://www.biomedcentral.com/14712296/14/127 nawawi, h, 1997,. manajemen sumber daya manusia, yogyakarta, gajah mada universitas notoatmodjo.s. 1990, pengantar perilaku kesehatan. jurusan pkip. fkm ui. jakarta. peraturan menteri kesehatan republik indonesia nomor 1691/menkes/per/viii/2011, tentang keselamatan pasien rumah sakit, bab i, ps. 1, ayat;1,2,3,4,5,6,7,8 robbins stephen p. 2001, perilaku organisasi,pt. prenhallindo, jakarta who draf guide lines for adverse event reporting and learning, 2005.hal.3 wijono, d. 1999,. manajemen mutu pelayanan kesehatan. teori, strategi dan aplikasi. volume 1 dan 2. airlangga university press. surabaya. wibawa,c, 2007, perbedaan efektifi tas metode demonstrasi dengan pemutaran video tentang pemberantasan dbd terhadap peningkatan pengetahuan dan sikap anak sd di kecamatan wedarijaksa kabupaten pati, jurnal promosi kesehatan indonesia vol. 2 / no. 2 / agustus 2007 indonesian journal of nursing practices 82 ijnp (indonesian journal of nursing practices) vol 3 no 2 december 2019 : 82-91 adisurya saputra1, bahrul ilmi2, yustan azidin3 1sekolah tinggi ilmu kesehatan (stikes) cahaya bangsa banjarmasin 2politekkes banjarmasin 3universitas muhammadiyah banjarmasin corresponding author: adisurya saputra email: adisurya.twins@gmail.com the assessment of nurse’s performance by using a logbook in hospital article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.3297 abstract background: nurses are the majority of human resources in the hospitals whose role determines the quality of health care and they are most closely associated with patients. they are the most dominating human resources in hospital who have the most frequent interaction with the patients. therefore, the primary indicator of the hospitals' quality service is in its nursing services. the capabilities and competencies of the nurses can be assessed through a nursing logbook strategy. objective: this research aimed to explore the implementation of performance assessments using the nursing logbook. method: this research was conducted using a qualitative method with a phenomenological approach. data collection was conducted from november to december 2017 by using in-depth interviews with six participants who were selected by using purposive sampling techniques. the participants were nurses in dr. h. moch. ansari hospital. results: the research results covered six themes, namely the existence of a nursing logbook for nurses, the purpose and the benefit of logging book in nursing, the relationship between a nursing logbook and credentials, the implementation of nursing logbook, the constraints or the barriers in the implementation of the nursing logbook, and the expectations of nurses towards the nursing logbook. conclusion: the system of implementing the logbook as a tool for the nurses' performance assessment is not optimal due to the limited socialization to the nurses in the hospital. keywords: nursing logbook; performance appraisal introduction nurses are the majority of human resources in hospitals whose role determines the quality of health care as they are responsible for patient safety. they are also the most frequently interacting hospital personnel with the patients. nursing services are part of the health service in the hospital that the quality of which is influenced by the quality of nursing services. it, moreover, becomes one of the indications of the community’s valuation towards the health services agency (hospital) as nurses are the largest working group in the hospital's service system and also the highest number of professions most closely associated with the patient. therefore, one of the indicators of the hospital service quality is the quality of the nursing service itself. one strategy to improve the quality of the nurse is through an effective nurse performance assessment mechanism as the goal of the assessment is to motivate and improve the performance. when the motivation of work is unwell, the performance of nurses is also low, 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/5435 vol. 3 no. 2 december 2019 83 vice versa (witjaksono, hartiningsih, & indriana, 2017). the performance assessment of nurses is a process by which the achievement of individual or group performance is measured, evaluated, and compared to the predefined standards (ellis, & hartley, 2012). besides referring to five nursing care standards, the nurse's performance assessment aspect also includes nursing practice quality, nurse education, nurse professional practice, collegiality, collaboration, ethical action, resource utilization, and research (ana, 2010). the results of the observation and the interview with several nurses in dr. h. moch. ansari saleh hospital regarding the implementation of performance assessments using the logbook in the get data is still empty based on their competence, their work, their nursing actions towards the patients as they have not implemented the logbook optimally. based on the assessment conducted, it showed that the supervisor (head of the room/team leader/charge shift) and the peer/co-worker did not observe the subordinates and their peers. the nurse stated that they hardly understood how to fill the logbook, and it was difficult to fill after performing such competency actions. the implementation of a performance assessment using the logbook in indonesia is still not yet widely used. however, this form of assessment is suggested by the committee of hospital accreditation (kars) because the logbook can ease the nursing committees to do the tasks, particularly the credentials section. logbook can be used as a proof of credentials and can also be a determinant of continuing professional development (cpd) or continuing education, setting a career-level in nursing or career-level development, as well as providing clinical authority and competence in the work unit. the development of education and training for nurses is highly crucial as it can affect the performance of nurses. (kars, 2011; ayed, 2015). method this research used a qualitative method with a phenomenological approach. this study explored the implementation of nurse performance assessments using a logbook. data collection was conducted by undertaking in-depth interviews or structured interviews, field records, and recording aids. the subject of the research was nurses at dr. h. moch. ansari saleh hospital banjarmasin, taken with the purposive sampling technique. there were six participants in this study selected based on their level of obedience. criteria of the selection were, such as the nurses had to have a logbook, understood about the logbook, would be willing to become a proven participant by signing a statement of research approval, and was able to disclose their experience well. the data collection was conducted for a month from november 2017 to december 2017 in emergency areas, pediatric areas, and medical areas at dr. h. moch. ansari saleh hospital. data analysis was done through data reduction, data presentation, and withdrawal of conclusions or verification (miles and huberman 1984 in sugiyono 2014). results the results of qualitative data analysis collected through an in-depth interview with six participants were 6 (six) themes and 23 (twenty-three) categories identified. the explanation of each theme based on the responses of participants is as follows: 1. the existence of a nursing logbook this nursing logbook is very good but raises several different perceptions among nurses, such as the definition of the logbook itself, the timing of the implementation of the logbook, and the procedure of how to fill a logbook. the following responses are: "this logbook for nurses hmm.. it is quite good because we can finally know the competencies that we have to master.” (participant 5). table 1. characteristics of participants kategori p1 p2 p3 p4 p5 p6 age 29 yo 42 yo 39 yo 43 yo 42 yo 34 yo gender female male male female female male working period 5 yo 5 yo 14 yo 17 yo 10 yo 8 yo education ners ners bachelor ners ners vocational indonesian journal of nursing practices 84 "in terms of the existence of the logbook, we can know along with what we have done because most of the time, there is a job that has no feedback yet. so it is like we are full of assumptions. nevertheless, the implementation of the logbook will ease us, and we will understand where we are heading on.” (participant 6). regarding the time of the implementation of the nursing logbook, it can be concluded from the research result that there is a difference in the starting time of the implementation of the nursing logbook in each treatment area, as responded by the following participants: "this is already the beginning of the year and the logbook is still not collected yet.. hmm.. still in the process. i think it will have been collected by the end of this year.” (participants 1) "the nursing logbook actually started to be applied by the beginning of 2017. nevertheless, not all of us here could have carried out optimally, including in the icu area.” (participant 2) “the mapping here started in 2015. it means the determination of the first career-levels development... and then the logbook was implemented in 2016.” (participant 4) the logbook owned by all nurses has a format of 9 (nine) columns divided into 3 (three). the first three columns named “supervision” indicate the actions of the nurse that correspond to the content of the logbook, and it should be viewed by the supervisor as much as three times. meanwhile, the next three columns named “peer group” indicates that the nurse does the action along with other nurses three times, and the last three columns are self-reliant, which indicates that the nurse can take action independently. furthermore, if the nurse wants to fill the logbook, they first have to complete the first three columns, and then it is followed by filling the next columns. however, by the time researchers sought the information in the field, it was found that many nurses still did not understand how to fill it, as expressed by the following participants: "i filled the logbook only based on what i understand so far as sometimes, others understand it differently.” (participant 1) "... what firstly is in the book is supervision, isn’t it? it means the person who supervises the nurses when they are doing the action… for example, the supervision is done today and who is supervising the nurse when they do the action. that is the person who has to sign" (participant 4) "there are three types of columns in the logbook, such as supervision, peer, and self-reliance that have to be filled. moreover, the supervision type here has levels." (participant 5) "to fill the logbook… there is a clue on how to fill it in the first page. like what i told... the action is done at least three times.... "(participant 6) 2. the purpose and the benefit of the nursing logbook the nursing logbook can be prerequisites for career development and a credit score for the promotion of nurses. as the following participants respond: "one of the purposes is for the promotion to raise the credit score… it is one of the requirements " (participant 2) "yeah, the benefit of the logbook is that the workload of the nurse can fit each of their career levels.” (participant 6) by using the logbook, we will be able to know what competencies have been mastered by the nurse. furthermore, we also can assess whether the workload is following the competencies of the nurse. "so, the benefit is to know the competencies.” (participant 1) "our work will be more directed and specific. thus, we will have our valuation on whether or not our work complies with the competence "(participant 3) "it is good to assess if the competence of clinical nurse has been achieved. for instance, some vol. 3 no. 2 december 2019 85 competencies have to be mastered by clinical nurse level 1, so we can measure whether a nurse has been able to achieve the competence of clinical nurse level 1 level.” (participant 4) the nursing logbook is very useful for nurses because it can improve their individual skills by referring to a list of competencies in the logbook. "the goal is actually to improve the individual ability, for example, to achieve competencies… like us, we are here in this room as an individual judgment.” (participant 4) participants revealed that the purpose and the benefit of the logbook are for the safety of patients, after all. "the benefit is, after all, for the safety of patients. if we work based on the standard operational procedure (sop), the patient will obtain a safe and good service.. as it is already based on the right procedure.” (participant 5) 3. the connection between the nursing logbook and the credentials participants reveal that there are nurses who take nursing actions based on their right career level, and there are some who do not. for instance, the nurse who is supposed to be still in clinical nurse level i already has authority in clinical nurse level ii or iii. "as there are many workloads they have to bear, they still carry the duty both in clinical nurse level 2 and clinical nurse level iii. in terms of the duty in clinical nurse level i, it is because the selection on both clinical nurse level i and clinical nurse level ii is still inappropriate.” (participant 2) "maybe, the morning shift is already appropriate because there are much personnel. however, the evening shift lacks personnel so that the duty that is supposed to be carried out by clinical nurse level iii is handled by clinical nurse level ii. thus the duty has not been carried out optimally.” (participant 4) the logbook is based on the white book of its clinical authority that it is also based on its career path and its departments, such as critical departments, surgery, children, psyche, and maternity. each department has a different logbook and career path. for example, the surgical department has various types of the logbook, such as clinical nurse level i, clinical nurse level ii, clinical nurse level iii, and clinical nurse level iv, as well as other departments. however, in fact, many nurses have not yet adjusted the action with the logbook and the career path. as the following participants responded: "hmm.. the fulfillment still depends on the level.” (participants 2) "yea... it has been divided into clinical nurse level i, clinical nurse level ii, and clinical nurse level iii.” (participant 5) "yea... it has been divided accordingly. each of the levels has a working period.” (participant 6) participants revealed that the nursing logbook is an essential element to credential proposal in the nursing committee. it is because when the nurse proposes a re-credential, they must submit a logbook that has already been filled as a portfolio that will later be verified by the nursing committee. "i do not know about it. it maybe has affected the valuation process because here they can know our real competencies and abilities.” (participant 1) "one of the purposes is to propose promotion and to apply credit scores.” (participant 2) "yes. it is useful for measuring instruments. for example, we will be able to know whether a nurse deserves to level up into the next clinical nurse level.” (participant 4) five participants revealed that there are still many nurses’ duties that have not yet corresponded well with the levels; for instance, the logbook for the children room is mixed with the one for the maternity room. "there are some nurses who do not perform 100% optimally because of an inadequate room… and competence is not optimal yet.” (participant 1) "there are some inappropriate divisions.” (participant 2) "sometimes, there are some duties which do not correspond with the patients. theoretically, this may already be in line with the clinical nurse level iii. indonesian journal of nursing practices 86 however, we sometimes get the duties which are not based on our level of competence.” (participant 5) 4. the implementation of the nursing logbook based on the results of the interview on the readiness of the nurse in the implementation of using the nursing logbook, it was revealed that some nurses are still confused and half-ready to implement the logbook, as responded by the following participants: "i am still half-ready because i need training.” (participant 1) "the nurses are ready to implement the logbook. however, it remains a plan. they have not mastered the sop.” (participant 2) "as far as i know, the division of the duty is still confusing.” (participant 3) in this category, participants revealed that human resources and hospital nursing committee had done socialization but it is still not yet in detail. as responded by the following participants: "the hospital committee may not have socialized it in a more detail" (participant 1) "the hospital committee only distributes the logbook. they said they would socialize it later.” (participant 3) "it has been socialized by the hr and quality department.. and then the socialization has been further carried out by ward leader, and then by the team leader.” (participant 4) the monitoring of the nursing logbook fulfillment was only carried out by the head of the division and the nursing committees, and not by the management of the nursing hospital. as stated by the following participants: "it is ward leader who handles it by far... and division of discipline explains how to fill the logbook. " (participant 1) "there is no direct supervision from the management of nursing hospital.. only from the committee.” (participant 4) the evaluation of the implementation of the nursing logbook is still carried out differently from one division to another. it is drawn from the expression of the participants taken by the researchers in three treatment areas, such as: "there may be an evaluation of the logbook from the hospital upon the submission at the end of this year.” (participant 1) "the duration of the logbook is four semesters per year. if i am not mistaken, it is four semesters per year... yea.. not quarterly.” (participant 2) "it is also once per three months.” (participant 3) "when we did accreditation, we had not filled the logbook that much. the purpose is to check how much we have filled it, isn’t it?. but when we did the accreditation, they instead asked us just to copy it.” (participant 5) 5. the constraints in implementing the nursing logbook the constraints in the implementation of the nursing logbook is most likely in the limited time to fill the logbook because of the heavy workload, as revealed by the following participants: "we are sometimes swamped and that we have no time to fill the logbook.” (participant 2) “it may be because of the limited time, or maybe we are too busy.” (participant 4) participants reveal that there are still many nurses who do not understand how to fill the logbook correctly, even though there is a guideline. "sometimes, i understand all.. hehe (giggling while smiling). however, there is a time when i do not understand some parts.” (participant 1) "there are some parts i do not understand.” (participants 4) vol. 3 no. 2 december 2019 87 participants reveal that they already know and understand. yet, they have not remembered the steps and the procedure. "they have already done the duty.. the important points in the clinical nurse level based on their level of competencies. however, the problem is that they are hard to remember the procedure in the sop.” (participant 2) two participants revealed that they do not understand how to fill the nursing logbook because there is no detail explanation. thus, the nurse does not know the detail of how to fill it correctly. "i do not understand. if they explain it further, i will probably understand. nevertheless, it has not been explained in detail, so i hardly understand.” (participant 3) "there are some who have not yet understood.” (participant 5) the constraint in the implementation of the logbook is also influenced by the willingness of the nurse to fill it. as revealed by the following participants: "hmm.. what is it? i think it is a matter of willingness. i mean the willingness to make time to fill the logbook.” (participant 5) furthermore, there is no appreciation received by the nurses when they perform correctly. as revealed by the following participants: "one more constraint is that there is no additional incentive to implement it.” (participant 2) 6. the nurse’s expectation towards the implementation of the logbook a participant reveals that the duty of each nurse is expected to be in line with each of their career levels. "i hope that the logbook is in line with each of the nurse’s career level and each clinical nurse level.” (participant 2) "hopefully, the nurse can master all the competencies based on their career level to achieve promotion.” (participant 5) participants revealed that in addition to the career level, they hope that the logbook implementation can be understood by at least 99% of the nurses. "hopefully, at least 99% of the nurses understand the implementation of the logbook.” (participant 6) participants revealed that the nurse could take action based on the standard in the sop. "the competence of the nurse is already based on the standard. for example, one division can be occupied with professional actions based on the sop.” (participant 4) "i hope at least they are responsible for their own duty, which is in line with the sop.” (participant 5) in terms of the nursing logbook update, participants expressed confusion towards the current logbook format. as revealed by the following participants: "to avoid confusion, the format of the logbook can be renewed. although there is a guideline already in the logbook, it needs to be explained further.” (participant 1) discussions 1. the existence of the nursing logbook the existence of a nursing logbook is implemented at dr. h. moch. ansari saleh hospital, the function of which is as one of the tools to raise the nurse’s competence. therefore, it is imperative to be understood by all nurses. the logbook encompasses how the nurse assesses and understands their performance and professionalism both as individuals and groups. the indicator of nurse performance is a variable in measuring the nurse’s activity within a certain period of time. the indicator focuses on the results of nursing care to the patient and the process of managing the department (rivai, 2008). the result of this study reveals that the perception of nurses towards a nursing logbook is that they perceive the logbook as a performance assessment, both individual assessment and clinical nurse assessment, and good competency development for them. however, in terms of the implementation, the nurse can hardly understand the procedure based indonesian journal of nursing practices 88 on the existing rules. human resource competence requires knowledge and skills to be able to help create a strategy of the company or organization (dessler, 2015). the implementation of the nurse's performance assessment by using the logbook should conform to the standard of nursing actions. due to the fluctuating complex health system, it is a reference to growing and increasing the level of nurse competence at step by step, which requires a lifelong learning process (liou & ching-yu, 2014). the performance of individual nurses in dr. h. moch ansari saleh hospital is recorded in the nursing logbook which is evaluated quarterly (three months). the fulfillment of the logbook to meet the targets of the nurse's competence is carried out based on each level such as the assessment from the supervisor (head of the room/team), peer/coworker, and self-assessment. it is described in american nurses association leadership institute tm (2013) that “competence in nursing practice must be evaluated by the individual nurse (self-assessment), nurse’s peers, nurse’s supervisor, coach, mentor, or preceptor. additionally, other aspects of nursing performance may be evaluated by professional colleagues and patients.” in this case, dr. haryati (kars surveyor) creates a model and a format of a logbook by dividing into 3 (three) types such as supervision, peers, and autonomy. the health department, known as declinical nurse leveles (2003) mentions that the nurse is expected to be proficient and able to do independent action and should be monitored by the supervisor as much as five times. as for this logbook, it requires nurses to be supervised three times, monitored by a peer three times, as well as carrying out a self-reliant action. 2. the purpose and the benefit of the nursing logbook the purpose of performance assessment is to improve performance and communication, strengthen positive behavior, communicate problems related to task termination (ultimately), provide the basis of reward to strengthen motivation, provide the basis for termination employment (if necessary), and identify the individual learning and development needs (huber, 2013; robbins & judge, 2008; tomey, 2009). career development of nurses is a career plan that can be used for the placement of nurses at a level that suits their expertise and provides better opportunities in accordance with the ability of potential nurses (marquis & huston, 2010). the benefits of the development of a nurse’s career can determine their competence and their clear career path so that the nurse can provide quality service. benner (2001), from a novice to an expert theory of this concept, explains that nurses develop skills and understanding of patient care over time that comes from a combination of education and experience. by the presence of a logbook, nurses will implement and can provide quality services in accordance with the competence-based on the standard operational procedure (sop). in addition to career development, the purpose and the benefit of logbooks are to know the competence, assess the competence, and improve ability. it is also in line with the opinion of vandenhouten et al. (2015), stating that to improve the competence of a nurse, it requires an accountable and sustainable system for assessment as competence can only be achieved through ongoing development and credentials. furthermore, it is in line with the research conducted by harlie (2010), revealing that there is a connection between career development and the performance of employees in tabalong tanjung south kalimantan. nurses who work based on their competence and area of authority, and are given the award based on their achievement will raise their motivation, and that their performance will increase, and surely they will give quality services. 3. the connection between the nursing logbook and the credentials nurses, as one of the hospital's healthcare professionals, play an important role in achieving health development goals, such as providing quality services for patients. the nurse’s career path starts from the time of recruitment to the process of the development of human nursing resources in the hospital. in terms of nurses who have worked in the hospital with the education level of nursing vol. 3 no. 2 december 2019 89 vocational high school, they will level up to maximum until clinical nurse level ii. meanwhile, nurses with a vocational degree can be assigned to clinical nurse level i upon undergoing a 2-year orientation period. they will level up to clinical nurse level ii if they meet other requirements set up. according to the directorate general of health and development (2013), upon undergoing a 4-year experience in the level of clinical nurse level ii, the nurses will be able to level up to clinical nurse level iii if they meet other requirements that have already been set up. furthermore, in terms of leveling up into clinical nurse level iv, meeting the requirement of the minimum working period is not enough. they have to meet the minimum standard of formal educational degrees, namely bachelor of nursing as well as a professional nurse degree. the system of a professional career-level contains three interconnected aspects, such as performance, professional orientation and nurse personality and competencies that influence professional performance. according to werther & davis, (1996), a career is interpreted as a person’s lifetime working journey. credentials are the process of an evaluation conducted to determine the clinical authority. it is in line with the regulation of health ministry, known as permenkes, about the nursing committee in 2013 that the credential is the process of evaluation of nurses to determine the clinical authority. in other words, it is the understanding of assigning the scope of tasks and authority. at the same line of thought, kleinpell, hravnak, and hinch (2008) stated that the credential process is there to obtain the clinical authority of nurses to provide clinical services to the patients. cusveller & akkerman (2016) suggest that a nurse’s competence, as well as the assessment tool, are ethical. the results of nursing research in taiwan, according to lin et al. (2016), showed that the competence of clinical nurses can be measured through the scale. ellis & hartley (2012), in his book entitled nursing in today's world: challenges, issues, and trends, state that credentials is a measuring instrument to assess the ability of a person. in this context, credentials are considered as a standard and a tool to assess a nurse's competence. an important aspect of professional development for nurses is maintaining competence (patricia, b & strasser, 2012). human resource competence requires knowledge, skills, and competence to be able to help create a strategy of the company or organization (dessler, 2015). hospitals, for example, need to ensure the competent nursing staff, resources, and patients’ needs. nurses who have not been competent have to join the training as a form of committee responsibility in maintaining the competence of the nurses. in other words, the nurse needs to be highly competent in the provision of nursing care. however, there is a challenge for the nursing committee to encourage their members in maintaining the competence, and to obtain remuneration. 4. the implementation of the nursing logbook assessing the individual nurses' performance by using the nursing logbook is also influenced by the nurse’s readiness to accept the new system. monitoring the performance assessment using the logbook has not been optimal because the head of the division only does it. the evaluation of the use of the logbook also does not work optimally. hence it can be said that the implementation of the logbook is hardly optimal. evaluating and monitoring the use of logbook are the most important part as they are the benchmark of the logbook implementation. thus, apart from readiness, supervision, and evaluation in the implementation of a logbook must be supported by proper management, which is the center of the hospital service system. it is in line with the theory presented by holt et. al. (2010), stating that readiness is one of the main factors that affect the performance and subsequent outcomes. 5. the constraints in implementing the nursing logbook the function of nursing management in the implementation of standard operational procedures (sop) is important to improve the quality of nursing services. it is in line with the indonesian health department (2003) explaining that hospitals should make efforts to improve the quality of public services and medical services, either through accreditation, certification or other quality improvements. indonesian journal of nursing practices 90 in addition to the heavy workloads that make nurses have no time to fill the logbook, some of them still do not understand how to fill the logbook and cannot comply with the sop-based actions. as a result, they do not perform the duty based on their sop. in this case, the nurses should be willing to provide time to fill the logbook. as stated by huber (2013), the work of the employee is measured based on the standard to provide an overview of the quality of job performance. however, the incentive is one of the constraints in the implementation of the nursing logbook which is later such a contrary to the importance of the award program for an organization. furthermore, it is said that hasibuan (2007) award is an action where the organization assesses the contributions of employees to distribute the monetary or non-monetary award either directly or indirectly as a form of the ability to organize based on the legal regulations. in relation to this, the guideline of the remuneration system drafted by health minister (2010), states that there is a component of the remuneration system for the hospital personnel’s performance. 6. the expectation of the nurse towards the implementation of logbook a professional career path can lead nurses to pursue the field of expertise and improve their professionalism. therefore, the greater the conformity between the expectations of nurses and the reality found in the workplace is, the higher the satisfaction will be. the opinion is in line with the research result conducted by suroso (2011), stating that the professional career path can improve nursing work satisfaction. the logbook is expected to be the basic standard of nurse competence that can determine the competence level of the nurses. it is in line with the opinion of vandenhouten et al. (2015), stating that creating a competent nurse requires an accountable system and competency assessment can only be achieved through credentials. furthermore, in terms of nurses’ expectations, they want the logbook format to be updated to get them to understand easily. lewin's theory expresses that the process of the update encompasses three stages, namely unfreezing, moving, and refreezing. the lewin theory also states that the update process can be carried out when the driving factor has arisen more than the inhibitory factor (marquis & huston, 2010). in addition, nurses also want the implementation of the logbook to be socialized. in the end, this research cannot avoid limitations, such as researchers do not conduct the interview optimally. they conducted interviews only in meeting rooms and the headroom of each serving participant and did not consider to conduct interviews outside the hospital to avoid interruption. the second limitation is that the interview with one of the participants did not go optimally as the participant had to accompany the doctor in the middle of the interview process. however, it continued after a three-hour break. conclusions the system of implementing the logbook as a tool for the nurses' performance assessment is not optimal due to the limited socialization to the nurses in the hospital. besides, the result of the research showed that there are several constraints in the implementation of the logbook such as limited time in filling the logbook, the inadequate understanding of the nurses about the procedure of filling the logbook, and a lack of appreciation towards the nurse when they fill the logbook. references american nurses association leadership institute. 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(2015). credentialing public health nurses: current issues and next steps forward. public health nursing, 32(5), 565576. werther, w. b. & davis, k. 1996. human resources and personnel management. (ed. ke-5). new york: mcgraw-hill companies. witjaksono, arif; siti sugih hartiningsih, & galih indriana. (2017). hubungan motivasi kerja dengan kinerja perawat instalasi rawat inap di pusat mata nasional rumah sakit cinendo bandung tahun 2017. jurnal sehat masada. 10(5), 1-10. indonesian journal of nursing practices 92 ijnp (indonesian journal of nursing practices) vol 3 no 2 december 2019 : 92-98 fahni haris1, sri yusrian1 1universitas muhammadiyah yogyakarta corresponding author: fahni haris email: hi_okt@yahoo.com correlation of e-learning courses toward nursing students’ cognitive skills article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.3298 abstract background: e-learning is one of the new learning methods in the indonesian education system. this system has been used to increase students’ understanding levels. the researcher has noticed that students had a lack of cognitive level due to the misinterpretation and mis-extrapolation of the materials. e-learning shall improve students’ cognitive level in courses. the researcher is interested in exploring the correlation between the effectiveness of online classes and nursing students’ cognitive level. objective: this study aims to identify the relationship between the effectiveness of online courses through the e-learning system and students’ understanding level at universitas muhammadiyah yogyakarta. method: this study implemented a quantitative method with a crosssectional design along with the pearson product-moment correlation to measure the correlation strength. results: the researcher found e-learning adequate to be applied to nursing students of universitas muhammadiyah yogyakarta (85.8% out of total respondents, n=288). the average score of the seven components measured (productivity, quality, efficiency, flexibility, eminence, development, and satisfaction) was 68.54, while the average rating of students’ cognitive level was 53.92. conclusion: there was a significant correlation between e-learning as an education system and nursing students’ cognitive level. keywords: e-learning; cognitive; correlation; nursing student; understanding introduction science has become one of the main demands for world development, especially in the learning process. the high demand requires each educational institution to improve its quality. currently, there is one perspective in a learning process regarding information and technology (it), which is an e-learning system. e-learning as a learning system allows both students and teachers to perform the learning process through online activities. regarding this matter, supriadi (2017) argues that the online learning system (e-learning) is believed to be more effective than the traditional learning system, with the average scores of 84.04 and 74.28, respectively. the e-learning system already has the privileges that make it advantageous to be applied, especially in higher education. the first privilege is that it is not only universal for all countries but also one of the interface products that are relatively easy to learn. the second privilege is that students are familiar with electronic devices to exchange information, and it has become a part of many people’s daily activities. as a result, informal education also has a vital role along with traditional and formal education. in this case, the young generation nowadays can independently gain various types of knowledge through technology and media, such as electronic media, mass media, e-books, 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/6727 vol. 3 no. 2 december 2019 93 encyclopedias, repository videos, even online courses, and open universities. the third privilege is that the modern world requires the fastest and cheapest ways to produce and distribute knowledge. the rapid growth of technology and education system initiates the electronic or online learning system, which is also known as e-learning, implemented in many countries to train the professionals in higher education (yanuschika, pakhomovaa, & batbolda, 2015). several factors influence the students' understanding level, and one of them is the learning method. arifanti (2016) claims that not all learning methods are useful; thus, this matter will also influence the students’ understanding level regarding the materials. as an example, the use of video as a learning tool has been argued to increase the interest, knowledge, and learning outcomes of the students, from 33.75/100 to become 78.25/100 (abidin, afidh, & mukhtar, 2015). yanuschika, pakhomovaa, & batbolda (2015) adds that through interactive videos in e-learning, the understanding level of students in mathematics, as well as their ability to solve problems, are proven to increase. the results of the study conducted by (cardoso et al., 2012), furthermore, affirms that students’ cognitive levels and skills improve along with the available informative video in a learning platform named moodle. other than the learning methods, the curriculum, tutors or teachers, moods of the students, and adequate learning resources influence the success of the e-learning system (fandino, munoz, & velandia, 2019). based on the background elucidated beforehand, along with the suitable curriculum, lecturers, and proper learning resources in universitas muhammadiyah yogyakarta, this study aims to discern the correlation between elearning and students’ understanding level in universitas muhammadiyah yogyakarta. method this study applied a qualitative method with a crosssectional approach to identify the relationship between the independent and dependent variables by using a one-time measure at the same time (sopiyudin, 2011). the researcher collected the data by distributing questionnaires to the students of nursing school of the faculty of medicine and health sciences universitas muhammadiyah yogyakarta class of 2015, 2016, and 2017 as many as 288 people. the questionnaires were the instrument of the research and became the source of the primary data of this study. the instrument validity test carried out to 30 respondents obtained the r coefficient from 0.372 to 0.775, so that the reliability test by implementing cronbach’s alpha method obtained a score of 0.88 (>0.70). the additional instrument used in this study was the questionnaire consisting of 30 statements developing seven components of online learning activities. meanwhile, the questionnaire regarding the comprehension level consisted of 3 development statements of 3 cognitive components, namely translation, interpretation, and extrapolation (bloom, 1978: 90) cit (harjanti, ningrum, & yani, 2014). the data analysis used in this study was pearson product-moment correlation to ascertain the average score of the components, effectivity, which was e-learning, and the average rating of students’ understanding level (cognitive level). results 1. e-learning in universitas muhammadiyah yogyakarta table 1. the results of the respondents’ responses on the seven components of elearning component average productivity quality efficiency flexibility eminence development satisfaction 73.02 68.46 69.11 73.66 67.84 70.78 59.49 from table 1, the seven components indicating the effectivity of e-learning in the nursing school in universitas muhammadiyah yogyakarta is in the range value of 59.49 to 73.66. table 2. the average of the seven components of e-learning mean median mode min max standard deviation 68.54 68.33 68.33 25.8 3 89.1 7 7.342 indonesian journal of nursing practices 94 table 2 denotes that the highest score of the seven components of e-learning is 89.17, while the lowest score is 25.83, with an average score of 68.54. 2. understanding the level of universitas muhammadiyah yogyakarta’s students table 3. the results of the respondents’ responses on each category of understanding after completing e-learning category average translation interpretation extrapolation 56.86 48.03 51.73 table 3 displays three categories of the understanding level measured; the average scores obtained are in the range of 48.03 until 56.86. table 4. students’ understanding level after completing e-learning mean median mode min max standard deviation 53.92 56.25 50.00 6.25 93.75 17.309 from table 4, the highest score for the understanding level is 93.75. the lowest score is 6.25, with an average score of 53.92. 3. the relationship between e-learning and students’ understanding level in universitas muhammadiyah yogyakarta tabel 5. the distribution of the correlation between e-learning and students’ understanding level in universitas muhammadiyah yogyakarta variable mean median mode min max st dev. p-value e-learning 68.54 68.33 68.33 25.83 89.17 7.342 0.000 understanding level 53.92 56.25 50.00 6.25 93.75 17.309 table 5 presents that the p-value obtained from both variables is 0.00 (p<0.05), which implies, statistically, a correlation between e-learning and the students’ understanding level. analysis the correlation between e-learning and students’ understanding level understanding level, particularly in this study, is influenced by several factors, for instance, students’ interests and learning methods that are suitable for students from higher education. this statement is in line with a study conducted by arifanti (2016). she concludes that students’ understanding level could be affected by the effectivity factors of the learning methods as well as the interests for learning. the learning method applied, in this case, is the one used for adult learners performed through online media, such as a website. discussion based on the analysis completed to the obtained data, the researcher can argue that the implementation of the e-learning system to the nursing students of the faculty of medicine and health sciences universitas muhammadiyah yogyakarta is noticeably effective. the effectiveness of the e-learning system, moreover, is influenced by several components, such as productivity, quality, efficiency, flexibility, eminence, development, and satisfaction levels of the students. the results of the analysis regarding this matter, additionally, can be decided as useful since the display, features, contents, and the natural use of the e-learning system increase the participation of the students during the learning process, seen from the mean score on the productivity of the e-learning, which is as much as 73.02. this result is similar to the research completed by alimron (2019) and suartama (2013). they infer that the completeness and suitability of the contents of the e-learning system are essential in improving the learning process. attractive display of the e-learning system, additionally, also contributes to rising students’ interests to participate more actively during the learning process (saifuddin, 2018). the e-learning system analyzed in this study can also be said as qualified with the mean score of 68.48, given the implementation of the system can be adjusted to the learning ability of the students. the vol. 3 no. 2 december 2019 95 smooth operation of the system also takes part in helping the students to optimize their learning ability. the research conducted by amaliyah (2017) and octavia (2017) complemented this study in the sense that the higher the level of the learning ability is, the more optimum the thinking and learning processes are. the different learning ability influences the learning capability. the learning ability, however, is also affected by the excellent and qualified learning methods (andartari, susanti, & andriani, 2013). the secure navigation system in e-learning, particularly on the matter of presenting learning materials, eases the students to obtain more knowledge and to understand and comprehend the learning materials uploaded in the system (abdulmajid, & pramuntadi, 2017; sulisworo & agustin, 2017). the results of the analysis on the efficiency level of the e-learning system generated the mean as much as 69.11, implying that the operation can be utilized at any time by the students. this result is in line with the results of the research piloted by wahyuni & halili (2017) and sefrika (2018). both pieces of research denoted that through the e-learning system, students, especially university students, could also conveniently study outside the school at any time, effectively and efficiently. the availability of the learning materials that are accessible every time and everywhere in the e-learning system is believed helping the students to study better and getting a better grade (dewi, 2018). regarding the flexibility of the e-learning system, the results indicated that the e-learning as the system applied had functioned effectively, with the mean score of 73.66, given the fact that it was within reach. the flexibility of the system, furthermore, was proven to help students in recalling the learning materials in the form of video or other media. the result of the flexibility of the e-learning system in this study is similar to the research carried out by cahyono (2015). he affirms that the enactment of elearning motivates the students to study more in their free time. its flexibility is visible through how easy it is to use at any place with an internet connection (cahyono, 2015). the e-learning system assessed in this study obtained the mean score of 67.84 at the matter of its eminence that, according to the users, e-learning could facilitate the teachers to achieve the learning objectives and to give the students feedback as a control of the students’ performances. by utilizing elearning, the students are aware that the teachers can easily keep track of their learning performances. abidin et al. (2015), in their research, have affirmed that feedbacks or suggestions from the teachers, along with small quizzes given to the students, also play essential roles during the learning process. cahyono (2015) suggests that further explanation or responses given by teachers are endeavors in keeping track of the students’ learning performances during the learning process. the obtained mean score of 70.78 is after analyzing the development level of the e-learning system as the object of this study, which denotes the welldeveloped system. proper development of the elearning system creates complete learning activities for the students, such as discussion forums and quizzes, to increase the understanding level and as a form of evaluation of how well the students comprehend the materials after carrying out online learning. regarding this matter, niswati, donna, lestari, & gustyani (2017); hakim (2018) agree that discussion forums included in the e-learning system might provide an opportunity for the students to give feedback and opinions on specific learning topics. quizzes, on the other hand, are believed as a way to develop learning activities, primarily through the e-learning system, as an evaluation of student learning outcomes (cahyono, 2015). the result of the analysis regarding the students’ satisfaction level on the e-learning system is still fair, proven by the mean score that is as much as 59.49. most students find it challenging to access the system and continue the learning process due to unstable and weak internet connection. supriadi (2017) and niswati, donna, lestari, & gustyani (2017) argued that poor internet connection is the biggest obstacle for the students to carry out online learning. thus, a stable internet connection, indeed, is indispensable in supporting the online learning process (priantama, 2015). riyanto (2014) added that a stable internet connection could help students to get more information needed as part of the learning process. after carrying out the analysis, the students’ understanding level in the learning process by utilizing the e-learning system is at a moderate level, with a mean score of 56.86. this score denotes that after completing online learning through the e indonesian journal of nursing practices 96 learning system, the students are familiar with the topic, material, and content of the course given. the appropriate understanding level might be because of the new learning system that attracts the students. the result of this analysis is in line with the results of the research conducted by karwati (2014), nasution (2017) and khoirunnisa et al., (2018) which concluded that discussion forums and provided learning materials in e-learning system helped the students to get more knowledge and to increase their understanding level. the submitted materials, furthermore, are accessible at any time and any place that can ease the students to review and deepen their understanding upon them (karwati, 2014; nasution, 2017). the discussion forum as a feature in the e-learning system has become one of the platforms for students to discuss things regarding the upcoming learning materials (kurniawan, suprianto, and sumardiyono, 2016; sinaga, 2015; khoirunnisa et al., 2018). the interpretation of the students on this online system is inadequate, seen from the mean score of 48.03. the result of the analysis indicates that a lack of learningsupport factors and a lack of feedback or explanations from the teachers might cause a low level of interpretation. oetary (2017) dan utomo dan imron (2017) suggested that several factors may increase students’ understanding level, such as the implementation of sufficient and complete learning media as well as a thorough explanation from the teachers. lack of learning support factors, namely unhealthy learning environment, unsupportive learning tools, for example, laptop or mobile phone, and troublesome internet connection may affect the success learning level of the students (oetary, 2017). the mean score of 51.73 indicated that the students’ extrapolation on the e-learning system is still weak. extrapolation itself can be described as the students’ ability to make summaries, descriptions, and conclude the learning materials learned through the e-learning system. the low score of students’ extrapolations can also have connections to the students’ translation and interpretation abilities. suhendar dan ekayanti (2018) claimed that the success of the students to understand the learning materials is inseparable from the level of knowledge and the ability to analyze and comprehend the methods and materials during the learning process. the exposure of the learning materials as well as the discussion forums, if well-benefitted, can be helpful for the students to increase their understanding of certain materials. the students’ habit, however, also needs to be taken seriously in noticing how students take advantage of the e-learning system to enhance their learning process (karwati, 2014; khoirunnisa et al., 2018; kurniawan et al., 2016; nasution, 2017; sinaga, 2015). the supporting factors of the learning process that have been described beforehand are also indispensable in increasing the students’ understanding level. the obstacle to using the elearning system, such as poor internet connection, is believed as an obstacle for the students to increase their level of understanding (oetary, 2017; priantama, 2015; riyanto, 2014; sinaga, 2015). further explanation of the learning materials by the teachers, on the other hand, becomes another essential role in the learning process caused by the fact that the presence of the teacher during the learning process can be useful to take notes on the students’ development as well as to explain the materials deeper should the students have questions to deepen their understanding level (abidin et al., 2015; niswati, donna, lestari, & gustyani (2017); utomo & imron, 2017). conclusion based on the analysis of the data elucidated, there is a correlation between online learning through the e-learning system and the students’ understanding level references abdulmajid, n. w., pramuntadi, a., riyanto, a. b., & rochmah, e. 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(2015). e-learning as a way to improve the quality of educational for international students. procedia social and behavioral sciences 215, 147 – 155. 146 muhammadiyah journal of nursing abstract patients with chronic renal failure require renal replacement therapy for life. one of renal replacement therapy is hemodyalisis. patient who is experiencing hemodialisa will experience degradation of quality of life. haemodialysis patients’s quality of life are fl uctuating because their health is infl uenced by physical, psychological, level of independence, social relationships, personal beliefs and their relationship with the environment. fluid management assists patient on adapating the change of their health status and improve their quality of life.the aim of this study was to determine the eff ect of fl uid management therapy to the quality of life on hemodialysis patient. this study used an experimental research design with pre-test post-test approach to controls. samples were divided into 2 groups: an intervention group of 6 people and a control group of 5 people were randomly assigned. the data was taken on 2 periods: the fi rst was before interventions were given, and the second was after 12-16 times of haemodyalisis after the interventions were given. the results showed that the quality of life of patients treated group was higher (53.82) than the control group (39.33). there were no diff erences in changes in quality of life based on the kdqol sf-36 questionnaire, between treatment groups with the control group. keywords: chronic renal failure, hemodyalsis, fl uid management, quality of life manajemen cairan pada pasien hemodialisis untuk meningkatkan kualitas hidup di rsud dr. harjono ponorogo isroin l, istanti y.p., soejono s.k, universitas muhammadiyah yogyakarta lailyisroin@ymail.com pendahuluan ginjal berfungsi sebagai pengatur volume dan komposisi kimia darah dengan mengekskresikan solut dan air secara selektif. sistem ekskresi yang terganggu menyebabkan menumpuknya zat-zat toksik dalam tubuh yang kemudian menyebabkan sindrom uremi. keadaan ini dapat menyebabkan terganggunya sistem organ lain yaitu sistem kardiovaskuler, sistem neurologis, sistem gastrointestinal, sistem respirasi, sistem dermatologis, sistem hematologi, sistem endokrin dan lain-lain. fungsi ginjal akan terganggu secara bermakna bila mengalami gagal ginjal kronik/terminal (brunner & suddarth, 2002).berdasarkan estimasi who, secara global lebih dari 500 juta orang mengalami penyakit gagal ginjal kronik. sekitar 1,5 juta orang harus menjalani hidup bergantung pada cuci darah. jumlah pasien gagal ginjal kronik di indonesia berdasarkan pusat data dan informasi perhimpunan rumah sakit seluruh indonesia diperkirakan sekitar 50 juta orang per satu juta penduduk, 60% nya adalah usia dewasa dan usia lanjut (setiawan, 2012). penelitian oleh prodjosudjadi dan suhardjono (2009) mendapatkan angka prevalensi penyakit ginjal terminal yang menjalani hemodialisis per sejuta populasi indonesia pada tahun 2002 sebesar 10,2, tahun 2003 sebesar 11,7, tahun 2004 sebesar 13,8, tahun 2005 sebesar 18,4 dan tahun 2006 sebesar 23,4. penelitian tentang distribusi geografi s penyakit ginjal kronik di bali mendapatkan prevalensi rata-rata penyakit ginjal kronik sebesar 56%. pasien gagal ginjal kronik memerlukan terapi pengganti ginjal seumur hidup. salah satu terapi 147 muhammadiyah journal of nursing pengganti ginjal adalah hemodialis. hemodialisa yang adekuat dapat meningkatkan kelangsungan hidup dengan komplikasi yang minimal, meningkatkan kualitas hidup sehingga hidup lebih sehat dan lebih baik. feroze (2011) mengatakan bahwa rendahnya kualitas hidup pasien hemodialisa dilaporkan oleh pasien dengan kesehatan fi sik yang buruk. gejala fi sik yang dialami pasien hemodialisa merupakan komplikasi dari hemodialisa yang meliputi hipertensi, hipotensi intradialisis, gagal jantung kiri, asites, pleural eff usion, gagal jantung kongestif dan dapat menyebabkan kematian. tujuan hemodialisa adalah untuk memperbaiki komposisi cairan sehingga mencapai keseimbangan cairan yang diharapkan untuk mencegah kekurangan atau kelebihan cairan yang dapat menyebabkan efek yang signifi kan terhadap komplikasi kardiovaskuler dalam jangka panjang (jeager & mehta ,1999). cairan yang diminum penderita gagal ginjal harus diawasi dengan seksama karena rasa haus bukan lagi petunjuk yang dapat dipakai untuk mengetahui hidrasi tubuh. asupan yang terlalu bebas dapat mengakibatkan beban sirkulasi menjadi berlebihan, edema dan intoksikasi air. sedangkan asupan yang terlalu sedikit akan mengakibatkan dehidrasi, hipotensi dan memperberat gangguan fungsi ginjal. parameter yang tepat untuk diamati selain data asupan dan pengeluaran cairan yang dicatat dengan tepat adalah pengukuran berat badan harian. pasien harus mematuhi pembatasan cairan agar mendapatkan berat badan kering. interdyalitic weight gain (idwg) merupakan indikator untuk mengetahui jumlah cairan yang masuk selama periode interdialitik dan kepatuhan pasien terhadap pengaturan cairan pada pasien yang mendapat terapi hd (thomas, 2003). menurut lopez (2005) asupan makanan juga akan menyebabkan kelebihan natrium dan air dan memberikan kontribusi untuk interdialytic weight gain /idwg. penilaian rutin idwg sangat penting bagi perawat dan pasien untuk menentukan jumlah cairan yang diperlukan selama dialysis. berat badan pasien adalah cara sederhana yang akurat untuk pengkajian tambahan cairan yang dibuktikan secara klinis adanya edema, peningkatan tekanan vena jugularis, hipo/hipertensi dan sesak nafas tanda klinis tersebut menyebabkan gangguan kesehatan fi sik dan mempengaruhi kualitas hidup pasien (thomas, 2003). pelaksanaan konseling makanan, pembatasan cairan, modifi kasi gaya hidup, penyakit dan pengobatan pada pasien gagal ginjal pada kelompok intervensi menunjukkan peningkatan kualitas hidup 2%, sedangkan pada kelompok kontrol mengalami penurunan kualitas hidup. jadi konseling valid dapat memperbaiki kualitas hidup pada pasien gagal ginjal kronik sehingga dapat sebagai model dalam merawat pasien gagal ginjal kronik (thomas, 2009). manajemen diri merupakan kepatuhan dan mitra pendukung individu dalam pengobatan mereka, pengetahuan dan keterampilan yang dimiliki untuk merawat diri mereka , membuat keputusan tentang perawatan mereka sendiri, mengidentifi kasi masalah, menetapkan tujuan, dan monitoring dan mengelola gejala. manajemen diri meliputi keterampilan pemecahan masalah, pengambilan keputusan dalam menanggapi berfl uktuasi tanda dan gejala, dan mengambil tindakan, misalnya belajar bagaimana untuk perubahan perilaku. kemampuan untuk menggunakan keterampilan dan pengetahuan, dengan menerapkan manajemen diri untuk diri sendiri pada saat yang tepat, sangat penting untuk efi sien manajemen diri. menurut welch (2003) yang dikutip oleh lindberg (2010) menjelaskan bahwa manajemen diri untuk pasien pada pengobatan hemodialisis sebagai proses “dari adaptasi perilaku sangat relevan, dengan premis yang mendasari adalah bahwa mengubah perilaku biasanya tidak terjadi sekaligus. ketidakpatuhan dapat dilihat sebagai 148 muhammadiyah journal of nursing bentuk kurangnya manajemen diri, maka dari itu mendorong strategi berkelanjutan untuk manajemen diri merupakan tujuan penting bagi tim perawatan ginjal. kualitas hidup pasien hemodialisa berfl uktuasi, karena dipengaruhi oleh kesehatan fi sik, psikologis, tingkat kemandirian, hubungan sosial, kepercayaan pribadi dan hubungan mereka dengan lingkungan. pasien gagal ginjal yang menjalani hemodialisa seumur hidup membutuhkan dukungan perawat dan keluarga untuk meningkatkan kualitas hidupnya sehingga pasien yang menjalani hd akan dapat mempertahankan dan menstabilkan kemampuan fungsional, memenuhi kebutuhannya, menghilangkan gejala dan mengembalikan rasa nyaman dalam menjalani sisa hidupnya (thomas, 2003). komplikasi hipotensi dan hipertensi intradialisis dapat terjadi selama hemodialisis dan bisa berpengaruh pada komplikasi lain (holley, bern & post, 2007). komplikasi ini dapat mengakibatkan timbulnya masalah baru yang lebih kompleks antara lain ketidaknyamanan, meningkatkan stress dan mempengaruhi kualitas hidup, memperburuk kondisi pasien bahkan menimbulkan kematian (jablonski, 2007). komplikasi ini perlu diantisipasi, dikendalikan serta diatasi agar kualitas hidup pasien tetap optimal dan kondisi yang lebih buruk tidak terjadi. hasil penelitian observasional nonrandom, pada kelompok kontrol, kualitas hidup menurun pada tingkat 2% dalam tiga bulan pertama atau tetap konstan dalam tiga bulan berikutnya. kelompok uji intervensi menunjukkan peningkatan konstan 2% pertumbuhan dalam periode tiga bulan pertama dan kedua pengumpulan data. tujuan penelitian ini untuk mengetahui efektivitas manajemen cairan pada pasien hemodialisis untuk meningkatkan kualitas hidup. manajemen cairan merupakan inovasi tindakan keperawatan untuk meningkatkan kualitas hidup pasien hemodyalisis. metode penelitian ini menggunakan desain penelitian eksperimen dengan pendekatan pre tes post tes dengan kontrol. sampel pada penelitian ini adalah pasien yang baru menjalani hemodialyalisis 3-4 kali sejumlah 11 orang. responden dibagi menjadi kelompok intervensi 6 orang dan kelompok kontrol 5 orang yang ditentukan secara random. penelitian ini menggunakan total sampling dengan kriteria inklusi sebagai berikut : bersedia menjadi responden dan bisa membaca dan menulis, usia pasien 20 – 60 tahun, pasien yang menjalani hemodialisis 3-4 kali, pasien menjalani hemodialisa 9 – 12 jam/minggu. kriteria eksklusi : pasien gagal ginjal yang tidak dapat diwawancarai, pasien gagal ginjal yang mempunyai penyakit penyerta (infark myokard, hepatitis, hiv aids), pasien yang tidak rutin menjalani hemodialisa dan pasien yang menjalani hd diluar jadwal yang ditentukan. instrumen penelitian yang digunakan antara lain buku panduan dan kuisioner kualitas hidup sf-36 yang telah dilakuan uji pakar, timbangan berat badan yang telah diuji realibilitasnya dengan repeat measure,tensimeter yang telah dilakukan kaliberasi, handgrip, pita ukur dan gelas ukur. kualitas hidup sf-36 terdiri dari 8 dimensi yaitu fungsi fi sik, keterbatasan peran karena masalah fi sik dan mental, energi, kesejahteraan mental, fungsi sosial, persepsi nyeri dan kesehatan umum. data diambil 2 periode, tahap pertama sebelum dilakuan intervensi dan tahap kedua setelah dilakuan intervensi meliputi data demografi kualitas hidup dn indikator fi sik kualitas hidup. penyuluhan tentang manajemen cairan dilakukan saat intradialysis. pasien juga mendapat penjelasan tentang pengisian data selama 12 minggu di rumah yang meliputi data jumlah urin setiap hari, jumlah minum setiap hari, asupan makanan, berat badan dan ukuran lingkar pergelangan kaki. pengambilan data tahap dua dilakukan setelah monitoring keseimbangan cairan selama 12 kali hemodialisis. 149 muhammadiyah journal of nursing analisa univariat meliputi mean, standart deviasi, nilai terendah, nilai tertinggi dan confi dens interval dari data umum, kualitas hidup dan indikator fi sik kualitas hidup (tekanan darah, idwg, kekuatan otot, edema, lla dan lingkar pergelangan kaki). analisa bivariat adalah analisa untuk mengetahui perbedaan kualitas hidup dan indikator fi sik kualias hidup responden sebelum dan sesudah dilakukan intevensi baik pada masing-masing kelompok intervensi dan kelompok kontrol dengan uji wilcoxon signed rank test digunakan jika distribusi data tidak normal dan menggunakan paired sampel test jika distribusi data normal. perbedaan kualitas hidup dan indikator fi sik kualitas hidup pasien pada kelompok kontrol dan intervensi yang menjalani hemodialysa sebelum dan setelah dilakukan intervensi dengan analisa bivariat dengan uji mann witney digunakan jika distribusi data tidak normal dan uji independent sampel t test digunakan jika distribusi data normal. hasil karakteristik responden adalah sebagai berikut umur responden pada kelompok perlakuan rata-rata 50 tahun, minimum berumur 38 tahun dan maksimum berumur tahun 60 (sd=4,61), dengan umur termuda 38 tahun dan umur tertua 60 tahun. rata-rata umur responden kelompok kontrol 50,20 tahun (sd=1,86), umur termuda 20 tahun dan umur tertua 70 tahun. jenis kelamin responden pada kelompok perlakuan seluruhnya kelamin laki-laki (100%). jenis kelamin responden kelompok kontrol sebagian besar perempuan (60%). pendidikan responden kelompok perlakuan sebagian besar sma (66,66%). pendidikan responden kelompok kontrol sebagian besar sd dan sma, masingmasing berurutan (40%). pekerjaan responden pada kelompok perlakuan (50%) dan responden kelompok kontrol sebagian besar (60%) adalah petani. kualitas hidup. rata-rata kualitas hidup sebelum perlakuan responden kelompok perlakuan 40 point (sd=9,95), nilai minimum 14,44 point dan maksimum 40 point. kualitas hidup responden kelompok kontrol rata-rata 14 point (sd=8,10), nilai minimum 14 point dan maksimum 35 ponit. idwg (interdyalitic weight gain). rata-rata idwg sebelum perlakuan responden kelompok perlakuan 1,57% (sd=6,25), nilai minimum -5,57% dan maksimum 12%. idwg responden kelompok kontrol rata-rata 10,96 % (sd=6,87), nilai minimum 0% dan maksimum 16,22%. lingkar lengan atas (lla). rata-rata ukuran lla sebelum perlakuan responden kelompok perlakuan 25,71 cm (sd=3,05), minimum 21 cm dan maksimum 28,30 cm. lla responden kelompok kontrol rata-rata 27 cm (sd=3,20), minimum 20 cm dan maksimum 27 cm. lingkar pergelangan kaki (lpk). rata-rata lpk sebelum perlakuan responden kelompok perlakuan 21,50 cm (sd=0,83), minimum 20 cm dan maksimum 22 cm. lla responden kelompok kontrol rata-rata 22,40 cm (sd=2,80), minimum 20 cm dan maksimum 26 cm. kekuatan otot. rata-rata kekuatan otot sebelum perlakuan responden kelompok perlakuan 12 kg (sd=5,12), minimum 5 kg dan maksimum 17 kg. kekuatan otot responden kelompok kontrol rata-rata 10 kg (sd=7,07), minimum 5 kg dan maksimum 20 kg. edema. rata-rata derajat edema sebelum perlakuan responden pada kelompok perlakuan derajat 2 (sd=0,83). derajat edema responden kelompok kontrol rata-rata derajat 2 (sd=0,70), minimum derajat 1 dan maksimum derajat 3. tekanan sistol sebelum hd. rata-rata tekanan sistol sebelum hd sebelum perlakuan responden kelompok perlakuan 118 mmhg (sd=2,40), minimum 80 mmhg dan maksimum 150 mmhg. tekanan sistol sebelum hd responden kelompok 150 muhammadiyah journal of nursing kontrol rata-rata 180 mmhg (sd=2,61), minimum 130 mmhg dan maksimum 180 mmhg. tekanan diastol sebelum hd. rata-rata tekanan diastol sebelum hd sebelum perlakuan responden kelompok perlakuan 73,33 mmhg (sd=1,03), minimum 60 mmhg dan maksimum 80 mmhg. tekanan diastol sebelum hd responden kelompok kontrol rata-rata 80 mmhg (sd=7,07), minimum 70 mmhg dan maksimum 90 mmhg. tekanan sistol sesudah hd. rata-rata tekanan sistol sesudah hd sebelum perlakuan responden kelompok perlakuan 136 mmhg (sd=1,40), minimum 140 mmhg dan maksimum 170 mmhg. tekanan sistol sesudah hd responden kelompok kontrol rata-rata 148 mmhg (sd=2,61), minimum 120 mmhg dan maksimum 150 mmhg. tekanan diastol sesudah hd. rata-rata tekanan diastol sesudah hd sebelum perlakuan responden kelompok perlakuan 83,33 mmhg (sd=5,16), minimum 80 mmhg dan maksimum 90 mmhg. tekanan diastol sesudah hd responden kelompok kontrol rata-rata 78 mmhg (sd=4,47), minimum 70 mmhg dan maksimum 80 mmhg. perbedaan indikator fisik dan kualitas hidup sebelum dan sesudah perlakuan pada pasien hemodyalisis. idwg (interdyalitic weight gain). hasil analisis diketahui bahwa perbedaan idwg sebelum dan sesudah perlakuan pada kelompok perlakuan tidak signifikan (nilai p=0,936). perbedaan idwg sebelum dan sesudah perlakuan pada kelompok kontrol tidak signifikan (nilai p=0,062). kekuatan otot. hasil analisis perbedaan kekuatan otot lengan sebelum dan sesudah perlakuan pada kelompok perlakuan signifi kan (nilai p=0,027). perbedaan kekuatan otot sesudah dan sebelum perlakuan pada kelompok kontrol tidak signifi kan (nilai p=0,062). lingkar lengan atas. hasil analisis perbedaan ukuran lingkar lengan atas sebelum dan sesudah perlakuan pada kelompok perlakuan signifi kan (nilai p=0,012). perbedaan ukuran lingkar lengan atas sebelum dan sesudah perlakuan pada kelompok kontrol tidak signifi kan (nilai p=0,374). lingkar pergelangan kaki. hasil analisis pebedaan ukuran lingkar pergelangan kaki sebelum dan sesudah perlakuan pada kelompok perlakuan tidak signifi kan (nilai p=0,157). perbedaan ukuran lingkar pergelangan kaki sebelum dan sesudah perlakuan pada kelompok kontrol signifi kan (nilai p=0,004). edema. hasil analisis pebedaan derajat edema kaki sebelum dan sesudah perlakuan pada kelompok perlakuan tidak signifi kan (nilai p=0,18). perbedaan edema kaki sebelum dan sesudah perlakuan pada kelompok kontrol signifi kan (nilai p=0,039). tekanan sistol sebelum hd. hasil analisis perbedaan tekanan sistol sebelum dan sesudah perlakuan pada kelompok perlakuan tidak signifi kan (nilai p=0,72). perbedaan tekanan sistol sebelum dan sesudah perlakuan pada kelompok kontrol tidak signifi kan (nilai p=0,64). tekanan diastol sebelum hd. hasil analisis perbedaan tekanan diastol sebelum dan sesudah perlakuan pada kelompok perlakuan tidak signifi kan (nilai p=0,157). perbedaan tekanan diastol sebelum dan sesudah perlakuan pada kelompok kontrol tidak signifi kan (nilai p=0,374). tekanan sistol sesudah hd. hasil analisis perbedaan tekanan sistol sesudah hemodyalisis sebelum dan sesudah perlakuan pada kelompok perlakuan signifi kan (nlai p=0,042). perbedaan tekanan sistol sesudah hemodyalisis sebelum dan sesudah perlakuan pada kelompok kontrol tidak signifi kan (nilai p=0,189). tekanan diastol sesudah hd. hasil analisis perbedaan tekanan diastol sesudah hemodyalisis 151 muhammadiyah journal of nursing sebelum dan sesudah perlakuan pada kelompok perlakuan tidak signifi kan (nilaip=0,157). perbedaan tekanan diastol sesudah hemodyalisis sebelum dan sesudah perlakuan pada kelompok kontrol tidak signifi kan(nilai p=1,00). kualitas hidup. hasil analisis perbedaan 8 dimensi kualitas hidup semuanya signifi kan. kualitas hidup secara keseluruhan sebelum dan sesudah perlakuan baik pada kelompok perlakuan signifi kan (nilai p=0,027). sedangkan perbedaan 8 dimensi kualitas hidup kelompok kontrol hanya 3 dimensi (fungsi fi sik, keterbatasan peran karena masalah emosi, kesejahteraan emosi) yang signifi kan. kualitas hidup sebelum dan sesudah perlakuan baik pada kelompok kontrol signifi kan (nilai p=0,016). perbedaan perubahan indikator fisik dan kualitas hidup dan pasien yang menjalani hemodyalisis antara kelompok perlakuan dan kelompok kontrol di unit hemoadyalisis rsud. dr. harjono ponorogo idwg (interdyalitic weight gain). hasil analisis perbedaan perubahan idwg antara kelompok perlakuan dengan idwg pada kelompok kontrol tidak signifi kan (nilai p=0,073). kekuatan otot. hasil analisis perbedaan perubahan kekuatan otot lengan antara kelompok perlakuan dengan kekuatan otot lengan pada kelompok kontrol tidak siginifikan (0,56). lingkar lengan atas. hasil analisis perbedaan perubahan ukuran lingkar lengan atas antara kelompok perlakuan dengan ukuran lingakar lengan atas pada kelompok kontrol signifikan (nilai p=0,027). lingkar pergelangan kaki. hasil analisis perbedaan perubahan ukuran lingkar pergelangan kaki antara kelompok perlakuan dengan ukuran lingkar pergelangan kaki pada kelompok kontrol signifakan (nilai p=0,024). edema. hasil analisis perbedaan perubahan edema antara kelompok perlakuan dengan edema kelompok kontrol signifikan (nilai p=0,01). tekanan sistol sebelum hd. hasil analisis perbedaan perubahan tekanan sistol sebelum hemodyalisis antara kelompok perlakuan dan kelompok kontrol tidak signifikan (nilai p=0,11). tekanan diastol sebelum hd. hasil analisis perbedaan perubahan tekanan diastol sebelum hemodyalisis antara kelompok perlakuan dengan kelompok kontrol tidak signifikan (nilai p=0,48). tekanan sistol sesudah hd. hasil analisis perbedaan perubahan tekanan sistol sesudah hemodyalisis antara kelompok perlakuan dengan kelompok kontrol signifikan (nilai p=0,04). tekanan diastol sesudah hd. hasil analisis perbedaan perubahan tekanan diastol sesudah hemodyalisis antara kelompok perlakuan dengan kelompok kontrol tidak signifikan (nilai p=0,17). kualitas hidup. hasil analisis perbedaan perubahan 8 dimesi kualitas hidup dan kualitas hidup secara keseluruhan antara kelompok perlakuan dengan kualitas hidup pada kelompok kontrol tidak signifikan (nilai p=0,74). namun kualitas hidup sesudah perlakuan antara kelompok perlakuan dan kontrol signifikan (p=0,023). diskusi karakteristik responden. umur. hasil penelitian menunjukkan rentang umur responden adalah 20 hingga 70 tahun (n=11). rentang rata-rata umur responden dalam penelitian ini berdistribusi 40,76 tahun sampai dengan 59,41 tahun. menurut niven (2008) salah satu faktor yang mempengaruhi kepatuhan adalah umur. faktor kepatuhan pasien dalam mentaati jumlah konsumsi cairan menentukan tercapainya berat badan kering yang optimal (riyanto (2011). kimmel, et al (2000) menunjukkan bahwa umur 152 muhammadiyah journal of nursing merupakan faktor yang kuat terhadap tingkat kepatuhan pasien. pasien berumur muda mempunyai tingkat kepatuhan yang rendah dibandingkan dengan pasien berumur tua. fefendi (2008) menjelaskan bahwa pasien dengan umur produktif merasa terpacu untuk sembuh, mempunyai harapan hidup yang lebih tinggi dan sebagai tulang punggung keluarga. jenis kelamin. secara keseluruhan responden yang berjenis kelamin laki-laki 72,72% (n=11). hal ini sesuai dengan karakteristik responden berdasarkan jenis kelamin yang ditemukan oleh the esrd incidense study group, (2006) bahwa terdapat peningkatan angka kejadian gagal ginjal kronik terjadi pada laki-laki. hal ini dikaitkan dengan gaya hidup yang kurang baik pada pasien seperti merokok, alkohol, bergadang, kurang minum air, kurang olah raga dan banyak makan makanan cepat saji pendidikan. sebagian besar dari 11 responden berpendidikan sma (54,54%). semakin tinggi tingkat pendidikan seseorang maka dia akan cenderung untuk berperilaku positif karena pendidikan yang diperoleh dapat meletakkan dasar-dasar pengertian dalam diri seseorang (azwar, 1995). namun studi yang dilakukan oleh barnett (2008) menunjukkan bahwa tingkat pendidikan tidak memberikan perbedaan terhadap kemampuan melakukan perawatan mandiri pada pasien hemodialsis. hal ini didukung oleh hasil penelitian thomas (2003) bahwa psikologis berkontribusi terhadap asupan cairan yang berlebihan pada pasien dialisis. model mengasumsikan bahwa ada ketegangan antara kebutuhan untuk membatasi asupan cairan dan keinginan untuk minum. berfokus pada gagasan kehausan akan menyebabkan peningkatan rasa haus, menghadapi pemicu misalnya melihat minuman lain, akan memulai proses haus atau sensasi somatik, yang semuanya bisa mengakibatkan perasaan ketidakberdayaan untuk melawan dorongan untuk minum pada diri pasien yang restriksi cairannya buruk. pekerjaan. secara keseluruhan dari 11 responden yang bekerja sebagai petani (54,54%). asupan cairan berhubungan dengan kebutuhan fisik, kebiasaan, adat istiadat, ritual sosial, atau penyakit (thomas,2003). menurut mistiaen (2001) dalam istanti (2011) bahwa rasa haus merupakan bagian dan masalah yang paling berat pada pasien yang menjalani hemodialisis. pekerjaan responden sebagai petani akan mempengaruhi timbulnya rasa haus. hal ini terkait dengan tingginya tingkat kesulitan untuk mengikuti rekomendasi pengobatan, pedoman cairan dan diet. indikator kualitas hidup interdyalitic weight gain (idwg), lingkar pergelangan kaki dan edema. konsekuensi asupan cairan kelebihan antara lain berhubungan dengan peningkatan idwg dan edema ekstremitas bawah. penurunan idwg 0,39% tidak mencapai tingkat nominal signifikansi. menurut christensen et al (1995), cvengros et al(2004) dalam arnold tl (2008) bahwa kepatuhan pasien terhadap pembatasan cairan dapat dievaluasi berdasarkan pada rata-rata berat badan dalam 12 sesi hemodialisis. menurut istanti (2011) masukan cairan merupakan faktor yang berkontribusi secara signifikan terhadap idwg. idwg lebih dari 2.5 kg menyatakan lemahnya kepatuhan pasien terhadap asupan cairan. idwg berada dalam kisaran 2,5% sampai 3,5% dari berat badan kering untuk mengurangi risiko kardiovaskular dan juga untuk mempertahankan status gizi yang baik (lindberg,2010). kelebihan cairan dapat dicegah dengan pemasukan cairan tiap hari 500 – 750 ml dalam situasi produksi urin kering. pemasukan natrium 80 – 110 mmol tiap hari, akan cukup untuk mengontrol haus dan membantu pasien mengatur cairan (thomas, 2003). idwg merupakan indikator untuk mengetahui jumlah cairan yang masuk selama periode interdialitik dan kepatuhan pasien terhadap pengaturan cairan pada pasien yang mendapat terapi hd. 153 muhammadiyah journal of nursing menurut linberg (2010) konsekuensi kelebihan asupan cairan berhubungan dengan kejadian edema. penurunan prosentase idwg juga akan menurunakan derajat edema ekstremitas bawah, dan ukuran lingkar pergelangan kaki. hasil penelitian ini ada penurunan idwg, lingkar pergelangan kaki dan edema, namun tidak mencapai tingkat nominal signifikansi. kekuatan otot. perbedaan kekuatan otot lengan sebelum dan sesudah perlakuan pada kelompok perlakuan signifikan. kekuatan pegangan terbukti menjadi penanda status gizi, massa otot dan prognosis pada pasien dialisis. (anne and noel,2008). perbedaan kekuatan otot kelompok perlakuan dan kelompok kontrol sesuai dengan data perbedaan asupan nutrisi. kelompok perlakuan memiliki nafsu makan yang baik. hal ini sesuai dengan pendapat cano et al (2007) morbiditas dan mortalitas pasien hemodialisis dapat dikurangi ketika ada peningkatan status gizi yang diperoleh dalam dukungan nutrisi. penelitian kualitatif terkait dengan kelemahan fisik oleh lee (2005) bahwa kelelahan fisik merupakan domain utama yang terdiri dari 4 tema yaitu kelelahan secara umum, kelelahan karena uremia, kelelahan akibat gangguan tidur dan kelelahan karena energi fisik yang tidak cukup. kemampuan pasien menerapkan petunjuk menjaga pembatasan cairan dan memonitor keseimbangan cairan akan membantu pasien untuk mendapatkan kesehatan fisik (thomas,2003). lingkar lengan atas. perbedaan lingkar lengan atas sebelum dan sesudah perlakuan pada kelompok perlakuan signifikan. tidak adanya retensi air, ketebalan lipatan kulit trisep dapat berguna untuk menilai lemak dan otot lingkar lengan dan untuk menilai massa otot (anne and noel,2008). diet rendah protein dan tinggi kalori menghilangkan gejala anoreksia dan nausea (mual) dan uremia, menyebabkan penurunan ureum dan perbaikan gejala (mansjoer,2001). penelitian terbaru menunjukkan bahwa penilaian nafsu makan bisa menjadi alat klinis yang sederhana dan berguna dalam mengidentifi kasi pasien dialisis pada risiko kematian (carrero et al,2007) tekanan darah sebelum hemodialsis. tekanan sistol sebelum hemodialsis sebelum dan sesudah perlakuan pada kelompok perlakuan tidak signifi kan. hal ini disebabkan peningkatan tekanan sistol melebihi rekomendasi k/dqoi (2006) 5 mmhg. kelebihan cairan pradialisis akan meningkatkan resistensi vaskuler dan pompa jantung. pasien yang mengalami hipertensi intradialisis terjadi peningkatan nilai tahanan vaskuler perifer yang bermakna pada jam akhir dialisis (landry, oliver, chou, lee, chen, hsu, chung, liu dan fang,2006). jika terjadi kenaikan tekanan darah postdialysis mencerminkan kelebihan volume subklinis, (chih-yu et al, 2012). tekanan sistol sebelum hemodyalisis antara kelompok perlakuan dan kelompok kontrol tidak signifi kan.tekanan darah sebelum hemodialisis ada penurunan (25/14 mmhg) namun tidak mencapai tingkat nominal signifi kansi. tekanan darah sesudah hemodialisis. tekanan sistol sesudah hemodyalisis antara kelompok perlakuan dengan kelompok kontrol signifi kan. hasil penelitian ini sesuai dengan hasil penelitian moatt ati (2012) bahwa tekanan sistolik/diastolik, berat badan interdialytic, hemoglobin dan kadar hematokrit secara signifi kan berbeda antara kelompok. kualitas hidup. perbedaan 8 dimensi kualitas hidup dan kualitas hidup secara keseluruhan sebelum dan sesudah perlakuan baik pada kelompok perlakuan maupun kelompok kontrol signifi kan. manajemen cairan berpengaruh terhadap perhitungan kenaikan berat badan interdialytic (idwg). menurut thomas (2009) dampak dari konseling meningkatkan kesehatan dan kualitas hidup pasien esrd. monitoring keseimbangan cairan dengan cara mencatat 154 muhammadiyah journal of nursing pemasukan dan pengeluaran cairan serta berat badan. pemasukan cairan meliputi jenis dan jumlah makanan maupun cairan. sedangkan pengeluaran cairan adalah jumlah urin, muntah dan diare. pasien mengisi buku catatan harian unutk memonitor keseimbangan cairan setiap hari. buku catatan harian membantu pasien dalam memecahkan masalah, mengambil keputusan dan tindakan dalam menanggapi respon haus. pasien mengikuti dan melaksananakan petunjuk menjaga keseimbangan cairan dapat membantu mempertahankan idwg 2,5% sampai 3,5% berat badan kering atau tidak melebihi 5% berat badan kering. kualitas hidup antara kelompok perlakuan dengan kelompok kontrol tidak signifi kan(p=0,074). namun kualitas hidup sesudah perlakuan antara kelompok perlakuan dan kelompok kontrol signifi kan (p=0,023). peningkatan kualitas hidup kelompok perlakuan lebih tinggi (25,97 point) dari kelompok kontrol (15,94 point). ada perbedaan yang signifi kan antara kelompok eksperimen dan kontrol sesudah perlakuan dalam skor self-effi cacy, pengurangan stres, dan pengambilan keputusan, di samping kualitas hidup secara keseluruhan dan semua dimensi termasuk dalam kualitas hidup berdasarkan kuesioner ini. selain tekanan sistolik/ diastolik, berat badan interdialytic, hemoglobin dan kadar hematokrit secara signifi kan berbeda antara kelompok (moatt ati et al, 2012). simpulan 1. kualitas hidup pasien yang menjalani hemodylisis di unit hemodialisis rsud dr. harjono ponorogo pada kelompok perlakuan lebih tinggi dari kelompok kontrol. 2. tekanan darah pasien sebelum dan sesudah hemodialisa,idwg,lingkar pergelangan kaki di unit hemodialisis rsud dr. harjono ponorogo pada kelompok perlakuan lebih rendah dari kelompok kontrol. 3. edema pasien hemodialisis di unit hemodialisis rsud dr. harjono ponorogo pada kelompok perlakuan dan kelompok kontrol tidak terjadi edema 4. lingkar lengan atas, kekuatan otot pasien hemodialisis di unit hemodialisis rsud dr. harjono ponorogo pada kelompok perlakuan lebih tinggi dari kelompok kontrol. 5. perbedaan idwg, lingkar pergelangan kaki, edema, tekanan sistol sebelum hemodialisis, tekanan diastol sebelum hemodialisis, tekanan diastol sesudah hemodialisis sebelum dan sesudah perlakuan pada kelompok perlakuan pasien hemodialisis di unit hemodialisis rsud dr. harjono ponorogo tidak signifi kan. 6. perbedaan kualitas hidup, kekuatan otot lengan, lingkar lengan atas, tekanan sistol sesudah hemodialisis,sebelum dan sesudah perlakuan pada kelompok perlakuan pasien hemodialisis di unit hemodialisis rsud dr. harjono ponorogo signifi kan. 7. perbedaan idwg, kekuatan otot lengan, lingkar lengan atas,edema, tekanan sistol dan diastol sebelum hemodialisis, tekanan sistol dan diastol sesudah hemodialisis, sebelum dan sesudah perlakuan pada kelompok kontrol pasien hemodialisis di unit hemodialisis rsud dr. harjono ponorogo tidak signifi kan. 8. perbedaan kualitas hidup,lingkar pergelangan kaki dan edema sebelum dan sesudah perlakuan pada kelompok kontrol pasien hemodialisis di unit hemodialisis rsud dr. harjono ponorogo signifi kan. 9. perbedaan perubahan kualitas hidup berdasarkan kualitas hidup, tekanan sistol sebelum hemodialisis, tekanan diastol sebelum hemodilaisis, tekanan diastol sesudah hemodialisis, idwg, lingkar pergelangan kaki, kekuatan otot lengan pasien heodialisis di unit hemodialisis rsud dr. harjono ponorogo antara kelompok perlakuan dengan kelompok kontrol tidak signifi kan. 10. perbedaan perubahan tekanan sistol sesudah hemodyalisis, edema, lingkar lengan atas, antara kelompok perlakuan dengan kelompok kontrol di unit hemodyalisis rsud. dr. harjono ponorogo signifi kan. 155 muhammadiyah journal of nursing saran 1. pasien hemodialisis memerlukan pendampingan perawat untuk konseling tentang penyakit, perubahan gaya hidup, proses penerimaan penyakit dan penghargaan untuk penguatan psikologis serta kepatuhan pasien, sehingga 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ect of empowerment on the self-effi cacy, quality of life and clinical and laboratory indicators of patients treated with hemodialysis: a randomized controlled trial, shiraz university of medical sciences, shiraz nephrology research center urologi shiraz, iran, diaskes tanggal 2 juli 2013 dari htt p:// www.ncbi.nlm.nih.gov/pubmed/3520754. sharp, 2005, a systematic review of psychological interventions for the treatment of nonadherence to fl uid-intake restrictions in people receiving hemodialysis, diakses tanggal 10 juni 2013 dari htt p://www.ncbi. nlm.nih.gov/pubmed/15696440 blank page jurnal mjn vol. 2 no. 2 2015.indd 79 muhammadiyah journal of nursing pendahuluan pasien yang mengalami kanker memperlihatkan adanya stres dan depresi yang ditunjukkan dengan perasaan sedih, putus asa, pesimis, merasa diri gagal, tidak puas dalam hidup, merasa lebih buruk dibandingkan dengan orang lain, penilaian rendah terhadap tubuhnya, dan merasa tidak berdaya. kemungkinan terjadinya gangguan psikologi seperti depresi, kecemasan, kemarahan, perasaan tidak berdaya dan tidak berharga dialami antara 23%-66% pasien kanker (hadjam 2000). berdasarkan permenkes ri nomor 1109 tahun 2007, terapi komplementer bisa dilakukan di sarana kesehatan, permenkes ri nomor hk.02.02/menkes/148/1/2010 terapi komplementer yang bisa digunakan adalah terapi hipnosis atau hypnotherapi, berdasarkan ketentuan di atas maka perawat mempunyai kewenangan memberikan hypnoterapi untuk menangani masalah pasien. hasil wawancara pada studi pendahuluan di dapatkan informasi tentang masalah keperawatan yang sering ditemukan pada pasien kanker kolon yang menjalani kemoterapi adalah nyeri dan kecemasan, perawat di rsu banyumas menggunakan intervensi kolaboratif farmakologis dengan pemberian analgetik dan motivasi spiritual untuk mengatasinya, penggunaan hypnosis sangat jarang dilakukan karena merasa belum menguasai, serta tidak ada standar operasional prosedur penerapannya. penelitian penggunaan hipnosis sebagai terapi untuk nyeri dan kecemasan sudah cukup banyak, tetapi sering dianggap belum mampu menjawab keraguan masyarakat tentang aspek ilmiah dan kecenderungan anggapan bahwa hypnosis sebagai terapi bertentangan abstract hypnoterapi action research on pain management and anxiety based colon cancer patients in the problems of pain and anxiety often expressed by colon cancer patients who have undergone surgery and is in the process of chemotherapy, anxiety will increase when individuals face the threat of a life change as a result of disease and duration of the treatment process. the root of the problem in this research is how hypnotherapy reduce pain and anxiety in patients with colon cancer in a surgical disease inpatient unit rsu banyumas. design a qualitative research approach action research/action research using elliot›s action research model, which consists of the process of identifying the initial idea, searching and analyzing facts about pain and anxiety, making planning hypnoterapi, action hypnoterapi, evaluate the success or failure of interventions hypnotherapy, revise ideas, the steps are performed in three cycles. formulation of the problem in this research is «how to decrease pain and anxiety in patients with colon cancermafter hypnotherapy in the inpatient surgical disease rsu banyumas». data processing and data interpretation using nvivo software 9.0.204.0. based on the data obtained during the application of the three cycles of action showed that hypnotherapy is eff ective in reducing pain and anxiety in patients with colon cancer who are undergoing chemotherapy inpatient unit rsu banyumas. decrease in pain every cycle between 4 to 6.3, while the average decrease anxiety between 7 to 15.8. conclusions in hypnotherapy research helpful in reducing pain and anxiety of patients who suff er from colon cancer and is undergoing chemotherapy in rsu banyumas. researchers hope hypnoterapi intervention can be arranged with a standard operating procedure nursing care in the health facilities and can be learned by nurses through nursing education curriculum. keywords: hypnotherapy, colon cancer, pain, anxiety. sakiyan1, elsye maria rosa2 1akper serulingmas cilacap 2universitas muhammadiyah yogyakarta action research: hypnotherapy to overcome pain and anxiety in colon cancer patients 80 muhammadiyah journal of nursing dengan keyakinan kepercayaan/ agama tertentu, sehingga diperlukan penelitian lebih lanjut untuk menjawab kebutuhan dan keraguan masyarakat tersebut. tinjauan pustaka 1. hypnoterapi hipnosis adalah keadaan dimana fungsi analitis logis pikiran direduksi sehingga memungkinkan individu masuk ke dalam kondisi bawah sadar, dalam kondisi ini dimungkinkan untuk mengakses beragam potensi internal yang dapat dimanfaatkan untuk lebih meningkatkan kualitas hidup (naibaho 2002). 2. tahapan hypnotherapi/ clinical hypnosis menurut heap et al (2007). a. persiapan pasien b. induksi dan deepening pasien c. therapy d. alerting e. diskusi posthypnosis 3. nyeri keperawatan mendefi nisikan nyeri sebagai apapun yang menyakitkan atau tidak nyaman yang dikatakan individu (perry dan pott er 2007). stimulus yang mengenai tubuh (mekanik, termal, kimia) akan menyebabkan pelepasan substansi kimia seperti histamin, bradikinin, kalium. substansi tersebut menyebabkan nosiseptor bereaksi, apabila nosiseptor mencapai ambang nyeri, maka akan timbul impuls saraf yang akan dibawa oleh serabut saraf perifer. serabut saraf perifer yang akan membawa impuls saraf ada dua jenis, yaitu serabut a delta dan serabut c. impuls saraf akan di bawa sepanjang serabut saraf sampai ke kornu dorsalis medula spinalis. impuls saraf tersebut akan menyebabkan kornu dorsalis melepaskan neurotrasmiter (substansi p). substansi p ini menyebabkan transmisi sinapsis dari saraf perifer ke saraf traktus spinotalamus. hal ini memungkinkan impuls saraf ditransmisikan lebih jauh ke dalam sistem saraf pusat. setelah impuls saraf sampai di otak, otak mengolah impuls saraf kemudian akan timbul persepsi dari nyeri juga respon refl ek protektif terhadap nyeri. 4. kecemasan kecemasan adalah kondisi emosional yang tidak menyenangkan, yang ditandai oleh perasaan-perasaan subyektif seperti ketegangan, ketakutan, kekhawatiran dan juga ditandai dengan aktifnya system syaraf pusat (heap et al 2007). tingkat kecemasan dipengaruhi oleh beberapa factor yaitu potensi stressor, maturasi /kematangan, status pendidikan, keadaan fi sik, sosial budaya, sosial ekonomi dan pekerjaan, lingkungan, umur, jenis kelamin (stuart 2005). kanker kolon ada 3 faktor predisposisi dari cancer colon menurut marijata (2006), yaitu kolitis ulceratifa, tumor jinak, poliposis familial. pemeriksaan diagnostik terdiri dari endoscopy (anoscopy, protocoscopy, fl exible sigmoidescopy dan colonoscopy, capsule endoscopy), imaging (plain x-ray dan contras, ct-scan, virtula colonoscopy, mri, pasitron emission tomography, angiography, endorectal dan endoanal ultrasound), physiologic and pelvic floor investigations (manometry, neurophsiology, evaluasi rectal), pemeriksaan laboratorium (perdarahan feces, pemeriksaan feces, serum tests, penanda tumor, tes dna). prinsip penanganan pada karsinoma kolon menurut marijata (2006) adalah sebagai berikut: a. jika tumor secara kinis tidak bisa dioperasi dengan ditentukan oleh perluasan area deposit sekunder, maka terapi menggunakan steroid bebas. terapi intravena dengan kemoterapi fl orourasil /12 mg perkg bb/ hari untuk 6 hingga 8 minggu kemudian 6 mg/ kg bb/ minggu. b. jika tumor dapat diangkat seluruhnya maka operasi dilakukan dengan 81 muhammadiyah journal of nursing kecurigaan metastase hepar atau tentorial, kemudian dilanjutkan dengan pemberian kemoterapi. c. jika tumor dipertimbangkan dapat disembuhkan dan tidak menimbulkan obstruksi, maka resekdi harus mencakup lesi dan sekurang-kurangnya 5 cm usus di atasnya dan di bawahnya bersama mesenterium yang berisi nodus limphatik daerah tersebut. d. jika tumor potensial sembuh dan ada obstruksi maka penting untuk membebaskan daerah obstruksi dengan kolostomi proksimal atau sekostomi sebagai tahap operasi pertama, kemudian ditunggu hingga usus berdefl asi daan pasien kembali fi t untuk dilakukan reseksi defi nitif. e. jika terjadi peritonitis umum sebagai akibat perforasi sekum yang sangat terdistensi, tumor atau ulcerasi sterkoral pada tumor, maka sekostomi atau kolostomi merupakan indikasi bersama dengan toilet perotoneal dan drainase. 5. teori keperawatan yang terkait dengan nyeri dan kecemasan kolcaba (2003) menyebutkan tipe-tipe kenyamaman didefi niskan sebagai dorongan (relief) yaitu kondisi resipien yang membutuhkan kebutuhan yang spesifi k dan segera. ketenteraman (ease) suatu kondisi yang tenteram atau kepuasan hati (transcedence) kondisi dimana individu mampu mengatasi masalahnya (nyeri). orem dalam teorinya menjelaskan tentang therapiutic self care demand yaitu tindakan yang dibutuhkan untuk memenuhi kebutuhan self care dengan metode dan tindakan yang benar, self care agency adalah kemampuan indifi du untuk memberikan perawatan. self care, self care agency dibagi menjadi tiga bagian lagi yaitu : agent adalah orang yang memberikan tindakan, self care agent adalah penyedia dari self care, dependent-self care agent adalah penyedia dari self care yang melayani bayi, anak, orang dewasa yang tergantung (orem 2001). self care defi cit adalah hubunganantara self care agency dengan therapiutic self care demand dimana self care agency tidak dapat memenuhi kebutuhan therapiutic self care demand, hal tersebut menjelaskan kenapa keperawatan dibutuhkan (alligood dan tomey 2006). metode penelitian 1. desain penelitian penelitian ini menggunakan desain penelitian kualitatif dengan pendekatan penelitian tindakan/action research dengan mengimplementasikan metode hypnotherapi sebagai upaya penangan nyeri dan kecemasan pada pasien kanker colon yang mendapatkan terapi kemoterapi di rsu banyumas. 2. variabel penelitian variabel dalam penelitian ini adalah : a. variabel bebas pada penelitian ini adalah hypnotherapi pada pasien kanker kolon. b. variabel terikat pada penelitian ini ada dua yaitu nyeri dan kecemasan. 3. populasi dan sampel penelitian populasi dalam penelitian ini adalah pasien kanker kolon yang sudah menjalani operasi pengangkatan kanker dan mendapatkan kemoterapi yang mengalami nyeri dan kecemasan di rsu banyumas. pengambilan partisipan menggunakan teknik purposif sampling berdasarkan karakteristik bersedia menjadi partisipan yang dinyatakan dalam lembar persetujuan dan tidak terdapat gangguan komunikasi verbal maupun nonverbal, setelah dilakukan penelitian di dapatkan partisipan sebanyak 6 orang. 4. prosedur pengumpulan dan analisa data data dikumpulkan dengan wawancara mendalam dan observasi partisipan sebelum dan 82 muhammadiyah journal of nursing sesudah dilakukan hipnotherapi. pengolahan data menggunakan software nvivo 9.0.204.0. peneliti melakukan analisa data menggunakan metode interpretasi data speziale, & carpenter (2007), langkah-langkah interpretasi tersebut meliputi mendeskripsikan fenomena yang diteliti, mengumpulkan deskripsi fenomena melalui pendapat partisipan, membaca seluruh deskripsi fenomena yang telah disampaikan oleh partisipan, membaca kembali transkrip hasil wawancara dan mengutip pernyataan-pernyataan yang bermakna, meneliti membaca kembali transkrip hasil wawancara, memilih pernyataanpernyataan dalam transkrip yang signifi kan dan sesuai dengan tujuan khusus penelitian dan memilih kata kunci pada pernyataan yang telah dipilih dengan cara memberikan penanda dan kode tujuan khusus, menguraikan arti yang ada dalam pernyataan-pernyataan signifi kan, peneliti membaca kembali kata kunci yang telah diidentifi kasi dan berusaha menemukan esensi atau makna dari kata kunci untuk membentuk kategori, mengorganisir kumpulan-kumpulan makna yang terumuskan ke dalam kelompok tema. peneliti membaca seluruh kategori yang ada, membandingkan dan mencari persamaan diantara kategori tersebut, dan pada akhirnya mengelompokkan kategori-kategori yang serupa ke dalam sub-sub tema, sub tema dan tema. hasil penelitian penelitian ini menghasikan 5 kategori tema yang menjelaskan proses hypnotherapi dan respon partisipan terhadap hypnotherapi yang dilakukan dalam tiga siklus. kategori tema di uraikan berdasarkan tujuan khusus sebagai berikut : 1. pra induksi proses pre-induksi dilakukan 3 kali yaitu sebelum induksi hypnoyherapi 1,2 dan 3, hasil pre induksi di dapatkan data partisipan mengeluh adanya nyeri yang dirasakan yaitu sangat nyeri, nyeri berat dan juga kecemasan. partisipan menginginkan nyeri dan kecemasannya hilang atau berkurang, pernyataan partisipan seperti diungkapkan sebagai berikut : “nggih niki sakite, ora mari-mari larane,...mbuh kapan marine, ora bisa turu, nek turu ngimpi ketemu karo sing wis mati...” /ya ini sakitnya, tidak sembuhsembuh, entah kapan sembuhnya, tidak bisa tidur, kalau tidur mimpi ketemu sama orang orang yang sudah meninggal (partisipan terlihat emosional, mata berkaca-kaca...) (p2). “nggih sakit sekali niki, kulo manut sing penting sakitnya saged ical... mantun”/ iya sakit sekali, saya nurut yang penting nyeri ini bisa hilang....sembuh (p2). 2. induksi dan deepening proses induksi dan deepening dilakukan bersama-sama, pada proses hypnoterapi i proses ini menggunakan metode nafas dalam, pada hypnotherapi tahap ii menggunakan metode nafas dalam dan metode mata berkedip sedangkan pada hypnotherapi tahap iii menggunakan metode nafas dalam, metode mata berkedip dan metode imagery oleh terapis. dari hasil penelitian di dapatkan data pada induksi dan deepening siklus 1 partisipan merasakan otot terasa kendor, rileks, nyaman, dan tidak terasa sakitnya, pada induksi dan deepening siklus 2 di dapatkan data respon partisipan berupa mata semakin lama semakin berat, mengantuk, tidur, lupa semua sakitnya, muncul rasa nyaman, pada induksi dan deepening siklus 3 di dapatkan data partisipan merasakan berada di pantai, di gunung dan di hutan, semuanya merasakan bisa tidur, badan terasa nyaman, terasa ringan dan hati gembira, hal tersebut diungkapkan partisipan sebagai berikut : “niku sing tarik nafas...teras otote sami kendo...teras rileks...ngantos turu... sekeca” / yang tarik nafas, semua otot terasa rileks dan tertidur...nyaman (p4). “...dangu-dangu matane kulo abot terus turu...dadi kelalen kabeh larane, karo penyakite” /....... lamakelaman mata saya berat mengantuk terus tidur 83 muhammadiyah journal of nursing dan saya lupa rasa sakite (p2). “....rasane mripate tambah abot...tambah ngantuk terus kulo turu....”/... saya rasakan mata saya semakin berat, semakin mengantuk terus saya tertidur (p5). “nggih situasi pas teng gunung” /ya situasi di gunung, “.... nggih niku wau sedoyo rasane mpun sekeca, ndamelaken pikirane tenang”/ semua rasanya nyaman, membuat pikiran tenang (p2). “niku pas jalan-jalan teng alas...hawane seger...akeh wit-wit sing ijo, suara manuk pada moni....rasane kepenak”/ itu pas jalanjalan di hutan...hawanya segar...banyak pohon-pohon hijau.. suara burung berkicau...rasanya enak di badan (p5). dari hasil induksi dan deepening ini tingkat kerentanan hypnosis partisipan/ scale of hypnotic susceptibility di ukur menggunakan davishusband scale dan di dapatkan data sebagai berikut : grafi k 1. scale of hypnotic susceptibility siklus 1: hypnoidal 1-5, light trance 6-12, medium trance 13-20, deep trance/ somnabulism 21-30 3. sugesti terapi proses pemberian sugesti terapi dilakukan setelah proses induksi dan deepening, pada proses hypnoterapi i sugesti terapi yang diberikan berupa metode relaksasi, pada hypnotherapi tahap ii menggunakan sugesti terapi yang diberikan menggunakan metode relaksasi dan metode perintah paradoks sedangkan pada hypnotherapi tahap iii sugesti yang diberikan menggunakan metode relaksasi, metode perintah paradoks dan metode pemisahan/ disosiasi. pada proses pemberian sugesti terapi yang menggunakan metode relaksasi di dapatkan hasil semua partisipan merasakan otot menjadi rileks, badan terasa nyaman, nyeri berkurang, tidak terasa nyeri lagi, nyeri terasa lagi dan sakit belum hilang. data tersebut di atas dinyatakan partisipan sebagai berikut : “...otote sedoyo kendo, terus rasane awak kepenak.... mandan mengurangi...ning siki malah krasa maning larane nang weteng”/ ... otot terasa kendor semua, rasanya badan nyaman....agak mengurangi,.... tetapi nyerinya sekarang terasa di perut saya (p2). “.... rileks, otote kendo, ...sing pas turu....niku rasane kepenak..” / ya itu... rileks, ototnya kendor, lemas, yang dalam kondisi tidur (p3). pada hypnotherapi tahap ii dengan menggunakan sugesti terapi yang diberikan menggunakan metode relaksasi dan metode perintah paradoks di dapatkan data pasrtisipan merasakan badan terasa nyaman, semua rasa hilang, tenang, tidak terasa sakit. pernyataan partisipan sebagai berikut: “wau niku sing pas ngitung siji sampai seket, ...., terus kula mboten kraos napa-napa”/ tadi itu yang berhitung satu sampai lima puluh,..., terus tidak terasa apa-apa (p1). “nggih niku sing kula ngitung...genah dadi turu terus kelalen kabeh....kepenak”/ iya itu tadi pas menghitung jadi tertidur terus lupa semuanya. “.....ya pas turu krasane kepenak niku, ora krasa sakite”/ ya pas tidur tadi rasanya enak, tidak terasa sakitnya (p2). pada hypnotherapi tahap iii sugesti yang diberikan menggunakan metode relaksasi, metode perintah paradoks dan metode pemisahan/ disosiasi partisipan yang merasakan melihat semua rasa sakit dan kecemasan, memasukannya ke dalam botol, badan menjadi nyaman dan kecemasan hilang, seperti data wawncara berikut : “nggih pas weruh sakite terus kulo lebetaken teng botol terus kulo bucal teng jurang....teras rasane awak kepenak...tambah kepenak niku”/ ya tadi pada saat melihat rasa sakit saya terus saya masukan 84 muhammadiyah journal of nursing ke botol terus saya buang ke jurang....setelah itu rasanya badan saya nyaman...tambah nyaman” (p2) “banjur kulo saged weruh werna-werni sakite kulo, saged nyekel sakite kulo...lajeng kulo pundhuti... teras kulo lebokaken teng botol niku....kulo buang teng laut.... kendang adoh pisan...ora keton malih.........bar niku kolo raose lega....kepenak awake kulo” /saya juga bisa melihat semua rasa sakit dan ketidaknyamanan saya, saya bisa memegangnya...lalu saya pegang,... saya masukan ke dalam botol tadi....saya buang ke laut....jauh sekali terbawa ombak laut...setelah itu sata merasa lega...nyaman badan saya (p3). 4. alerting proses alerting bertujuan untuk membawa partisipan kembali ke alam sadar, pada semua tahap hypnotherapi menggunakan metode menghitung 1-10, berdasarkan hasil penelitian di dapatkan data bahwa partisipan menghitung dan tiap hitungan merasakan badan nyaman, segar dan hitungan ke sepuluh terbangun. data wawancara partisipan pada saat proses alerting sebagai sebagai berikut: “....... pas ngitung sampe sepuluh rasane awak kulo tambah kepenak....terus kulo tangi”/pada saat mengantuk dan tidur ya tidak merasakan apaapa, pada saat mengitung sampai sepuluh badan terasa semakin enak.....terus saya bangun (p1). “pas ngitung satu sampai sepuluh....teras setiap hitungan rasane awak tambah seger, kepenak... lajeng itungan sing kaping sepuluh kulo tangi...” / ketika menghitung satu sampai sepuluh,...setiap hitungan badan rasanya segar dan nyaman...terus saya terbangun ketika hitungan ke sepuluh (p3). 5. penurunan nyeri dan kecemasan penurunan tingkat nyeri dirasakan oleh semua partisipan setelah proses hypnoterapi di lakukan terlihat dari penurunan scala nyeri yang di keluhkan partisipan, walaupun rasa nyeri muncul lagi sebelum hypnotherapi tahap berikutnya, penurunan yang paling banyak terjadi pada hypnotherapi tahap 3, rata-rata penurunan scala nyeri pasca hypnotherapi tahap 1 adalah 4, pada hypnotherapi 2 adalah 4,3 dan pada hypnotherapi 3 sebesar 6,3 ini menunjukan bahwa angka rata-rata penurunan nyeri terbanyak pada hypnotherapi tahap 3. penurunan nyeri juga di kemukakan oleh responden sebagai berikut : “nggih kirang sakite ....nggih wau pas turu sekeca, ..../ iya berkurang sakitnya.... tadi pas tidur rasanya nyaman, ...”(p4). “rasanya enak, sakitnya berkurang, otot tubuh rileks ya.., di badan terasa semua...”(p6). “nggih alhamdulillah berkurang sanget...” /iya berkurang,berkurang sekali (p1). penurunan nyeri dan kecemasan tergambar dalam grafi k berikut : grafi k 2. penurunan nyeri grafi k 3. penurunan kecemasan 85 muhammadiyah journal of nursing pembahasan pada pelaksanaan hypnotherapi peneliti menggunakan komunikasi terapeutik dengan pendekatan interpersonal agar supaya segala sesuatu yang berkaitan dengan nyeri dan kecemasan partisipan dapat terungkap dan kemudian pesan-pesan hynotherapi dapat diterima sehingga akan membawa manfaat/ efektif pada nyeri dan kecemasan yang dialami partisipanhal ini sesuai dengan nurindra (2008), hypnosis adalah suatu seni komunikasi yang persuasif untuk membuka pintu gerbang alam sadar seseorang sehingga sugesti bisa di berikan. sendjaja (2004) juga menyampaikan bahwa dalam komunikasi interpersonal memliki karakter humanistik yaitu keterbukaan, empati, perilaku suportif, perilaku positif. komunikasi interpersonal akan efektif bila memiliki perilaku positif (sendjaja 2004). sikap positif dalam komunikasi interpersonal yang peneliti lakukan adalah dengan memandang positif terhadap diri sendiri sehingga yakin akan keberhasilan hypnotherapi dan akan menularkan keyakinan tersebut kepada partisipan, di samping itu peneliti juga senantiasa menjaga perasaan positif terhadap partisipan terkait dengan respon partisipan pada saat hypnotherapi dan interaksi lainnya sepanjang waktu penelitian. 1. pra induksi tahap pra induksi bertujuan untuk mendapatkan data terkait dengan hal-hal yang dirasakan oleh partisipan, termasuk harapan dan keinginan terhadap penyelesaian masalah yang dihadapi. informasi mengenai hal tersebut akan dapat diperoleh jika terjadi hubungan saling percaya antara terapis dengan partisipan, dalam hal ini adalah peneliti dengan partisipan. interaksi antara peneliti dan partisipan dilakukan menggunakan pendekatan komunikasi terapeutik yaitu dengan berhadapan dengan partisipan, menampilkan sikap tubuh yang rileks, mempertahankan kontak mata, mempertahanan sikap terbuka. berdasarkan hasil wawancara dan observasi pra induksi diketahui bahwa partisipan mengalami nyeri dan kecemasan. patisipan yang mengalami nyeri dalam kategori sangat nyeri sejumlah 3 orang dan 3 orang mengalami nyeri berat. sedangkan yang mangalami kecemasan terdiri dari 5 orang mengalami kecemasan berat dan 1 orang mengalami kecemasan sedang hal ini tidak sesuai dengan perry & pott er (2010), yang menyatakan bahwa lansia cenderung memendam nyeri yang dialami, karena mereka menganggap nyeri adalah hal alamiah yang harus dijalani dan mereka takut kalau mengalami penyakit berat atau meninggal jika nyeri diperiksakan. partisipan mengalami kecemasan karena sakit yang tidak kunjung sembuh, nyeri yang dirasakan yang menyebabkan terjadinya gangguan tidur baik kualitas maupun kuantitasnya, cerita orangorang tentang penderita penyakit kanker yang tidak berumur panjang, kekhawatiran tidak bisa beribadah dengan sempurna, serta sering mengalami mimpi buruk. kecemasan/ansietas adalah perasaan atau tidak nyaman atau kekhawatiran yang samar disertai respon autonom (sumber seringkali tidak spesifi k atau tidak diketahui oleh individu); perasaan takut yang disebabkan oleh antisipasi terhadap bahaya. hal ini merupakan isyarat kewaspadaan yang memperingatkan individu akan adanya bahaya yang memampukan individu untuk bertindak menghadapi ancaman (nanda 2012). sejalan dengan hal tersebut perry dan pott er (2010) menyatakan bahwa ansietas/ cemas meningkatkan persepsi terhadap nyeri dan nyeri bisa menyebabkan seseorang cemas. seseorang yang mengalami kecemasan akan menunjukan perilaku penurunan produktifi tas, gelisah, insomnia, kesedihan yang mendalam, ketakutan, perasaan ketidakberdayaan, bingung, khawatir, rasa tidak percaya diri. secara fi siologis juga akan nampak ketegangan di wajah, suara bergetar, peningkatan ketegangan, hal ini 86 muhammadiyah journal of nursing tentu saja akan berdampak kepada penurunan kualitas hidup penderitanya (sovodka 2010). kondisi ketidaknyamanan ini tentu saja membuat partisipan memerlukan bantuan untuk penanganan keperawatan yang sesuai, dan mau bekerja sama dalam upaya mengatasi masalah nyeri dan kecemasan yang dihadapi, dengan dasar inilah maka peneliti membuat suatu perencanaan untuk melakukan hipnotherapi sebagai upaya penanganan nyeri dan kecemasan yang dialami oleh partisipan. 2. induksi dan deepening induksi adalah merupakan suatu metode yang digunakan oleh terapis (peneliti) untuk membimbing pasien (partisipan) untuk mengalami suatu trance hypnotheray. kondisi ini merupakan proses ini terjadi perpindahan pikiran pasien dari pikiran sadar (conscious mind) ke alam pikiran bawah sadar (subconscious mind). trance hypnosis adalah suatu kondisi kesadaran dimana bagian kritis pikiran sadar tidak aktif, sehingga partisipan sangat reseptif terhadap sugesti yang diberikan oleh hypnotist (smeltz er dan bare 2006). deepening merupakan kelanjutan dari induksi yang bertujuan untuk membawa partisipan pada tingkatan trance hypnosis sehingga akan meningkatkan kemampuan partisipan untuk menerima sugesti. trance hypnosis dibagi menjadi beberapa tahap berdasarkan davishusband scale menjadi hypnoidal, light trance, medium trance, deep tranceatau somnambulism (heap et al 2007). berdasarkan pengukuran tingkat sugestifi tas setelah dilakukan induksi dan deepening diketahui ada perbedan yang cukup tajam terkait dengan tingkat sugestifi tas pada masingmasing tahap siklus hypnotherapi, pada siklus 1 diketahui rata-rata partisipan masih berada pada tahap midle trance, sedangkan pada siklus 2 dan siklus 3 partisipan sudah bisa mencapai tahap deep trance, sehingga lebih sugestif terhadap sugesti therapi, hal ini juga di dukung dengan hasil penurunan nyeri dan kecemasan yang lebih dirasakan pada hypnotherapi siklus 2 dan semakin meningkat pada siklus 3, hal ini sesuai dengan sovodka (2010) bahwa pada kondisi deep trance pasien akan lebih sugestif terhadap sugesti therapi. ada banyak metode yang dapat digunakan dalam rangka untuk induksi dan deepening dalam hypnotherapi. ada banyak ragam metode induksi dan deepening tetapi peneliti hanya menggunakan metode nafas dalam/deepth breathing, metode membuka dan menutup mata/mata berkedip dan metode imagery oleh terapis, hal ini dilakukan dengan beberapa pertimbangan yaitu untuk keseragaman perlakuan, kondisi latar belakang pendidikan partisipan yang sebagian besar berpendidikan sekolah dasar, mudah karena tidak banyak perintah yang rumit sehingga tidak memerlukan banyak waktu bagi partisipan untuk mencerna, serta karena tidak adanya masukan dan saran dari partisipan pada masing-masing metode karena dirasakan sesuai dengan kondisi partisipan. 3. sugesti therapi sugesti terapi yang di berikan kepada partisipan pada penelitian ini menggunakan metode relaksasi, perintah paradoks dan pemisahan/disosiasi, pemberian dilakukan ketika partisipan sudah memasuki kondisi trance, akan lebih efektif apabila sampai pada deep trance atau somnabulism karena pada tahap ini kondisi mental atau pikiran pasien menjadi sangat sugestif (smeltz er dan bare 2006). setelah menjalani semua siklus hypnotherapi di dapatkan data terjadi penurunan nyeri dan kecemasan pada masing-masing siklus, penurunan nyeri dalam kisaran 4 sampai 6,3 dan penurunan kecemasan pada kisaran 7 sampai 15,8. rata-rata penurunan nyeri tertinggi pada siklus hypnotherapi 3 yaitu pada angka 6,3, 87 muhammadiyah journal of nursing hal ini kemungkinan disebabkan karena pada tahap induksi dan deepening siklus 3 ini semua partsipan bisa memasuki level deep trance yang lebih dalam sehingga partisipan lebih sugestif terhadap sugesti terapi yang peneliti berikan, hal ini sesuai dengan sovodka (2010). berbeda dengan penurunan kecemasan yang berdasarkan pengukuran dengan menggunakan hars ternyata di dapatkan penurunan kecemasan angka rata-rata tertinggi pada siklus 1 disusul siklus 3 dan paling sedikit penurunan kecemasan pada siklus 2, hal ini dimungkinkan karena sebelum siklus 1 parisipan banyak mengalami gangguan tidur/ insomnia dan setelah hypnotherapi siklus 1 partisipan menyatakan bisa tidur walaupun masih belum puas tidurnya, hal tersebut dijelaskan oleh stuart (2005) dan sundeen (2007) bahwa kecemasan akan menimbulkan respon fi siologis terhadap tubuh, di mana akan menimbulkan respon neuromuscular berupa insomnia, gelisah, wajah tegang, kelemahan umum dll, selain itu hasil penelitian ini juga didukung oleh penelitian wahyu dan arif (2008) yang menyatakan bahwa ada hubungan antara kecemasan lansia dengan kecenderungan insomnia di panti wredha dharma bakti surakarta. partisipan mengungkapkan bahwa mereka bisa memenuhi kebutuhan tidur mereka dengan hypnosis, lebih rileks dan nyaman serta tidak lagi mengalami mimpi buruk yang mengganggu kualitas tidur mereka. hal ini didukung oleh penelitian iriana (2014) analisa menunjukkan ada hubungan antara kecemasan dengan kualitas tidur ibu hamil di poliklinik kia puskesmas helvetia medan tahun 2013. pada penelitian schnur et al (2009), menggunakan pendekatan rct dengan menggabungkan terapi perilaku (cognitive-behavioral therapy and hypnosis intervention/cbth) pada pasien kanker payudara yang menjalani radiotherapi di dapatkan hasil bahwa cbth memiliki potensi untuk meningkatkan motivasi dari perempuan yang menjalani kanker payudara radioterapi. gunawan (2007) menjelaskan saat seseorang terhipnosis, fungsi analitis logis pikiran direduksi sehingga memungkinkan individu masuk ke dalam kondisi bawah sadar, dimana tersimpan beragam potensi internal yang dapat dimanfaatkan untuk lebih meningkatkan kualitas hidup. individu yang berada pada kondisi hypnotic trance lebih terbuka terhadap sugesti dan dapat dinetralkan dari berbagai rasa takut berlebih, trauma ataupun rasa sakit. individu yang mengalami hipnosis masih dapat menyadari apa yang terjadi di sekitarnya berikut dengan berbagaistimulus yang diberikan oleh terapis. kolcaba (2003) menyatakan seseorang yang mengalami nyeri berarti tidak terpenuhi kebutuhan rasa nyaman dari partisipan, seseorang yang nyeri akan mencari pertolongan untuk memenuhi kebutuhan rasa nyamannya, dengan hipnosis peneliti dapat memenuhi kebutuhan rasa nyaman partisipan sejak tahap prainduksi, yaitu dengan menggali permasalahan yang melatar belakangi nyeri kemudian membantu menyelesaikannya sehingga partisipan merasa terbebas dari permasalahan dan tentram (ease), partisipan juga merasa mampu mengatasi permasalahannya (transendece) karena ada orang yang akan membantunya, hal tersebut terbukti saat penelitian, partisipan menyatakan nyerinya berkurang langsung setelah selesai sesi hipnosis, partisipan juga merasa lebih lega dan lebih segar saat terbangun dari hipnosis, partisipan tampak lebih bersemangat dan lebih bugar. kondisi ketidaknyamanan berupa nyeri dan kecemasan yang dialami akan membawa partisipan untuk mendapatkan tipe-tipe kenyamanan didefi niskan sebagai dorongan (relief) berupa kondisi partisipan yang membutuhkan kebutuhan yang spesifi k dan segera, ketenteraman (ease) yaitu kondisi yang tenteram atau kepuasan hati dan transcedence yaitu suatu kondisi dimana individu mampu mengatasi nyeri dan kecemasanya. 88 muhammadiyah journal of nursing berdasarkan teori orem, maka praktek dari aktivitas yang dimulai individu untuk menjaga kehidupan dan kesehatannya dalam hal ini adalah kegiatan partisipan untuk penanganan masalah nyeri dan kecemasannya disebut self care. hal yang dibutuhkan untuk menjaga kegiatan self care adalah self care requisites, yang terdiri tiga bagian, yaitu universal self care requisites, developmental self care, health deviation self care requisites. kebutuhan universal self care requisites yaitu kebutuhan yang dibutuhkan oleh manusia berupa udara, air, makanan, eliminasi, aktivitas dan istirahat, menyendiri dan bersosialisasi serta pencegahan bahaya, sedangkan developmental self care requisites adalah kebutuhan tumbuh kembang dari manusia sepanjang perjalanan kehidupan, sedangkan health deviation self care requisites adalah ketika seseorang sakit dan menggangu fungsi seseorang maka dia akan membutuhkan bantuan seseorang (alligood dan tomey 2006). berdasarkan data penelitian kebutuhan universal self care requisites yang belum terpenuhi oleh partisipan adalah kebutuhan akan istirahat, aktifi tas dan pencegahan dari bahaya nyeri sehingga mendorong health deviation self care requisite untuk meminta dukungandan bantuan orang lain sehingga kebutuhan self care/ menjaga kehidupan dan kesehatannya terpenuhi (march et al 2009). nursing system dibagi menjadi tiga bagian yaitu wholly compensatory nursing system yaitu orang yang membutuhkan pelayanan keperawatan secara total, partly compensatory system yaitu orang yang membutuhkan pelayan keperawatan sebagian, perawat dan pasien bekerja sama untuk memenuhi kebutuhannya, supportive educative system, adalah situasi dimana pasien dapat memenuhi kebutuhannya namun masih membutuhkan bimbingan (orem 2001). dalam konteks permasalahan nyeri dan kecemasan yang di hadapi oleh partisipan, ketika partisipan berada pada kondisi sangat nyeri, nyeri berat, kecemasan berat maka patisipan berada pada wholly compensatory sehingga membutuhkan secara total pelayanan keperawatan untuk mengatasinya, dan hypnotherapi layak menjadi salah satu pilihan untuk mengatasi masalah nyeri dan kecemasan, ketika sudah sampai pada nyeri sedang, kecemasan sedang maka partisipan pada posisi partly compensatory system, partisipan hanya membutuhkan sebagian pelayanan keperawatan, partisipan masih bekerjasama dengan peneliti untuk memenuhi kebutuhannya, dan pada kondisi ini perawat bisa memulai mempertimbangkan untuk memberikan pembelajaran tentang self hypnotherapi kepada pasien untuk mengatasi masalahnya, ketika sudah berada pada level nyeri ringan, kecemasan ringan, partisipan berada pada situasi supportive educative system dimana partisipan bisa memenuhi sebagian kebutuhannya namun masih membutuhkan bimbingan, ketika pasien sudah berada pada kondisi nyeri ringan dan kecemasan ringan maka pasien sudah bisa melakukan self hypnosis. 4. alerting alerting sering disebut juga dengan awakening merupakan tahap akhir dari seluruh proses terapi. nurindra (2008) menyebutkan pengakhiran adalah tahap untuk mengakhiri hipnotis dan membawa partisipan kembali ke kondisi normal. pada tahap ini pasien perlahanlahan dibangunkan dari tidur hypnosis dan mengembalikan sepenuhnya kepada kesadaran, tahap yang paling menyenangkan dari serangkaian tahap hypnotherapi adalah ketika partisipanterbangun, membuka mata dan tersenyum kepada therapis, hal ini menandakan proses hypnosis telah memberikan manfaat kepada pasien. pada pelaksanaan alerting pada 3 siklus hypnotherapi peneliti menggunakan 89 muhammadiyah journal of nursing metode menghitung 110 secara perlahan-lahan dengan memberikan ucapan yang menguatkan terhadap proses sugesti, hal ini sesuai dengan sovodca (2010) bahwa untuk mengakhiri proses hypnotherapi, seorang therapis boleh mengucapkan kata-kata yang semakin membuat pasien bersemangat dan yakin bahwa masalahnya sudah terselesaikan. hal yang paling banyak ditemukan adalah ekspresi senyum partisipan, yang menunjukan bahwa nyeri dan kecemasannya berkurang atau hilang. penutup 1. simpulan penelitian ini mendapatkan gambaran tentang manfaat hypnotherapi untuk mengatasi nyeri dan kecemasan pada pasien dengan kanker kolon yang sedang menjalani kemotherapi, gambaran tersebut sebagai berikut : a. pemberian hypnoterapi dilakukan tiga kali/ tiga siklus pada masingmasing partisipan. b. proses hypnotherapi dilakukan melalui tahap pra induksi, induksi dan deepening, pemberian sugesti terapi dan alerting. c. hypnoterapi siklus 1 proses induksi dan depeening menggunakan metode nafas dalam, proses sugesti terapi menggunakan metode relaksasi, proses alerting/awakening menggunakan metode menghitung satu sampai sepuluh diiringi dengan kata-kata penguatan sugesti. d. hypnoterapi siklus 2 proses induksi dan depeening menggunakan metode nafas dalam dan mata berkedip, sugesti terapi menggunakan metode relaksasi dan perintah paradoks, proses alerting/ awakening menggunakan metode menghitung satu sampai sepuluh diiringi dengan kata-kata penguatan sugesti. e. hypnoterapi siklus 3 proses induksi dan depeening menggunakan metode nafas dalam, mata berkedip, dan imagery oleh terapis, sugesti terapi menggunakan metode relaksasi dan perintah paradoks, dan metode pemisahan/ disosiasi, proses alerting/ awakening menggunakan metode menghitung satu sampaisepuluh diiringi dengan kata-kata penguatan sugesti. f. penurunan tingkat nyeri dirasakan oleh semua partisipan setelah hypnoterapi di lakukan pada masing-masing siklus. g. penurunan tingkat nyeri yang paling besar dirasakan pada hypnotherapi tahap 3, rata-rata penurunan scala nyeri pasca hypnotherapi siklus 1 adalah 4, pada hypnotherapi siklus 2 adalah 4,3 dan pada hypnotherapi siklus 3 sebesar 6,3. h. penurunan tingkat kecemasan dirasakan oleh semua partisipan setelah dilakukan pada masing-masing siklus. i. pada penurunan kecemasan paling besar terjadi pada siklus 3, dengan rata-rata rata-rata penurunan kecemasan pada hypnotherapi tahap 1 adalah sebanyak 15,8 pada tahap 2 sebanyak 7, pada tahap hypnotherapi 3 sebanyak 9,83. 2. saran berdasarkan simpulan hasil penelitian di atas, peneliti memberikan saran sebagai berikut : a. diharapkan pemberian hypnotherapi menjadi salah satu intervensi keperawatan yang diatur dengan standar operasional yang berlaku pada tataran pelayanan kesehatan. b. penguasaan terapi hypnosis untuk mengurangi nyeri dan kecemasan hendaknya dimasukan dalam kurikulum pendidikan keperawatan sehingga perawat akan belajar menguasai teknik ketrampilan hypnotherapi mulai dari proses pendidikan. 90 muhammadiyah journal of nursing c. bagi para perawat, pemberian intervensi hypnotherapi bisa menjadi salah satu pilihan untuk menurunkan nyeri dan kecemasan. d. perlu penelitian lebih lanjut tentang penggunaan metode-metode hypnotherapi sebagai salah satu intervensi non farmakologis pada manajemen nyeri dan kecemasan. 3. keterbatasan keterbatasan penelitian terdapat pada distribusi partisipan yang hanya berjenis kelamin laki-laki sehingga belum diketahui bagaimana manfaat hypnotherapi untuk penurunan nyeri dan kecemasan pada pasien wanita yang menderita kanker kolon dan sedang menjalani kemoterapi daftar pustaka alligood, mr; tomey, am;. 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(2006). buku ajar keperawatan medikal bedah brunner & suddarth (8 ed., vol. iii). (m. ester, penyunt., a. hartono, h. y. kuncara, e. s. siahaan, & a. waluyo, penerj.). jakarta: egc. sovodka, p. (2010). secret of hypnotherapy. jogjakarta: flashbooks. speziale, h., streubert, h., & carpenter, d. (2007). qualitative research in nursing. advancing the humanistic imperative. london: lippincoot williams & wilkins. stuart, g. w. (2005). principles and practice of psychiatric nursing. (9th ed.). canada: mosby elsevier. wahyu, w. arif, w. (2008). hubungan antara tingkat kecemasan dengan kecenderungan insomnia pada lansia di panti whreda dharma bakti mulia. surakarta; tidak dipublikasikan indonesian journal of nursing practices 46 ijnp (indonesian journal of nursing practices) vol 4 no june 1, 2020 : 46-52 ni luh widani1, sondang sianturi1 1stik sint carolus corresponding author: ni luh widani email: widani24@gmail.com relationship between drug consumption, supervisors' knowledge and support, and patients' obedience to take tuberculosis drugs article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.41107 abstract background: tuberculosis (tb) is a disease caused by mycobacterium tuberculosis generally attacking lungs, and the treatment is a minimum of six months. the recovery of tb clients requires adherence to medication treatment and drug consumption supervisors (pmo). objective: this study aims to analyze the relationship between drug consumption, supervisors' knowledge and support, and patients' obedience to take tuberculosis drugs. method: this research employed a quasi-experiment with a total population sampling technique. the study was conducted in mayaugust 2019 in sector one, east jambe, karawang district (4 villages), and it employed 101 respondents of tb patients and 101 respondents of supervisors (family). analysis in this study is used in the spearman rho test. result: the supervisor analysis reveals that 71.3% of the supervisors are 25-49 years old, 59.4% of them are female, 80.1% of them are unemployed, 70.3% of them have low education, and 52.5% of them are married couples. tb patient analysis reveals that 59.4% of the patients are 25-49 years old, 63.4% of them are male, and 59.4% of them have new tb the level of supervisors' knowledge is good at 78.2%, and their support is good at 63.4%, while the patients' adherence to taking drugs is good at 93.1%. the relationship analysis reveals there is no relationship between the supervisors' knowledge and patient's medication adherence (p-value 0.13); otherwise, there is a significant relationship between the supervisors' support and drug-taking adherence (p-value 0.04). conclusion: the supervisors' knowledge does not affect adherence, but their support significantly influences the patients' obedience of taking tb drugs. keywords: assistance; drugs consumption supervisor; healing; obedience; tuberculosis introduction tuberculosis disease becomes a global problem, especially in developing countries such as indonesia. tb is an infectious disease that primarily attacks the pulmonary parenchyma. the condition can also affect other parts of the body, such as brain membranes, kidneys, bones, and lymph glands. tuberculosis is caused by mycobacterium tuberculosis, which is categorized as an aerobic bacterium that is acid-resistant and usually spreads from person to person through droplets when he is talking and coughing (black & hawks, 2010). the number of patients with tuberculosis in the world increases from time to time, in 2017 who global tuberculosis report writes that indonesia occupies the 2nd position for the world's highest tb cases after india (who, 2017). the data from the ministry of health of the republic of indonesia (2018) records that indonesia has 360,770 tb cases 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/7465 vol. 4 no. 1 june 2020 47 of all types in 2017. meanwhile, karawang, a region in west java, occupies the highest tb cases among indonesian subdistricts for 78,698 cases and 31,589 new cases. most of the patients with tuberculosis are school-age period or productive ages (15-24 years old) for 14,163 patients. the recovery rate in west java is still low for 40.80%, and complete treatment is only 59.20%. tb becomes the second most common disease suffered after diarrhea for 1,291 cases. the total of tb patients in east telukjambe are 83 patients (12.97%), and east telukjambe becomes the third-highest subdistricts with tb cases of 30 subdistricts in karawang. world health organization (who) and the indonesian government have conducted and applied various efforts and programs to eliminate the global tb epidemic in 2030 (who, 2019). there are three indicators related to the target; 1) the death amount of tb per year, 2) tb per year incident, and 3) percentage of the household impact that experiences tb the target in 2030 is reducing 90% of death due to tb and cutting 80% of tb cases compared to 2015 (who, 2015). meanwhile, the near term target is in 2020 by reducing 35% of death due to tb and 20% of tb incidences compared to 2015. the government program to respond to tb, such as directly observed treatment short-course (dots), aims to increase and expand the service of dots or a qualified tuberculosis countermeasure strategy to reach all tuberculosis patients and increase cases discovery as well as the success of treatment (puspita, yanti, putri, supriyanto, & atiqah, 2019). one of the strategies is conducting drug consumption supervisors (pmo) presence (supervision of drug swallowing) for each tb patient. the pmo can be from family, health officers, and health cadres, or social workers (faizah & raharjo, 2019). tb prevention program continuously improves. in 2018, the government made a program called "care for tb, indonesia is healthy." the government expects all parties and communities to actively participate in program known as temukan obati sampai sembuh tuberkulosis (toss tb) movement or find and treat it to heal as an effort to prevent and control tb (ministry of health r.i., 2017). the program aims to investigate as many tb patients as possible and treat them to heal, and thus, the chain of transmission in the community can be stopped (ministry of health r.i., 2015) tb disease can be cured by giving antituberculosis drugs, and the primary goal of the medication is to treat tb patients for at least six months (the medication must not stop). a person with tb symptoms is suggested to immediately undergo a medical check to investigate the possibility of suffering from tb (ministry of health r.i., 2015). most tb patients who take antituberculosis drugs for two weeks have felt cured. consequently, they often stop taking their tb drugs. studies investigating 72 families of tb patients reveal the existence of a significant relationship between the self-efficacy of respondents and the role of a family to a tb drop-out event (kim & lee, 2017). tb patients who break to take the medication are in danger of suffering from multi-drug resistant tuberculosis (mdr-tb). a study conducted at dr. moewardi hospital surakarta to 150 tb patients reveals that there is a significant relationship between the absence of supervisors of drug consumption and the treatment failure of mdr-tb events (jufrizal, hermansyah, mulyadi, 2016). drug consumption supervisors have a role in succeeding in the cure of tb patients. a research conducted by kurniasih and sa'adah (2017) to tb patients in community health center (puskesmas) of ngawi reveals that there is a significant relationship between the supervisors' role of drug-taking and the patients' obedience to pulmonary tuberculosis treatment in puskesmas of ngawi. the cure rate indicates the percentage of bacteriostatic lung tb patients who recover after completing the treatment. the cure rate is employed to determine the outcome of the treatment. the compulsory minimum rate to achieve is 85%. qualitative studies conducted on ten informants obtain that the level of healing and low success of tb treatment are related to patients' obedience to consume the drugs, and are influenced by knowledge and motivation, access to health, administration and finance, socio-cultural aspects, and other factors. method this research was a quantitative study with quasiexperiment design. it employed a total population sampling technique. the respondents of this research were all tb patients in public health center indonesian journal of nursing practices 48 (puskesmas) of sector one eastern teluk jambe (including the areas of pinayungan, tanjung pura, wadas, and sukamakmur village) who underwent tb treatment, had drug consumption supervisors known as pmo in indonesia, and willingly participated as respondents. the samples of this research were 101 tb patients. puskesmas of wadas had trained cadres of drug consumption supervisor whose job was to visit patients suspected of suffering from tb and provide assistance to have a regular medical check-up in puskesmas. there were 7 cadres of drug consumption supervisor in a puskesmas. their job was to examine a new tb case in selected areas and to monitor tb patients to take the drugs. the cadres' regular meetings were conducted monthly. in addition, the cadres were trained to be an assistant in data retrieval. the data were collected by questionnaire composed by the researchers who had conducted a validity test. the result of questionnaire test shows that the value of cronbach's alpha is 0.844 with 25 questions. it indicates that the questionnaire is reliable. during the process, the researchers collaborated with puskesmas of wadas after completely receiving research consent from badan kesatuan bangsa dan politik (national unity and politics agency) karawang district and head of health office karawang district. the researchers held meeting with the nurses and doctors in charge of tb and cadres of drug consumption supervisors in puskesmas of wadas to gain the data of the patients who received treatment as the samples of the research. after the meeting, the researchers invited tb patients and drug consumption supervisors to attend a socialization program of tb held in the puskesmas to get more detail comprehension of tb from the researchers. the collected data were analyzed by utilizing difference testing analysis to determine the relationship between the supervisors' level of knowledge and support and the patients' adherence of tb drug, and the test was spearman rho. it is one of the nonparametric associative bivariate tests to examine the suitability between two variable groups derived from different subjects from the ordinal data scale (hidayat, 2017). the research conducted ethical eligibility test with the number 046/ke/stiksc/xi/2018. results the characteristics of drug consumption supervisor respondents are based on gender, ages, level of education, and their relationship with tb patients as shown in table 1. meanwhile, the characteristics of patient respondents are based on age, gender, and length of suffering from tb as shown in table 2. table 1. the characteristics of drug consumption supervisor respondents. characteristics total of respondents n % age (year old) 25-49 50-60 72 29 71.3 28.7 gender male female 41 60 40.6 59.4 occupation employed unemployed 20 81 19.9 80.1 level of education none low (elementary-junior high school) high (>senior high school) 4 71 26 3.9 70.3 25.8 relationship with the patients husband/wife son/daughter parent sibling 53 18 20 10 52.5 17.8 19.8 9.9 table 1 shows that 72 people are 25-49 years old (71.3%), 60 females (59.4%), unemployed 81 people (80.1%), low education level (elementary-junior high school) 71 people (70.3%), and a spouse (husband or wife) 53 people (52.5%). table 2. the characteristics of tb patients characterisitic total of respondents n % age (year old) 25-49 50-70 60 41 59.4 40.6 gender male female 64 37 63.4 36.6 length of suffering from tb 1-2 months 3-5 months 60 41 59.4 40.6 vol. 4 no. 1 june 2020 49 table 2 shows the majority of tb patients 25-49 years old is 60 people (59.4%), 64 males (63.4%), and length of suffering 1-2 months is 60 people (59.4%). table 3. drug consumption supervisors' level of knowledge level and support and patients' level of obedience of drug taking characteristics total of respondents n % knowledge of the supervisors good good enough 79 22 78.2 21.8 support from the supervisors good good enough 64 37 63.4 36.6 obedience to take medicine good good enough 94 7 93.1 6.9 table 3 shows the majority of pmo have good knowledge levels in treating tb patients with total 79 people (78.2%) and give good support to 64 people (63.4%). the majority of obedience to take drug is good obeyed or 94 people (93.1%). the correlation between the drug consumption supervisors' knowledge and support and the patients' obedience of drug-taking as shown in table 4. table 4 shows that the majority of supervisors, as many as 75 people, have good knowledge with good adherence. statistically, there is no significant relationship between the supervisors' knowledge and the patients' obedience of tb drug taking since the p-value is 0.13 (> 0.05). variable support shows that the majority of supervisors and patients, as many as 62 people, provide good support with good obedience. thus, statistically, there is a significant relationship between the supervisors' support and the patients' obedience to taking a tuberculosis medication with a p-value of 0.04 (p < 0.05). table 4. spearman rho test result good obedience enough obedience total p-value good knowledge good enough knowledge 75 19 4 3 79 22 0.13 good support good enough support 62 32 2 5 64 37 0.04 discussion the relationship between knowledge and obedience this research statistically indicates that there is no relation between pmo knowledge and the obedience of taking the drugs in tb clients. it can be explained that the level of knowledge is only limited at the level of knowledge. the results of this research are supported by the research conducted by herda, tunru, & yusnita (2018) investigating 45 patients with lung tuberculosis at puskesmas of baru jakarta pusat. the research reveals that the majority of the respondents have good knowledge (39.3%). however, there is no relationship between knowledge and the success of treatment (p = 0.069; p > 0.05). in psychology, one of the factors influencing behavior is cognitive. the knowledge factor relates to a person's belief to make justification or not. this result is not in line with that of sutarto, susiyanti, & soleha's research (2019) investigating 44 pmos of tb patients who undergo treatment at least 2 months. the research reveals that there is a relationship between the levels of knowledge of pmos (p = 0.000) and the conversion of lung tuberculosis in puskesmas of bandar lampung. a study by arifin, nur & uzair (2019) investigating 80 patients with lung tuberculosis treatment in puskesmas of simpang tiga pidee, aceh reveals that the variable supporting dominant information affects compliance with the dots strategy in lung tb patients with or value = 3.5, and p value = 0.009. in addition, the previous study by prameswari (2018) investigating 9 tb patients in rs x reveals that the implementation of dots has not been optimal, a political commitment is required to overcome the existing problems such as the absence of officers' training experience, the absence of tb units, overwhelming and double job description, bad microscopic examination, non-standardized antituberculosis drugs management. a pmo family is expected to have a well-related knowledge in treating tb patients. some researches illustrate the level of knowledge of tb clients, one of them is a research conducted by gurning & manoppo, (2019) in papua scoloo's hospital which investigates 105 patients with drug-related pulmonary tuberculosis. the majority of the patients' education in elementary school (36.2%), they have good enough comprehension (52.4%), indonesian journal of nursing practices 50 and the majority of the patients are disobedient (53.3%). good knowledge enables the family to provide good support to the other family members. knowledge implemented in the form of support can increase the awareness of tb patients to obey the drug-taking, and thus, they can achieve healing and quality life. this argument is supported by hariadi, aryani, & buston (2019) investigating 50 pulmonary tb patients who undergo treatment in the outpatient unit of a puskesmas in slebar district health centers bengkulu. the research reveals that the majority of the family's support is good, the life quality of physical and mental condition is good, and the relationship is significant (p < 0.05). relationship between pmo support and patients' obedience to take medicine program of health centres in the management of tb disease one of which is to involve the family as pmo, as well as in practice found in the health centres of wadas village are obtained by all tb patients accompanied by at least one pmo. the designated pmo is the one staying with the patient. pmo criteria of this study correspond to a systematic review study by putri (2019) who investigates 10 quantitative studies and 4 qualitative studies on pmo family. their characteristics are over 17 years old, female, unemployed person, minimum education of senior high school, no relationship cohabitation, housemate, and jobless person. the role of pmo among others is to ensure that the patients swallow the drug daily, provide counselling, assist the medication process, give emotional support, and engage in patients' weight gain program. the family approach is puskesmas' strategy to improve health services for the community. as the main focus of health program implementation, family has a health care function: to maintain the health condition of the family members in order to escalate high productivity. family is a support system for an individual (client). in addition, family can help the patients realize their needs and develop healthy ways to meet those needs. the most important part to consider, which is one of pmo programs, is that family has an important role in facilitating the patients to completely undergo the tuberculosis treatment (ministry of health r.i., 2017). the success of the dots strategy is necessarily evaluated, research conducted by reviono, ramadhiana, probandi, & setianingsih (2019) in 158 hospitals in central java in the application of dots strategy, where the data came from the provincial health office of central java in 2013 and 2016. there are 110 hospitals with complete data. the study reveals that there is no significant relationship between commitment and organization of dots hospital team, care, medical supervision, internal/external networks, and health facilities and the success rate of tb treatment (p > 0.05). the results of this research, which is conducted by taking samples of tb patients in the puskesmas, is in accordance with those of several studies which prove that the role of pmo successfully supports the treatment of tb clients. research by herda, tunru, & yusnita (2018) finds that 56 tb respondents (80.4%) in the puskesmas jakarta johar baru successfully undergo tb treatment, and pmo is instrumental in the treatment (71.4%). yuda & utoyo (2018) deploy that there is a significant relationship between the role of the medical care supervisor (pmo) and the results of treatment tbc cured (p = 0.000) in puskesmas of gombang ii, and the researchers recommend for improving the role of pmo in treating pulmonary tuberculosis patients. tb patients need long treatment for at least six months because tb drugs must be able to kill both the active and inactive (dormant) tb bacteria and prevent the resistance. the main requirement for therapeutic success is the obedience to consume the drug. obedience means that patients follow or obey the clinical recommendation from the health officers (neil, 2002). the results of this study show that (1) in variable support, the majority of the support is good with good compliance from 62 people (61.38%), and (2) statistically, there is a significant relationship between pmo's support and the observance of tb drug donor with a p-value is 0.04 (p < 0.05). this research is in line with research by wulandari (2018) investigating 70 tb patients. the research reveals that the tb patients' obedience to take drugs is significantly influenced the presence of drug ingestion (pmo), with p=0.003, in which a tb patient vol. 4 no. 1 june 2020 51 with active pmo has 16 times more obedient than those with inactive pmo. similarly, the research by sumarman and bantas (2011) reveals that pmo's poor role is at risk of 3.013 times to make the patients disobey the recheck of phlegm in the final phase of treatment compared to patients who have a good role of pmo. conclusion it can be concluded that supervisors' knowledge does not affect adherence, but their support significantly influences the patients' obedience of taking tb drugs. references arifin, v. n., nur, a., & uzair, f. m. (2019). the relationship of social support with medication adherence pulmonary tuberculosis patients through dots strategy in pidie aceh indonesia. in iop conference series: materials science and engineering, 469(1), p. 012055. indonesia: iop publishing. black, j. m. & hawks, j. h. (2010). medical-surgical nursing clinical management for positive outcomes (8th ed). philadelphia: elsevier saunders. faizah, i. l., & raharjo, b. b. (2019). penanggulangan tuberkulosis paru dengan strategi dots (directly observed treatment short course). higeia (journal of public health research and development), 3(3), 430-441. https://doi.org/10.15294/higeia.v3i3.2695 1 gurning, m., & manoppo, i. a. (2019). hubungan pengetahuan dan motivasi dengan kepatuhan minum obat pada pasien tbc paru di poli tb rsud scholoo keyen. wellness and healthy magazine, 1(1), 4147. https://wellness.journalpress.id/wellness/a rticle/view/w1106 hariadi, e., aryani, f., & buston, e. 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(2019). hubungan antara karakteristik pengawas minum obat (pmo) dengan konversi tb paru kasus baru di puskesmas panjang bandar lampung tahun 2017. jurnal majority, 8(1), 188-195. http://juke.kedokteran.unila.ac.id/index.ph p/majority/article/viewfile/2318/2285 world health organization. (2017). global tuberculosis report 2017. geneva: who. https://www.who.int/tb/publications/glob al_report/gtbr2017_main_text.pdf?ua=1 world health organization. (2019). who global tb programme: end tb accelerator package. geneva: who. https://www.who.int/tb/package.pdf world health organization. (2019). the end tb strategy. geneva: who. https://apps.who.int/iris/bitstream/handle /10665/331326/who-htm-tb-2015.19eng.pdf wulandari, d. h. (2018). analisis faktor-faktor yang berhubungan dengan kepatuhan pasien tuberkulosis paru tahap lanjutan untuk minum obat di rs rumah sehat terpadu tahun 2015. jurnal arsi: administrasi rumah sakit indonesia, 2(1), 17-28. http://dx.doi.org/10.7454/arsi.v2i1.2186 yuda, h. t., & utoyo, b. (2018). peran pengawas menelan obat (pmo) terhadap hasil pengobatan penderita tuberculosis paru di wilayah puskesmas gombong ii. jurnal ilmiah kesehatan (jik), 11(2), 393-398. https://journal.stikesmuhpkj.ac.id/index.php/jik/article/view/108 vol. 5 no. 1 june 2021 1 ijnp (indonesian journal of nursing practices) vol 5 no 1 june 2021: 1-8 ike wuri winahyu sari1, dwi kartika rukmi1 1universitas jenderal achmad yani yogyakarta, indonesia corresponding author: ike wuri winahyu sari email: ike.wuri@yahoo.com the correlation between being informed on complementary and alternative medicine and its reported use among cancer patients in yogyakarta 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.v5i1.9558 : 13 august 2020 : 18 february 2021 : 18 february 2021 abstract background: previous studies have indicated that the majority of cancer patients have used self-selected complementary and alternative medicine to relieve disease-related symptoms and treatment-related adverse effects untreated by conventional treatment to improve the quality of life. unfortunately, studies on complementary and alternative medicine use among cancer patients, especially in yogyakarta, the city with the highest cancer prevalence in indonesia, are still limited. objective: this present study aims to identify the correlation between being informed on complementary and alternative medicine and its reported use among cancer patients. methods: this study was a descriptive correlational study on 75 consenting cancer patients. the respondents were selected using a purposive sampling technique. data about their complementary and alternative medicine use were collected by administered questionnaires and analyzed using descriptive statistics and bivariate analysis. results: 25.3% of respondents had used complementary and alternative medicine. being informed on complementary and alternative medicine and its reported use among cancer patients were significantly correlated (r=0.331; p=0.002). conclusion: complementary and alternative medicine use among cancer patients was still limited. health providers need to discuss complementary and alternative medicine use with their patients openly. keywords: cancer; complementary and alternative medicine; information; palliative care introduction cancer is categorized as one of the noncommunicable diseases, with its prevalence reaching 1.8% per 1,000 population in indonesia. the highest cancer prevalence in indonesia has occurred in the yogyakarta special region, reaching 4.9% per 1,000 population for all ages (ministry of health republic indonesia, 2018). cancer patients could experience physical and psychological problems while undergoing treatment for their illness in the hospital (american cancer society, 2017; dy & apostol, 2010; effendy et al., 2014). the most common physical symptoms are fatigue, pain, sleep disturbance, nausea, vomiting, and decreased immune function. also, the psychological symptoms are anxiety, depression, fear of the illness’s severity, fear of going through disease examination, fear of having repeated relapse of the illness, and death (effendy et al., 2014). 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 2 complementary and alternative medicine (cam) emerges as one of the options favored by cancer patients at a different stage of the diagnosis and treatment, ranging from 30% to 50% of patients during adjuvant chemotherapy or radiotherapy, perioperative, and palliative phases (ben-arye et al., 2014; shin et al., 2012). cam is a various system, practice, and medical and health product commonly understood as non-conventional treatment (national center for complementary and alternative medicine, 2011). cancer patients use cam because it is easy and affordable, with no side effects, and their belief in the positive effects of cam (almasdy et al., 2018). the use of cam is based on the patients' sociodemographics, the clinical characteristics of the cancer patients, cultural factors, and the patients' coping patterns associated with the disease. as many as 25.5% of 2.661 respondents were reported using cam (shin et al., 2012). high income, metastasis, longer diagnosed time, low trust in the hospital, low satisfaction, and a higher need for information were related significantly to the use of cam (shin et al., 2012). other studies also discussed that younger age, being in a stable relationship, a normal bmi (paepke et al., 2020), and a higher educational level were predictors of the use of cam (gentry-maharaj et al., 2017; paepke et al., 2020). correlation between knowledge about cam and its use, whether being used with or without the accompaniment of conventional treatment, becomes significant to be identified because cancer patients are often faced with more complex psychological and physiological situations compared to other non-communicable diseases (shin et al., 2012). in indonesia, especially yogyakarta, to date, almost no nationwide studies have reported cam use. data obtained from padang, indonesia, reported that 65% of patients had used cam (almasdy et al., 2018). nurses also play an essential role in exploring the use of cam and improving the cancer patients' understanding of cam in terms of its procedure and the reason for its use. this present study aims to identify the correlation between the experience of getting information about cam and its use among cancer patients. methods setting and population this study was a descriptive correlative study using a cross-sectional approach. data were collected from oncological and surgical outpatient wards at one of the general hospitals in the special region of yogyakarta from july to august 2019 and selected using purposive technique sampling. analyses included adults (older than 18 years) with all types of cancer who have had surgery and or were undergoing chemotherapy or radiotherapy treatment and willing to consent to participate in this study, excluding patients who suddenly experienced the emergency status. the cancer patients who met inclusion and exclusion criteria were identified through the medical record. after being identified as respondent candidates, they were fully informed about the study’s purpose and signed the informed consent. a total of 75 consenting patients formed our final sample. they completed the questionnaires assisted by the researchers and two research assistants. measure a questionnaire survey was designed to collect data about cam use and demographic characteristics (age, gender, education, health insurance, marital status, the number of symptoms, stage of cancer, metastasis, and the experience of getting information about cam). we defined cam based on the widely established nccam taxonomy (national center for complementary and alternative medicine, 2011). the specific cams questioned in this study were herbs and vitamin supplements; spiritual healing or therapy; massage; relaxation technique, imagery, or yoga; lifestyle diets, music therapy; acupuncture or acupressure; hypnosis; and an open question about the other kinds of cam. a positive response to at least one question in the questionnaire determined the respondent's classification as a cam user. in contrast, a negative response to all questionnaire items led to the respondent's classification as a non-user. the number of symptoms was measured using the edmonton symptom assessment system (esas) (watanabe et al., 2012) and categorized into a dichotomous variable (less than five symptoms and more than five symptoms). vol. 5 no. 1 june 2021 3 statistical analyses first, we determined the prevalence of total age, gender, education, health insurance, marital status, the number of symptoms, stage of cancer, metastasis, the experience of getting information about cam, and cam use using descriptive analysis. next, we used the contingency coefficient test to identify the correlation between being informed about cam and its reported use with p<0.05 indicating significance. all statistical analyzes were performed using the statistical package for the social sciences (spss) version 16 (spss inc., 2007). ethical consideration the health research ethics committee, faculty of health, universitas jenderal achmad yani yogyakarta, approved this study (number: skep/068/kepk/v/2019). all the patients gave their written informed consent to participate in this study. results general characteristic of cancer patients most of the respondents were between 40 to 60 years old (53.3%), women (81.3%), married (85.3%), educational background varied between elementary school and senior high school levels, only 1.4% and 98.7% of them owned health insurance. meanwhile, based on the characteristics of the illness, from 75 cancer patients being the respondents, most of them experienced less than five symptoms (58.7%), categorized into stage iii of cancer (42.7%), had no metastasis (54.7%), and had never received any information about cam (96.0%). the characteristics of the respondents are summarized in table 1. cam use the majority of the respondents did not use cam, totaling 56 respondents (74.7%). cam use among cancer patients is displayed in table 2. the most frequent types of cam used by the respondent were herbs and vitamin supplements (12 respondents), followed by acupuncture/acupressure (six respondents). the remaining were massage, spiritual healing or therapy, relaxation technique, imagery or yoga, physiotherapy, music therapy, and lifestyle diets. in this case, eight respondents used more than one kind of cam. the combinations of cam they used were herbs and vitamin supplements with acupuncture, massage, music therapy, or spiritual therapy. the types of cam used by 19 respondents are listed in figure 1. correlation between being informed on cam and its reported use there was a significant correlation between being informed on cam and its reported use among cancer patients. the bivariate analysis was demonstrated in table 3. discussion in this study, 19 cancer patients (25.3%) used cam. several research studies have suggested the use of cam (berretta et al., 2017; john et al., 2016; klafke et al., 2012; pihlak et al., 2014; shin et al. 2012). this result is in line with the study by shin et al. (2012) conducted on 2,661 cancer patients in korea, in which 25.5 % of respondents used cam. the low use of cam was also seen in israel in a study conducted by ben-arye et al. (2014), in which from 313 cancer patients, 39.6% of them used cam. this number is still considered low compared to the use of cam in australia (61.5%) (klafke et al., 2012) and in the united states (79%) (john et al., 2016). the high number of patients who did not use cam may be due to the unclear description and efficacy of cam since 96% of respondents in this study were not informed about cam. in this study, 25.3% of cam users utilized this treatment based on the information obtained from health care providers and mostly obtained information from friends and neighbors through word-of-mouth information exchange. this result assertion follows the study conducted by almasdy et al. (2018), stating that the information about cam was not from health care providers but friends or family (70.91%). meanwhile, only 5.45% of the patients obtained information from healthcare providers (almasdy et al., 2018). herbs and vitamin supplements were the most used type of cam by the respondents; the number was 63.16 % from 19 respondents. this result is in line with a study conducted by ezeome & anarado (2007) in nigeria, showing that, from 160 respondents who participated in the study, 51.9% of them used herbs intended for treatment. a study by field et al. (2009) also presented similar data, in which 54.4% out of 892 women with breast cancer in australia and new zealand used cam in the form indonesian journal of nursing practices 4 of supplements or vitamins. the use of herbs has also been confirmed as the most used cam (92.72%) in a study by almasdy et al. (2018) in padang, indonesia, conducted on 85 breast cancer patients. herbs and vitamin supplements became the most used cam due to their availability in the market and the easy access in obtaining them for people living in either rural or urban areas (almasdy et al., 2018; frenkel et al., 2013). compared to other types of cam, the use of herbs has increased in number because of their popularity and the cultural factors related to the use of natural products (almasdy et al., 2018). another factor was its low price due to the patients’ belief that natural products were safe for the body (almasdy et al., 2018). the patients’ belief was the main reason for the cam use because there were four phases of the cam use decisionmaking process. the first phase was fitting with the cultural belief lifestyle before seeking information and clarification about cam, evaluating the effectiveness of the cam use, and balancing the cost and benefit (chiu et al., 2006). the patients used herbs and vitamin supplements to reduce the side effects of chemotherapy, organ toxicity, stimulate the immune system, or prevent further growth and relapse of cancer (frenkel et al., 2013). however, herbs and vitamin supplements were often consumed without recommendation and supervision from health care providers. as a result, misunderstandings related to the use of herbs and vitamin supplements between health care providers and patients emerge, in which this type of cam has been considered as an unreliable treatment (frenkel et al., 2013). there was a significant correlation between knowledge about cam indicated by their experience of obtaining information about cam and cam use among cancer patients (r=0.331; p=0.002). the majority of the patients using cam have not possessed any experience in given information on the use of cam; the number was 16 respondents (84.2%). only three respondents obtained information about the use of cam from healthcare providers and used cam. the case is different in the study by dogu et al. (2014). it was conducted on 494 cancer patients in turkey, in which 78.6% of patients had obtained information related to cam from health care providers. the rest of them gained information from friends and family (dogu et al., 2014). information related to the use of cam is an attempt to empower the patients to perform selfcare management. a small number of patients rejected the information related to cam, fearing that this additional option might be interfering with their decision to select the ongoing treatment (evans et al., 2007). health care providers should discuss cam openly with patients. patients must report cam use they perform alongside the convention treatment to prevent misunderstanding between the health care providers and them regarding cam use. this study has limitations, namely the sample size supposed to be higher. this condition was due to the limited number of cancer patients in the study area. this study also did not provide the health care providers’ knowledge about cam that needed to be explored as the factors affecting cam use. however, this study provided the essential data and had a low level of missing data indicating the fit analyses. conclusion this research outcome has generated new perspectives on cam use by cancer patients. the few cancer patients informed about cam have resulted in a limited effect on the use of cam. cam must be freely shared with patients by health care professionals. to avoid confusion between the health care providers and the patients about cam use, the patients must disclose the use of cam they carry out alongside convention therapy. further research needs to explore the awareness of cam by health care professionals to enrich the data on factors affecting cam use in cancer patients. acknowledgments the authors gratefully acknowledge universitas jenderal achmad yani yogyakarta for the funding and the respondents in this study. vol. 5 no. 1 june 2021 5 authors’ contribution the authors, ike wuri winahyu sari (i.w.w.s) and dwi kartika rukmi (d.k.r), made a substantial contribution to the conception and design of the study. i.w.w.s conceived the study, participated in its design and coordination, collected the data, participated in the statistical analyses, and drafted the manuscript. d.k.r participated in the design and coordination of the study and helped draft the manuscript. both authors read and approved the final manuscript. conflict of interest none. references almasdy, d., eptiyeni, e., khamri, d., & kurniasih, n. 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(2012). the edmonton symptom assessment system, a proposed tool for distress screening in cancer patients: development and refinement. psychooncology, 21(9), 977-85. https://doi.org/10.1002/pon.199 https://doi.org/10.1080/13697137.2017.1301919 https://doi.org/10.1080/13697137.2017.1301919 https://doi.org/10.1007/s11764-016-0530-y https://doi.org/10.1093/annonc/mdr521 http://nccam.nih.gov/health/whatiscam/ https://doi.org/10.1016/j.ejca.2008.09.023 https://doi.org/10.1111/ecc.12132 https://doi.org/10.1155/2012/212386 https://www.uni-muenster.de/imperia/md/content/ziv/service/software/spss/handbuecher/englisch/spss_brief_guide_16.0.pdf https://www.uni-muenster.de/imperia/md/content/ziv/service/software/spss/handbuecher/englisch/spss_brief_guide_16.0.pdf https://www.uni-muenster.de/imperia/md/content/ziv/service/software/spss/handbuecher/englisch/spss_brief_guide_16.0.pdf https://www.uni-muenster.de/imperia/md/content/ziv/service/software/spss/handbuecher/englisch/spss_brief_guide_16.0.pdf https://doi.org/10.1002/pon.199 vol. 5 no. 1 june 2021 7 table 1. general characteristics of cancer patients (n=75) characteristics n (%) ages <40 years old 40-60 years old >60 years old 8 (10.7) 40 (53.3) 27 (36.0) gender female male 61 (81.3) 14 (18.7) marital status single widow/widower married 2 (2.7) 9 (12.0) 64 (85.3) education illiterate elementary school junior high school senior high school college 3 (4.0) 25 (33.3) 11 (14.7) 26 (34.7) 10 (13.3) health insurance no yes 1 (1.3) 74 (98.7) the number of symptoms <5 symptoms >=5 symptoms 44 (58.7) 31 (41.3) cancer stage stage i stage ii stage iii stage iv 16 (21.3) 23 (30.7) 32 (42.7) 4 (5.3) metastasis no yes 41 (54.7) 34 (45.3) being informed about cam no yes 72 (96.0) 3 (4.0) table 2. cam use among cancer patients (n=75) characteristic n (%) cam use nonusers cam users 56 (74.7) 19 (25.3) indonesian journal of nursing practices 8 table 3. correlation between being informed on cam and its reported use (n=75) variable being informed on cam coefficient contingency (r) p-value not getting information about cam getting information about cam cam use nonusers 56 0 0.331 0.002* cam users 16 3 *p<0.05 indicates significant figure 1. types of cam 1. 9558-ike wuri winahyu sari; bookmark (1) clean.pdf 1. 9558-ike wuri winahyu sari-lampiran tabel 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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(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). 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. 4 no. 1 june 2020 37 ijnp (indonesian journal of nursing practices) vol 4 no june 1, 2020 : 37-45 siti khuzaiyah1, anies anies2, sri wahyuni3 1universitas muhammadiyah pekajangan pekalongan 2universitas diponegoro 3poltekkes kemenkes semarang corresponding author: siti khuzaiyah email: khuzaiyahpenulis@gmail.com the effects of hypnosis relaxation towards fetus heart frequency and vital signs among pregnant women with pre-eclampsia article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.41106 abstract background: one of the causes of maternal mortality ratio (mmr) in indonesia is pre-eclampsia. mothers with pre-eclampsia disorder who are followed by anxiety tend to have specific vital sign change included increasing blood pressure, heart rate, respiratory rate, and fetus heart rate. pregnant suffered pre-eclampsia should keep the balance of mind and emotion, as well as to reduce a complication of pre-eclampsia towards mothers and their fetus. objective: the objective of this study was to analyze the effects of the relaxation hypnosis on fetus heart rate and vital signs of pregnant women with pre-eclampsia. method: this study was a quasi-experiment with a pretest-posttest design. the total subjects were 32 pregnant women with preeclampsia, which selected by purposive sampling techniques. the researcher did hypnosis relaxation for three times. a wilcoxon test was used to analyze the paired bivariate for systolic blood pressure, while the mann-whitney test and independent t-test were used to analyze fetus heart frequency. result: this study shows that hypnosis relaxation can reduce the systole blood pressure (p-value = 0.000; ci=12.185-23.109), reduce diastole (p-value = 0.000; ci= 8.630 – 14.311), reduce heart rate (p value = 0,004; ci= 2.07 – 8.989) and reduce respiratory rate (p value = 0.000; ci = 2.785 – 6.275). in terms of the effect on the fetus, hypnosis relaxation affect the fetus heart rate (p value = 0,000; ci = 5.834 – 13.930). conclusion: hypnosis relaxation influences the change of fetal heart rate and vital signs of pregnant women with pre-eclampsia. keywords: fetal heart rate; hypnosis relaxation; pre-eclampsia; vital signs introduction based on the health demography survey of indonesia in 2015, maternal mortality ratio (mmr) in indonesia reached 305/100.000 birth of life. meanwhile, the target of mmr from sustainable development goals (sdgs) was 70/100.000 birth of life (health department of pekalongan district, 2019). in central java, in 2019, the mmr reached 76,93/100.000 delivery of life with hypertension and pre-eclampsia as the significant causes (28%) (health department of central java province, 2020). pre-eclampsia is a specific syndrome suffering pregnant in more than 20 weeks of age gestationwho was healthy tension in previous age. the signs of pre-eclampsia are increasing blood pressure (140/90 mmhg) and following by appearing of protein urine (cunningham et al. 2010). preeclampsia could affect on fetal well-being. babies 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/7423 indonesian journal of nursing practices 38 who are born by mother with pre-eclampsia, tend to have a few problematic temperament styles in the first three months after birth. moreover, its negative impact was amplified by the mother's antenatal depression (nomura et al., 2014). mothers with pre-eclampsia disorder who are followed by anxiety and stress tend to have specific vital sign change included increasing blood pressure, heart rate, respiratory rate, and fetus heart rate. the physiologic response of fear is activating the center nervous system to enable the hypothalamuspituitary-adrenal axis and sympathetic nervous system signed by increasing the frequency of heart rate and blood pressure (agorastos et al. 2019). however, kafali, derbent, keskin, simavli, & gözdemir (2011) are evaluating the association between maternal anxiety and baseline fhr claimed that stress-induced high maternal state anxiety increased baseline fhr. there is a strong relationship between mother psychology and of the fetus. studies have shown that maternal exposure to stressful events during pregnancy is linked to adverse outcomes in children (ferrari, faccio, peccatori, & pravettoni, 2018). antenatal anxiety predicts poor infant physiological, mental, and psychomotor development as well as behavioral and emotional difficulties in early childhood (o’donnell et al., 2017; vehmeijer, guxens, duijts, & el marroun, 2019). thus, the mother should keep the balance if the emotion to gain happiness and peace along with the pregnancy. the healthcare provider can choose hypnosis relaxation as an alternative way to keep the balance of the body (andriana, 2011). a combination of standard care and a brief hypnosis intervention holds sufficient promise for antenatal stress relief to justify testing its efficacy in larger groups of pregnant women (legrand et al., 2017). in 2014, from 35 district in central java, pekalongan district was the 7th district with the highest mmr up to 29 cases (health department of pekalongan district, 2014). the data of the health department of pekalongan district indicated that the mmr in 2018 was 69/100.000 life birth (11 cases), which pre-eclampsia was one of the causes of mmr (health department of pekalongan district, 2019). several measurements have been taken to control pre-eclampsia. in the case of a mother with a high risk of pregnancy, including pre-eclampsia, the ways were a consultation to the obstetricians and hospital visits to monitor blood pressure once a week routinely. however, no psychological and spiritual treatment has been taken. hypnosis is the kind of appropriate complementary therapy with minimum side effects. hypnosis is safe, efficient, and economical compared to other complementary therapies because no specific equipment is needed (saha et. al., 2012; shorofi, & arbon, 2017). the other additional therapy methods need more material, such as acupuncture, aromatherapy, and music therapy. such as lavender aromatherapy in lowering blood pressure, health care should prepare some drops of aromatherapy and diffuser (maisi, suryono, widyawati, suwondo, & kusworowulan, 2017); or they need a banana when using ambon banana as the alternative way in reducing blood pressure (susanti, & resti, 2019) moreover, any drugs, surgery, and special medic equipment are not required to give hypnosis; only use the power of suggestion, which will relax the patients directly and make them comfortable quickly (iserson, 2014; larasati & wibowo, 2012). yoganita, sarifah, & widyastuti (2019) suggested that nape massage and hypnosis can reduce blood pressure, either systolic (15.62 mmhg) or diastolic (6.72 mmhg). hypnotherapy can also overcome stress, relax the body, inhibit cortisol hormone secretion, and this condition prevents vasoconstriction of blood vessels so that blood pressure decreases (purnomo, nur, rahim, & pulungan, 2020) in terms of fetal heart rate (fhr), relaxation reduced the basal fetal heart rate (akbarzade, rafiee, asadi, & zare, 2015). in regards to this study, hypnosis, which has a function as relaxation, was used to stabilize both fetus heart rate and mother vital signs. the study aimed to analyze the impacts of the relaxation hypnosis on fetus heart rate and vital signs of pregnant women with pre-eclampsia. method this study was a quasi-experimental with a pretestposttest with a control group design. the variables were hypnosis relaxation, fetus heart rate, and vol. 4 no. 1 june 2020 39 mother's vital signs. the population in this study were pregnant women with pre-eclampsia in the working area of the health department of pekalongan district in 2016. the criteria were under the supervision of the health department of pekalongan district, including in the top eight community health center that had similar regional characteristics and had the highest incidence of preeclampsia in 2016. the community health center with the highest prevalence of pre-eclampsia in 2016 is kedungwuni ii, kedungwuni i, karangdadap, bojong i, wiradesa, tirto, wonopringgo, and buaran. the number of samples needed for each group was 16 respondents (federer, 2012). to maintain the number of member groups in enough quantities, the researcher made a correction number by determining a dropout value of 10% (f: 0.1). based on the sample calculation and drop out correction considerations, the number of respondents needed was 18 respondents in each group. sample collected by purposive sampling technique. patients who were determined to be respondents must have met the inclusion criteria and eliminate the patients who met the exclusion criteria. the inclusion criteria in this study were: did not suffer from an infection, that was defined by fever in the last three days, or signs of inflammation in the body (color, dolor, rubor, tumor, functionolaesa), the fetus lives, a single embryo, did not suffer from chronic diabetes mellitus, mothers were willing to be a respondent and were ready to be given standard pregnancy care and hypnosis (for the intervention group), and they were willing to do standard pregnancy care (for the control group). a random technique used to determine the group members. both groups then performed initial tests for vital signs and the fetus's heart rate. the intervention group then gets the intervention, i.e., hypnosis relaxation and regular services included vital sign check-up routinely, health education, and emotional support. the hypnotherapy had been done by a certified hypnotherapist using a standardized procedure. the intervention was done in the patient's home and was carried out three times with the distance of each therapy for one day. the researcher re-examined the vital signs and fetus heart rate on day three after treatment. on the other hand, the control group received regular services included vital sign check-up routinely, health education, and emotional support. the main instruments in this study were sphygmomanometer, stethoscope, watch, doppler (digital fetus heart rate meter), and questionnaire, which could record: age, gravida, bmi, gestational age, and the data of vital signs and fetus heart rate. data collected after obtaining a research permit from all relevant parties, and the researcher coordinated with the community health centers in the pekalongan district health department's working area. data collection assisted by the midwives and the staff of the community health center selected. univariate analysis was used to describe the data in percentage form. the researcher used a test of homogeneity to test whether variants were homogenous or not. based on the homogeneity test of age and gravida variable, age and gravida showed that they were homogeneous with a p-value of age 0.252 and the p-value of gravida 0.155. a shapiro wilks test was used to test the normality of the data. the test results showed the asymptotic significance >0.05 (was normally distributed) or asymptotic significance <0.05 (the data distribution was not normal). in the control group, the results of the normality of systolic blood pressure test before treatment were 0.001, diastole before intervention 0.002, diastole after those was 0.002, gravida 0.026, and length of education was 0.001. this study showed that systolic blood pressure before treatment, systole after those, diastole before those, gravida, and education level have abnormal data distribution. meanwhile, normality test results for systole after intervention were 0.053, age 0.591, bmi 0.36, and gestational age 0.089. this study also showed that systolic blood pressure after hypnosis, age of respondent, bmi, and gestational age have normal data distribution. in the treatment group, the normality test results for diastole before treatment were 0.002, gravida 0.009, and length of education was 0.001. this research showed that diastole before hypnosis, gravida, and education level had abnormal data distribution. meanwhile, the results of the normality data of the systole-in the treatment group was 0.096, systole after treatment 0.512, diastole after indonesian journal of nursing practices 40 treatment 0.058, age 0.598, bmi 0.144, and gestational age 0.54. this study showed that systole before hypnosis, systole after those, diastole after those, age, bmi, and gestational age had normal data distribution. wilcoxon test was used to analyze the paired bivariate for systolic blood pressure before and after the control group treatment, diastole before and after the control group treatment. meanwhile, the bivariate analysis paired the systole before and after the treatment group using paired t-tests because the data had a normal distribution. the researcher used linear regression analysis for further analysis. in the non-paired data analysis with the normal distribution, the data analysis was carried out using an independent t-test, while the mann-whitney test analyzed the data with the abnormal distribution. meanwhile, the data of fetus heart frequency appeared normal and abnormal. thus the mann-whitney u test and independent ttest were used to analyze the data. ibm spss statistic version 23 was used to analyze the data. in this study the implementation of research ethics followed these steps: assigning an informed consent form, using an anonymity form, keeping the confidentiality, caring for self-determination (free to participate or not participate), giving benefits, doing veracity, protecting from discomfort and harm condition, and passing ethical clearance. the ethical issue was obtained from the research ethics commission of the faculty of public health, diponegoro university, semarang. besides, the therapeutic process was carried out by researchers, namely midwives, who have been certified hypnotherapist (cht). results we found 18 respondents in the experimental group and 18 respondents in the control group. at the time of the research, process dropout occurred in the experimental group of two respondents because respondents refused to do the second intervention and experienced labor before completing the therapy, and drop out in the control group of 2 respondents because the health care referred patients. the final number of samples was 16 respondents in the experimental group and 16 samples in the control group. characteristics of respondents shows in table 1. based on age showed that the average age of respondents in the control group was 32 years, with a minimum age of 20 years and a maximum age of 40 years. in the treatment group, the average age of respondents was 32 years, with a minimum age of 21 years and a maximum age of 42 years. based on the categorical frequency distribution, there were 22 (68.8%) and in the healthy age range (20-35), and 10 (31.2%) were in the high-risk age range (<20 or >35). based on gravida showed that the average respondent of the third gravida with a minimum of first gravida and maximum of the sixth gravida. in contrast, the treatment group showed the average gravida of the treatment group was the third gravida, with minimum was the first gravida, and the maximum was the sixth gravida. the data frequency was 11 primigravidas (34.4%), 16 multigravidas (50%), and five grande-multiparas (16.6%). characteristics of respondents based on length of education showed that the average level of school in the control group was 7.87 ± 2.66, minimum education level at 6 (elementary school), and highest education was 12 (high school). meanwhile, the average duration of treatment group education was 7.81 ± 3.06, with a period of at least six years (elementary school), and the most extended education period was 17 years (bachelor). based on body mass index (bmi) showed that bmi in the control group was 24.09, with the lowest bmi 20 and the highest bmi 29. in the treatment group, the bmi average was 23.51, with the lowest bmi 19 and the most elevated bmi 29. based on gestational age showed that in the control group, the average gestational age was 32.2 weeks with the youngest gestational age of 20 weeks, and the oldest gestational age was 41 weeks. whereas in the treatment group, the average gestational age was 33.8 weeks with the youngest gestational age of 20 weeks, and the oldest gestational age was 41 weeks. characteristics of respondents by occupation showed that 16 (60%) respondents worked as textile workers and 12 (37.5mmhg) mothers who did not work. vol. 4 no. 1 june 2020 41 table 1. the comparisons of blood pressure pre-post intervention (n= 32) variable pre post blood pressure change pvalue blood pressure mean±sd min-max mean±sd min-max decreased increased no change control group systole 155.31±27.415 130 – 240 150.06±36.852 86 245 9 (56.3%) 2 (12.5%) 5 (31.3) 0.059a diastole 95.5±15.535 80 – 140 95.5 ± 15.535 80 140 6 (37.5%) 0 (0%) 10 (62.5%) 0.02b experiment group systole 146.88±13.889 130 – 170 126.88 ± 13.765 106 160 15 (93.8%) 0 (0%) 1 (6.3%) 0.025c diastole 9.50 ± 7.746 80 – 100 81.88 ± 12.230 60 100 13 (81.3%) 1 (6,3%) 2 (12.5%) 0.002d table 2. the comparison of the frequency of the pulse, respiratory, and fetus heart between the pre-post intervention (n = 32). variable mean ± sd min-max univariate test n (%) paired sample decreased increased no change pre-post intervention test value pvalue pulse rate among mothers in the control group pre 91.25 ±10.927 74-110 9 (56.25%) 6 (37.5%) 1 (6.25%) 1.485 0.158g post 88.50 ±8.929 76-100 pulse rate among mothers in the experiment group pre 92.25 ± 10.376 72-116 14 (87.5%) 1 (6.3%) 1 (6.3%) 3.159 0.002h post 84.69 ± 10.268 6610-14670 the respiratory rate among mothers in the control group pre 24.06 ±3.151 18-30 11 (68.8%) 5 (31.3%) 0% 0.871 0.397g post 23.38 ±3.557 16-30 the respiratory rate among mothers in the experiment group pre 24.50 ±3.615 18-30 15 (93.8%) 1 (6.3) 0% 5.537 0.000 g post 18.69 ±3.198 16-25 fetus heart rate among mothers in the control group pre 141.94±9.344 128-155 9 (56.3%) 6 (37.5%) 1 (6.3%) 0.405 0.692 g post 141.38 ±8.229 130-152 fetus heart rate among mothers in the experiment group pre 143.81 ±12.411 115-160 14 (87.5%) 1 (6.25%) 1 (6.25%) 5.870 0.000 g post 132.50 ±8.602 110-145 table 3. the comparison of the delta value of the frequency of the pulse, respiratory, and fetus heart between control – experiment group (n = 32). variable value ci score p-value differences between pulse rate in control and experiment group 3.159 0.016i undefined differences between respiratory rate in control and experiment group -3.903 0.000j (-7.807) (-2.443) differences between fetus heart rate in control and experiment group -4.524 0.000j (-15.603) (-5.897) table 1 shows that in the experiment group, there were significant differences between systole and diastole pre and post-intervention with p-value 0.025 and 0.002. meanwhile, in the control group, the only diastole that was considerable indifference with the p-value was 0.02, and there was no significant difference in systole (p-value 0.059). table 2 indicates that there were no significant differences between pre-intervention and postintervention in the control group either for pulse rate (p-value= 0.158), respiratory rate (0.397) or fetus heart rate (0.692). meanwhile, there were significant differences between pre-intervention and post-intervention in the experiment group either for a pulse, respiratory, and fetus heart rate; these were 0.002, 0.000, and 0.000, respectively. table 3 suggests that there were significant differences between the delta value of the pulse rate between the control and experiment group (0.016), respiratory rate (0.000), and fetus heart rate (0.000). discussion hypnosis gives positive effects on blood pressure decrease within pregnant mothers with pre indonesian journal of nursing practices 42 eclampsia. findings showed that there was a significant effect of hypnosis towards those. hypnosis is an effective communication method which passes directly to the critical factor. hypnosis reduces blood pressure through steps (1) relaxation; (2) parasympathetic nerve activation; (4) reducing cardiovascular activity; (5) increasing vasodilatation; (6) increasing vegf; (7) reducing sflt-1 in the plasma and; (8) reducing blood pressure (olendzki, elkins, slonena, hung, & rhodes, 2020). on the hypnosis treatment, pregnant womensubjectswere lied on the left side of the stomach; two small pillows were put under the abdomen and between two legs. rested on the left side of the abdomen gives benefits both for mother and baby. on the one hand, the baby will get the maximal flow of blood and nutrition to the placenta since the vena cava inferior located at the back right side of spin flow back the blood flow from the lower part of the heart. on the other hand, the mother with high blood pressure will get the maximum effect of blood pressure decrease, and this is suitable with a statement that people in lay positions are having lower blood pressure (grindheim, estensen, langesaeter, rosseland, & toska, 2012). when the women turned from the left lateral to supine to the right lateral positions, the blood pressure invariably rose slightly as the women were (cicolini et. all., 2011). therefore, this study suggested that hypnosis effecting on blood pressure decrease both in systole and diastole among pregnant women with preeclampsia, furthermore, it will drop mortality risk on mother affected by pre-eclampsia. the mean of the systole and diastole decrease was 20 mmhg and 7.5 mmhg, respectively. clinical hypnosis-called hypnotherapy also makes a mother more relax, stabilizes the pulse frequency, respiratory rate, and fetus heart rate frequency. hypnosis relaxation creates a depth rest, either physical rest or spiritual and emotional rest. relaxation is a technique used to support and obtain depth relaxation to low the unwanted signs and the symptoms in the body (e.g., pain, muscle stress, and anxiety). this result supports the research conducted by holdevici (2019) that ericksonian hypnosis can reduce essential and secondary hypertension with p-value < 0.005 (u = 23.7; n = 52). furthermore, the stress perceived by the patients in the experimental group is lower than the scores reported at the beginning (u = 109.5, n = 52; p = 0.003). another study find that hypnosis reducing hypertension both in a short time, middle, and longterm (kekecs, szekely, & varga, 2016). a significant lowering of both systolic and diastolic pressures was obtained in both the no drug and drug groups receiving hypnosis treatment (deabler et al., 2011). people in hypnosis relaxation state will have an entirely relaxed body, calmed, similar to sleep condition, but they do not have a total loss of conscious (beevi, low, & hassan, 2016). moreover, vanhaudenhuyse, laureys, & faymonville, (2014) argued that in hypnotherapy states, there is a stimulus to the reticular activator system in the brain. it causes nervous autonomy response, including pulse decrease, blood pressure decrease, and respiratory rate decrease. besides, it will also control the feeling, emotion, and stress. relaxation will inhibit the increase of the sympathetic nerve activity; therefore, it can reduce the number of the hormone caused dysregulation of the body. the parasympathetic nervous system has a contradiction function with the sympathetic nerve system, and it slows the work of internal body systems. the effects of the relaxation are reducing pulse, respiratory rhythm, blood pressure, muscle tension, metabolic level, and the production of the stress hormone. as a result, the whole of the body starts to get maximum function and healthier circumstances with the higher of the healing energy, restoration, and rejuvenation (pal, pal, & wal, 2019). hypnosis relaxation stabilizes fetus heart rate in pregnant women with pre-eclampsia. fetal heart rate (fhr) monitoring is an essential tool for fetal welfare assessment (reddy, & jim, 2019). relaxation during pregnancy is associated with salutogenic effects that include regulation of emotional states, physiology, and positive impact both on fetal behavior and on obstetric and neonatal outcomes (fink, urech, cavelti, & alder, 2012). fetus heart rate illustration shows how the condition of the fetus's health. based fetus heart rate decreases sharply along with the increasing gestation age as the result of the maturity of parasympathetic tonus. the researcher measured the fetus's heart rate (fhr) in one full minute vol. 4 no. 1 june 2020 43 (baston & jennifer, 2012). however, in the reality of service, that fhr measurements on prenatal care are only to find out whether there is a sound, without knowing the frequency, so that it cannot detect if there is a possibility of irregularities or rates lower than 110x/minute and higher than 160x/minute (chabibah & laela, 2017). bradycardia is a condition when the fhr is less than 110 x/minute) is defined as bradycardia. in contrast, tachycardia is a condition when the fhr is higher than 160 x/minute, which is caused by factors such as fetus hypoxia, anemia, and drugs (holmes & baker, 2011). there are various factors influencing fetus heart rate, including the mother's position, uterine activity, and the age of the mother's pregnancy due to the balance of maturity of the sympathetic and parasympathetic nerves, fetus stress, and anxiety felt by pregnant women (gondo & suwardewa, 2011). relaxation hypnosis conditions will make pregnant women relaxed and calm. someone who has a quiet mind, his heart rate will be regular and not too fast. in contrast, a stressed mother, his heart rate will tend to be faster. mother and baby have strong bonds since in the womb, what the mother feels is also felt by the fetus. therefore if the mother feels calm, the fetus can feel it, and one of the responses is a slowing down but regular and stable heartbeat (ghodrati & akbarzadeh, 2018). also, in previous research hypnosis can reduce anxiety and heart rate (legrand et al., 2017) data analysis showed that there were significant differences between fhr before and after hypnosis relaxation, with a significance value (p-value) of 0.000. in conditions before hypnosis relaxation, the frequency of fhr tends to be high at an average of 144.59x/minute, the lowest 115x/minute, and the highest frequency 160x/minute. even though this is still within normal limits, this value is at the upper limit of average numbers, so there is a risk of tachycardia. after hypnosis relaxation, the djj frequency looks more stable with an average of 134 x/minute, with the lowest rate being 134.71 x/minute and the highest frequency of 155x/minute. this study suggested that relaxation hypnosis affects the stabilization of the fetus's heart rate. at least the heart rhythm does not beat fast but slows down regularly. the length of time study became the limitations of this study. this study took about six months, just for taking the data. it occurred because of the difficulties in finding respondents who met inclusion criteria. conclusion hypnosis relaxation influences the change of fetus heart rate and vital signs of pregnant women with pre-eclampsia, including blood pressure, heart rate, and respiratory rate. hypnosis relaxation also influences the stabilization of the fetus's heart rate in pregnant women with pre-eclampsia. health care services should include hypnosis relaxation as an alternative way for caring for pregnant women with pre-eclampsia so that the fetus and mother's welfare can be improved. acknowledgements thank you conveyed to the 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(2014). neurophysiology of hypnosis. neurophysiologie clinique/clinical neurophysiology, 44(4), 343-353. https://doi.org/10.1016/j.neucli.2013.09.006 vehmeijer, f. o., guxens, m., duijts, l., & el marroun, h. (2019). maternal psychological distress during pregnancy and childhood health outcomes: a narrative review. journal of developmental origins of health and disease, 10(3), 274-285. https://doi.org/10.1017/s2040174418000557 yoganita, n. e., sarifah, s., & widyastuti, y. (2019). manfaat massage tengkuk dengan minyak zaitun untuk mengurangi nyeri kepala pasien hipertensi. profesi (profesional islam): media publikasi penelitian, 16(2), 34-39. vol. 3 no. 1 juni 2019 9 ijnp (indonesian journal of nursing practices) vol 3 no 1 juni 2019 : 9-21 titan ligita1, intansari nurjannah2, kristin wicking1, nichole harvey3, karen francis4 1 nursing, midw if ery and nutrition, college of healthcare sciences, james cook university, tow nsville, australia 2 school of nursing, universitas gadjah mada, yogyakarta, indonesia 3 medicine, college of medicine and dentistry, james cook university, tow nsville, australia 4 school of health sciences, college of health and medicine, university of tasmania, launceston, australia korespondensi: titan ligita email: titan.ligita@my.jcu.edu.au seb uah storyline mengenai proses bagaimana penderita diab etes di indonesia mempelajari mengenai penyakitnya info artikel online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.3187 abstrak latar belakang: edukas i di abetes bermanfaat pada perbai kan dalam pengel ol aan di abetes s ecara mandi ri s erta peni ngkatan pengendal i an kadar gul a darahnya. tetapi , s ampai dengan s aat i ni bel um terdapat penel i ti an dan publ i kas i mengenai pros es bagai mana penderi ta di abetes di indones i a mempel aj ari tentang penyaki tnya. tujuan: adapun tuj uan dari penul i s an arti kel i ni adal ah untuk menyampai kan has i l penel i ti an mel al ui s ebuah storyline/al ur cer i ta yang di kembangkan dari s ebuah penel i ti an grounded theory. metode: studi penel i ti an yang di maks ud i ni bertuj uan untuk memahami l ebi h bai k pros es bagai mana penderi ta di abetes mempel aj ari mengenai penyaki tnya mel al ui metodol ogi grounded theory. dua pul uh enam parti s i pan di perol eh mel al ui metode purposive dan theoretical sampling. wawancara di l akukan kepada parti s i pan. hasil: has i l penel i ti an menunj ukan pengembangan s ebuah teori “learni ng, choos i ng, and acti ng: s el f-management of di abetes i n indones i a” (mempel aj ari , memi l i h dan berti ndak: manaj emen di ri di abetes di indones i a) yang merupakan pros es penderi ta di abetes mempel aj ari tentang penyaki tnya, yang bers i fat s i kl us dan l i ni er. kesimpulan: sebuah s toryl i ne atau al ur ceri ta di gunakan untuk menj el as kan teori mengenai pros es mempel aj ari , memi l i h dan berti ndak dal am manaj emen di ri di abetes i ni . rekomendas i di tekankan pada perbai kan dal am memberi kan edukas i pada penderi ta di abetes . kata kunci: di abetes , grounded theory, manaj emen di ri , pros es mempel aj ari penyaki t, storyline abstract background: diabetes education is beneficial to enhance both knowledge and attitudes towards self-care management and glycemic control improvement. however, little is known about the process of how people with diabetes in indonesia receive and engage in education that promotes their health. objective: the purpose of this article is to share the findings in the form of a storyline developed from a grounded theory study. mailto:titan.ligita@my.jcu.edu.au 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/5698 indonesian journal of nursing practices 10 method: the aim of the study was to better understand this process using grounded theory methodology. twenty-six participants were recruited through purposive and theoretical sampling methods. the participants were interviewed. result: the results showed a cyclic and dynamic process that lead to the development of a theory entitled learning, choosing, a nd acting: self-management of diabetes in indonesia. conclusion: this theory will be explicated using a storyline, along with recommendations to help improve the provision of diabetes education. keywords: diabetes, grounded theory, process of learning the disease, self-management, storyline pendahuluan diabetes menempati empat besar penyakit tidak menular di indonesia dengan prevalensi rata-rata yang semakin meningkat (world health organization, 2014) dan sejak tahun 1980an, penyakit kronis ini sudah menjadi isu permasalahan yang mengkhawatirkan (waspadji, ranakusuma, suyono, supartondo, & sukaton, 1983) . data dari hasil riset kesehatan terkini dalam lingkup nasional menunjukkan peningkatan prevalensi diabetes. prevalensi diabetes pada populasi penduduk perkotaan tercatat sebesar dari 6.9% dan dalam periode 5 tahun, terdapat peningkatan proporsi diabetes pada populasi penduduk perkotaan dan pedesaan menjadi 8.5% (national institute for health research and development, 2013, 2018). berbagai strategi dilakukan untuk menangani penyakit diabetes melalui pengelolaan diabetes yang tepat, di antaranya adalah melalui pengobatan, pengelolaan diet, olahraga, pemantauan kadar gula darah (yacoub, 2014) serta pemberian edukasi. penderita dituntut pula u n tu k paham apa tujuan dan bagaimana cara melakukan manajemen diabetes tersebut, sehingga mereka dapat mempraktekkan manajemen diabetes tersebut dengan benar. penderita yang memperoleh informasi yang benar dan baik se cara formal melalui edukasi diabetes maupun i n f ormal melalui penyebaran informasi dari orang lai n ak an mempengaruhi bagaimana mereka memutuskan manajemen diabetes yang tepat bagi dirinya. edukasi yang diberikan kepada penderita diab etes menunjukkan hasil yang positif terhadap kondisi pasien, salah satunya adalah dengan bukti adanya perbaikan kadar gula darah penderita. tetapi, karena penderita diabetes mengalami penyakit sepanjang kehidupannya, mereka membutuhkan dukungan yang berkelanjutan (funnell, 2011). seringnya, edukasi yang diberikan tidak memadai sehingga penderita sulit mempertahankan perilaku yang positif. perawat yang merupakan salah satu tenaga kesehatan yang berinteraksi intensif dengan penderita akan dapat memberikan dukungan y an g berkelanjutan melalui edukasi kepada penderita, di mana perawat menunjukkan sumber daya yan g membantu penderita dalam mengubah perilaku dan menunjukkan mekanisme pemecahan masalah yang baik (funnell, 2011). salah satu contoh bagaimana perawat dapat membantu penderita diabetes adalah dengan cara menyediakan sumbe r informasi yang benar (misalnya secara online) dari sumber yang terpercaya seperti situs web national diabetes education program (ndep) (funnell, 2011). situs tersebut merupakan situs pemerintah di negeri berkembang seperti amerika serikat yang dikelola oleh pusat pencegahan dan kontrol penyakit yang berisi informasi mengenai diab etes , sehingga praktisi maupun penderita diabetes dapat mengunjunginya. beberapa studi telah dilakukan untuk meneliti mengenai program-program pendidikan diabetes yang diberikan kepada penderita diabetes di indonesia dengan tujuan untuk menilai kemampuan pasien dalam manajemen perawatan diri (hartayu, izham, & suryawati, 2012a, 2012b; ng et al., 2010; sae-sia, maneewat, & kurniawan, 2013). adapun strategi yang ditawarkan melalui penelitian tersebut adalah dengan memberikan pendidikan bagi penderita diabetes melalui dukungan, nasihat dan/atau pendekatan interaktif. hasil akhir yang dapat dicapai melalui edukasi vol. 3 no. 1 juni 2019 11 diabetes ini adalah perilaku perawatan diri yang positif, peningkatan pengetahuan mengenai perawatan diri dan kepatuhan terhadap manajemen perawatan diri pada diabetes. akan tetapi, pencapaian yang positif melalui program edukasi diabetes yang dievaluasi melalui penelitian tersebut belum menunjukkan pemahaman yang mendalam mengenai proses pemberian edukasi kesehatan bagi penderita diabetes terutama dalam konteks yang terjadi di indonesia. studi yang pernah ada pun tidak memberikan perhatian terhadap siapa saja yang terlibat dalam pembelajaran penderita diabetes melal ui e d u kas i kesehatan terkait penyakitnya. tidak hanya itu, sebagian besar penelitian yang dilakukan te rs eb ut tidak meneliti tentang peran tenaga kesehatan, khususnya perawat, dalam memberikan pendidikan diabetes (hartayu et al., 2012a, 2012b; ng et al., 2010). efektifitas edukasi diabetes yang diidentifikasi d ari beberapa studi tidak menunjukkan secara jelas proses yang dilakukan oleh penderita diabetes melalui informasi yang mereka dapatkan dari edukasi diabetes tersebut. proses bagaimana pasien mempelajari penyakitnya sangat penting dalam meningkatkan edukasi yang efisien dan efektif bagi penderita diabetes. maka dari itu melalui studi grounded theory, kami melakukan sebuah penelitian mengenai proses bagaimana penderita diabetes di indonesia mempelajari mengenai penyakitnya. pertanyaan umum penelitian pada studi ini adalah bagaimana p ro s e s penderita diabetes di indonesia mempelajari tentang penyakitnya. adapun tujuan dari artikel in i adalah untuk menyampaikan hasil penelitian melalui sebuah storyline (alur cerita) pada teori yang kami kembangkan, yaitu teori mengenai proses bagaimana penderita diabetes mempelajari mengenai penyakitnya. storyline atau al ur cerita adalah salah satu teknik yang dapat membantu peneliti mengembangkan sebuah teori dan menampilkan hasil penelitian berupa sebuah narasi (birks & mills, 2015). metode penelitian tujuan penelitian ini bertujuan untuk menjelaskan p ro s e s sosial dasar yang digunakan penderita diabetes di indonesia untuk mempelajari mengenai penyakitnya, termasuk di dalamnya proses di mana penderita diabetes menerima edukasi kesehatan yang terkait dengan diabetes. faktor penghambat dan pendukung dalam pemberian pendidikan kesehatan bagi masyarakat dengan diabetes ini akan diidentifikasi sebagai bagian dari proses tersebut. hasil dari mengetahui proses ini, diharapkan akan memberikan arahan pada pembuat kebijakan dan praktisi kesehatan terutama perawat dapat mengembangkan strate gi yang kreatif melalui pemberiaan edukasi kesehatan yang lebih baik kepada penderita diabetes sehingga penderita dapat memilih dan menerapkan terapi dengan benar dan sesuai. desain penelitian ini menggunakan pendekatan ku al itatif dengan metodologi grounded theory sebagai rancangan penelitian. tujuan penelitian yang sesuai dapat membantu peneliti memilih rancangan penelitian yang sesuai (mills, 2014). grounded theory merupakan rancangan penelitian yang dianggap sangat cocok bagi pertanyaan penelitian yang ingin mengetahui sebuah “proses”. penelitian grounded theory menghasilkan sebuah teori yang dikembangkan dari proses pengumpulan data dan analisis data yang terjadi secara bersamaan atau dikenal dengan istilah concurrent data collection and analysis (charmaz, 2006; corbin & strauss, 2008; creswell, 2013), di mana proses analisis data dilakukan pada setiap data yang dikumpulkan (misalnya melalui wawancara) sebelum peneliti mulai melakukan wawancara selanjutnya. berdasarkan pada hasil analisis data ini, peneliti akan menentukan data tambahan apa saja yang perlu dikumpulkan melalui wawancara, yang dikenal dengan istilah theoretical sampling. grounded theory adalah pilihan yang tepat dilakukan bagi sebuah topik yang tidak memiliki bukti yang memadai mengenainya dan dengan demikian diperlukan pemahaman dan pengetahuan yang lebih mendalam mengenai fenomena te rk ait (mills, birks, & hoare, 2014). peneliti dalam penelitian ini menggunakan seperangkat prinsip grounded theory yang dipengaruhi oleh filosofi constructivism dan symbolic interactionism. penelitian grounded theory memberikan perhatian pada pentingnya mengetahui posisi filosofis peneliti dalam penelitian kualitatif, karena para peneliti akan secara efektif menggunakan rancangan penelitian yang sesuai sehingga dapat mencerminkan sudut pandang mereka mengenai kenyataan/realitas dan indonesian journal of nursing practices 12 metodologi penelitian yang mereka terapkan (birks, 2014). secara metodologi, penggunaan constructivism yang didukung oleh symbolic interactionism pada peneltitian grounded theory telah populer di kalangan peneliti perawat k are n a desain ini memungkinkan mereka untuk memahami sikap dan pengalaman partisipan s e rta mengeksplorasi proses yang digunakan dalam memberikan pelayanan kesehatan (higginbottom & lauridsen, 2014). prinsip constructivism yang digunakan adalah bahwa peneliti bersama d e n gan partisipan penelitian membentuk ( construct) realita/kenyataan melalui pandangan dan hal y an g bermakna bagi partisipan (charmaz, 2014). melalui prinsip symbolic interactionism, peneliti melihat bahwa hal yang bermakna bagi partisipan dibentuk melalui interaksi sosial (blumer, 1969) sehingga peneliti akan melihat interaksi -interaksi yang dilakukan oleh partisipan pada data yang dianalisa. metode studi penelitian ini menggunakan langkah-langk ah penting yang seharusnya dilakukan dalam sebuah penelitian grounded theory, seperti misalnya purposive sampling method, theoretical sampling method, concurrent data collection/generation and analysis, constant comparative analysis, coding processes, theoretical saturation, theoretical sensitivity dan memo writing (birks & mills, 2015). hal ini dilakukan untuk memastikan kecermatan dan kualitas penelitian dengan pendekatan kualitatif ini. purposive sampling method adalah pengambilan data pada partisipan yang memiliki potensial untuk memberikan informasi yang diharapkan (cres we ll , 2013). sedangkan theoretical sampling method merupakan metode yang dilakukan untuk menentukan data apa yang akan diperoleh selanjutnya setelah dilakukan pengumpulan dan analisa pada data yang pertama sehingga didapatkan informasi yang lengkap untuk mendukung analisa data (birks & mills, 2015). concurrent data collection/generation and analysis merupakan proses pengambilan data dan analisa secara berkesinambungan, artinya setiap data yang diperoleh, dilakukan analisa pada data tersebut sebelum dilakukan pengambilan data selanju tn ya. constant comparative analysis merupakan proses analisa data yang membandingkan data yang satu dengan data yang lain; data yang dimaksud terdiri dari kode, kategori maupun kejadian (birks & mills , 2015). sedangkan coding processes merupakan proses mengembangkan kode dan kategori dari data yang dikumpulkan, misalnya hasil wawan cara berupa transkrip, sehingga terbentuk kategori inti untuk mendukung terbentukan teori sebagai produk akhir penelitian grounded theory. theoretical saturation adalah salah satu proses di dalam melakukan analisa data di mana peneliti menemukan bahwa data terakhir yang dikumpulkan tidak menunjukan adanya informasi baru, yang artinya data sudah tersaturasi. theoretical sensitivity merupakan tingkat kepekaan dan intelektualitas peneliti di mana komp o n e n i n i diperlukan mulai dari awal hingga akhir proses penelitian (birks & mills, 2015). memo writing merupakan proses pencatatan ide, pandangan, keputusan yang dilakukan dalam proses analisa data sehingga peneliti memiliki catatan me n ge nai proses yang penelitian lakukan untuk membuat keputusan (birks & mills, 2015). penelitian ini dilakukan melalui tiga tahapan periode pengambilan data. penelitian tahap atau periode pertama dan kedua dilakukan melalui wawancara secara tatap muka dengan total 24 partisipan (7 partisipan pada tahap pertama dan 17 partisipan pada tahap kedua), sedangkan penelitian tahap atau periode ketiga dilakukan melalui telepon pada empat orang partisipan (dua orang partisipan berasal dari periode pengambilan data sebelumnya). selain teknik purposive sampling dan theoretical sampling, teknik snowballing sampling juga digunakan untuk memperoleh informasi mengenai partisipan berikutnya dari partisipan sebelumnya, terutama pada saat pengumpulan data pada tahapan ketiga. partisipan yang terlibat dalam penelitian ini terdiri dari penderita diabetes, keluarga penderita diabetes, perawat, dokter, ah l i gizi, apoteker, mahasiswa keperawatan, kader, staf pomosi kesehatan rumah sakit dan instruktur senam. untuk kriteria praktisi kesehatan (perawat, dokter, ahli gizi, apoteker) adalah seorang p rak ti s i yang memiliki pengalaman dalam memberikan pelayanan kesehatan dan/atau perawatan diabetes, bekerja pada lingkup rawat inap ataup u n rawat jalan dan dalam praktiknya sehari -hari berinteraksi secara langsung dengan individuindividu yang hidup dengan diabetes. sedangkan vol. 3 no. 1 juni 2019 13 kriteria penyedia layanan kesehatan ( mahasiswa keperawatan, kader, staf pomosi kesehatan rumah sakit dan instruktur senam) adalah seorang yang memiliki pengalaman dalam memberikan perawatan diabetes dan sehari -hari berinteraksi secara langsung dengan individu-individu yang hidup dengan diabetes. untuk kriteria penderita diabetes seseorang yang didiagnosa dengan pre diabetes atau diabetes mellitus dan tinggal di kalimantan barat. kriteria keluarga penderita diabetes adalah seseorang yang memiliki dan/atau merawat anggota keluarga yang hidup dengan diabetes. saat wawancara, partisipan diberikan pertanyaan-pertanyaan terbuka yang dapat mengungkapkan pengalaman partisipan atau informasi lainnya yang tidak pernah dipikirkan sebelumnya oleh peneliti (charmaz, 2006). contoh pertanyaan yang diberikan kepada prak ti s i kesehatan adalah tolong anda ceritakan kepada saya mengenai pengalaman anda dalam memberikan pendidikan kesehatan untuk penderita diabetes di indonesia, tolong jelaskan faktor-faktor yang memfasilitasi anda dalam memberikan pendidikan kesehatan bagi penderita diabetes, dan tolong jelaskan faktor-faktor yang menghambat anda dalam memberikan pendidikan kesehatan bagi penderita diabetes. ini merupakan contoh pertanyaan grand tour, di mana peneliti akan memulai dengan memberikan pertanyaan mendasar (grand tour questions) dan kemudian memberikan pertanyaan tambahan yang bersifat mengklarifikasi dan menyelidik, guna mengeksplorasi lebih jauh aspek yang telah disebutkan oleh partisipan, dan memberikan kesempatan bagi partisipan untuk memimpin percakapan (glaser, 1998). proses pengambilan data dilakukan secara bersamaan dengan analisis data dan istilah ini disebut dengan concurrent data collection and analysis. penelitian ini melewati tiga tahapan coding dalam menganalisa data, yaitu initial coding, intermediate coding dan advanced coding. initial coding adalah proses awal dalam membuat kode melalui data yang dikumpulkan (birks & mills, 2015). birks dan mills melanjutkan bahwa proses ini disebut juga proses pemberian nama pada fenomena yang ditemukan pada data. intermediate coding merupakan lanjutan dari proses initial coding di mana, kode-kode yang dikembangkan/dibentuk, dikelompokkan me n jad i kategori-kategori dan kategori tersebut diberikan sifat dan dimensi (birks & mills, 2015). pada tahapan intermediate coding, peneliti sudah dap at memilih kategori inti yang memiliki konsep yang bersifat abstrak. selanjutnya pada advanced coding, peneliti sudah berada pada tahapan mengintegrasikan teori dan menjelaskan teori yang merupakan produk akhir penelitian (birks & mills, 2015). adapun teknik di dalam menganalisa data hasil wawancara tersebut menggunakan constant comparative data analysis, di mana data hasil penelitian yang berupa kode, kategori dan subkategori dibandingkan satu sama lain dan teknik analisis tersebut digunakan untuk membantu peneliti dalam meningkatkan derajat abstraksi dari data yang dikumpulkan (birks & mills, 2015). hasil penelitian pada penelitian ini dijelaskan dalam bentuk storyline. storyline merupakan salah satu bagian/bentuk dari publikasi hasil peneliti an p ad a studi yang menggunakan grounded theory sebagai rancangannya (ligita, wicking, harvey, nurjan n ah, & francis, 2019). etika penelitian sebelum melakukan pengambilan data, penel itian ini sudah memperoleh dua persetujuan penel itian dari james cook university australia (h6445) dan fakultas ilmu keperawatan universitas indonesia (0367/un2.f12.d/hkp.02.04/2016). empat aspek utama yang perlu dipertimbangkan dalam penelitian ini adalah respect for autonomy dan confidentiality, non-maleficence, beneficence dan justice (beauchamp & childress, 2001, 2009, 2013). partisipasi dalam penelitian ini adalah sepenuh ny a sukarela. para partisipan dapat diperbolehkan untuk batal atau mengundurkan diri berpartisip asi dalam studi ini setiap saat tanpa penjelasan atau prasangka apapun. pernyataan-pernyataan mengenai otonomi peserta dan kerahasiaan ini diberikan dalam lembar informasi ( information sheet) dan lembar persetujuan penelitian ( informed consent). indonesian journal of nursing practices 14 hasil melalui storyline, teori yang dikembangkan dari sebuah penelitian, akan dijelaskan melalui s e b uah narasi yang mempresentasikan hasil dari penelitian tersebut (birks, mills, francis, & chapman, 2009) . birks et al. menambahkan bahwa peneliti perlu menggunakan teknik storyline ini sebab teknik ini dapat digunakan sebagai alat analisis untuk menghasilkan teori yang terintegrasi dan berasal dari data, sehingga teori sebagai hasil akhir dari penelitian ini pun dapat disebarluaskan ke masyarakat luas dan pembaca. hal-hal yang perlu diperhatikan dalam penulisan alur cerita atau storyline dalam penelitian grounded theory menurut birks et al. (2009) adalah: a) penjelasan teori merupakan hal yang penting ( theory takes precedence); b) adanya variasi dalam menjelaskan data (allow for variations); c) identifikasi kesenjangan atau inkonsistensi pada saat menulis storyline (limit gaps); d) bukti didapatkan dari d ata (evidence is grounded); dan menggunakan gaya menulis yang sesuai dengan tujuan dan target pembaca (style is appropriate). ligita, francis, wicking, harvey, and nurjannah (in press) menambahkan komponen sharing, di mana perlunya membagikan atau menyampaikan storyline sebagai bagian dari hasil peneliti an p ad a pembaca yang ditargetkan oleh si peneliti, misal penderita diabetes dan/atau keluarganya. storyline berikut ini adalah storyline dari sebuah proses mengenai bagaimana penderita diabetes mempelajari mengenai penyakitnya melalui teori yang dinamakan learning, choosing, and acting: self-management of diabetes in indonesia atau ‘mempelajari, memilih dan bertindak: manaj emen diri diabetes di indonesia’ (ligita et al., 2019). storyline yang sudah diterjemahkan ke dalam bahasa indonesia ini merupakan bentuk sederhana dari storyline dalam versi berbahasa inggris. berikut adalah storyline dari hasil penelitian yang dimaksud: mencari dan menerima informasi terkait diabetes (‘seeking and receiving diabetes-related information’) individu-individu yang menderita diabetes mempelajari mengenai diabetes melalui d u a cara: secara aktif mencari informasi dan secara pasif mendengarkan dan memperoleh bacaan mengenai informasi kesehatan yang disediakan tentang diabetes. terdapat dua periode waktu yang penting di mana individu-individu yang menderita diabete s mulai mencari informasi kesehatan terkait diabetes untuk memahami penyakit diabetes yang mereka alami. pertama, individu dengan diabetes secara aktif mencari informasi kesehatan mengenai kondisi mereka sebelum mereka didiagnosa, di mana mereka menyadari terjadinya perubahan yang pada tubuh mereka dan pada akhirnya mereka ingin mencari tahu apa yang sebenarnya sedang terjadi. kedua, individu-individu yang menderita diabetes mulai mencari informasi secara aktif setelah mendapatkan konfirmasi bahwa ia mengalami diabetes yang di dapatkan melalui tes gula darah dan/atau setelah individu didiagnosa oleh dokter. pendekatan untuk bisa mendapatkan informasi ternyata bervariasi antara sebelum dan sesudah diagnosa diabetes tersebut ditegakkan. mencari informasi secara aktif sebelum mereka didi agn os a diantaranya adalah dengan melakukan tes gula darah sendiri dan meminta informasi atau pendapat dari seorang dokter mengenai adanya perubahan pada tubuh yang telah mereka sadari. sumber-sumber informasi kesehatan yang dicari secara aktif oleh individu-individu yang men d eri ta diabetes tidak terbatas hanya pada tenaga kesehatan professional. kerabat yang juga menderita diabetes, individu-individu lain yang dikenal, buku-buku dan internet merupakan sumber lain yang digunakan oleh penderita diabetes (untuk memperoleh informasi tersebut). individu-individu yang menderita diabetes secara pasif memperoleh informasi kesehatan dengan cara mendengarkan dan memperoleh bacaan pad a saat mereka menerima edukasi kesehatan dan informasi dari sumber-sumber yang berbeda. adapun sumber-sumber yang berbeda tersebut antara lain: tenaga kesehatan professional, kerabat, teman serta orang lain yang memil iki kerabat yang menderita diabetes. sedangkan sumber informasi lainnya berupa media cetak, elektronik maupun audio-visual. memproses/mengolah informasi yang diterima (‘processing received information’) vol. 3 no. 1 juni 2019 15 bagi penderita diabetes, mencari informasi te rk ai t diabetes merupakan titik awal untuk mulai memproses informasi terkait diabetes yang mereka terima. pertama kali, mereka menyaring atau memilah informasi. ada beberapa cara yang dilakukan untuk memilah informasi tersebut. beberapa di antara mereka mengandalkan pengetahuan sebelumnya untuk menentukan efektifitas dari informasi atau rekomendasi yang ditawarkan. kemudian mereka menggunakan pengalaman sebelumnya. ada juga yang mengandalkan pendapat pribadi serta pendapat orang kedua yang mereka anggap ahli ataupun bersumber dari internet. setelah mereka memilah , mereka kemudian memutuskan untuk percaya atau tidak mempercayai informasi yang mereka dapatkan itu. dua hal yang mempengaruhi hal tersebut, yaitu keahlian dan pengalaman hidup si penyampai informasi. setelah mereka percaya atau tidak percaya, hal yang dilakukan selanjutnya adalah memberikan respon terhadap informasi tersebut. hampir sebagian besar informasi yang direspon adalah berupa rekomendasi, yang berasal dari tenaga kesehatan maupun orang lai n yang bukan tenaga kesehatan professional. bagi mereka yang tidak mempercayai informasi tersebut, dengan otomatis mereka mengabaikannya. sedangkan informasi yang dalam hal ini berupa rekomendasi yang mereka percayai, terdapat dua hal yang mereka lakukan: mengikuti rekomendasi atau tidak mengikuti rekomendasi tersebut. ini yang dinamakan kategori ‘responding to recommendations’. merespon atau menanggapi rekomendasi rekomendasi (‘responding to recommendations’) tiga faktor yang mempengaruhi bagaimana individu-individu dengan diabetes berespon terhadap informasi/rekomendasi yang mereka anggap benar adalah: faktor fisiologis atau fisik, faktor psikologis dan faktor sumber daya. faktor-faktor fisiologis meliputi peningkatan k ad ar gula darah, penurunan berat badan, timbulnya luka dan komplikasi yang memburuk (misalnya keadaan luka di kaki yang memburuk). sementara itu, faktor-psikologis antara lain rasa takut terhadap efek samping pengobatan, rasa takut terhadap tindakan medikasi (contohnya penyuntikan), merasa cukup, merasa bingung ketika mereka mendapatkan informasi yang terlalu banyak dan pada saat mereka diminta untuk membuat pilih an terhadap berbagai intervensi yang ditawarkan, merasa putus harapan terhadap penyakit dan preferensi mereka sendiri. faktor yang terakhir adalah adanya sumber daya yang dapat meningkatkan ataupun justru menghambat respon mereka terhadap informasi. sumber daya yang terkait tersebut meliputi waktu, dana, pengetahuan yang dimiliki sebelumnya, lokasi geografis dan isu-isu terkait kemudahan dan kepraktisan (seperti adanya bahan-bahan herbal untuk membuat ramuan sendiri/rumahan). pada individu yang mengikuti rekomendasi dengan caranya sendiri, ada 4 (empat) pilihan yang mereka dapat lakukan: menjalankan terapi konvensional secara utuh menjalankan terapi konvensional secara parsial menjalankan terapi non-konvensional menjalankan terapi konvensional dan nonkonvensional secara bersamaan manajemen diabetes yang ada saat ini mencakup pengobatan, berolahraga, mengelola diet dan pemantauan kadar gula darah. meskipun penderita diabetes mengikuti rekomendasi tenaga kesehatan untuk mengelola diabetesnya, tidak semua orang mengikuti keempat rekomendasi untuk pengelolaan diabetes (pengobatan, pemantauan kadar gula darah, olahraga dan diet yang be nar). hal ini dipengaruhi oleh ketiga faktorfaktor yang telah disebutkan sebelumnya: fisik, psikolo gis d an sumber daya. meskipun pengelolaan manajemen diabetes secara mandiri sangat dianjurkan, bagaimanapun, tin gk at kepatuhan masing-masing penderita bervariasi. penerimaan informasi yang tidak lengkap dapat mempengaruhi seseorang dalam menerapkan rekomendasi pengelolaan diabetes mandiri. misalnya, orang-orang yang menerima informasi yang tidak lengkap mengenai diet diabetes yang tepat bisa salah menafsirkan jumlah atau porsi makanan yang harus mereka konsumsi, yang pada akhirnya dapat kemudian mempengaruhi kadar gula darah mereka. bila penderita diabetes memilih untuk menggunakan terapi non-konvensional saja, mereka umumnya menggunakan ramuan tradisional atau herbal buatan sendiri secara oral, membeli dan mengkonsumsi produk herbal buatan indonesian journal of nursing practices 16 pabrik dan / atau mengenakan sebuah alat di tubuh mereka. akan tetapi efektivitas terapi tradisional atau terapi alternatif ini belum begitu jelas. terdapat penderita diabetes yang mengikuti terap i konvensional dan terapi non konvensional secara bersamaan. mereka terkadang misalnya mengkonsumsi obat herbal dan terkadang memilih obat yang diresepkan. terapi tersebut tidak dilakukan pada waktu (jam) yang bersamaan, ak an tetapi dalam satu hari, penderita diabetes ini bisa mengkonsumsi kedua terapi tersebut. ataupun, mereka menggunakan terapi yang berbeda pada hari yang berlainan. penderita diabetes yang memilih untuk tidak mengikuti rekomendasi termasuk rencana perawatan medis sering menganggap remeh tingkat keparahan penyakit diabetes mereka. biasanya ini terjadi karena orang tersebut tidak memperhatikan kesehatan mereka sendiri de n gan baik, sebaliknya mereka lebih sering membandingkan pengalaman kondisi mereka sendiri dengan orang lain yang juga menderita diabetes. orang-orang ini sering menganggap orang lain memiliki penyakit diabetes yang lebih parah daripada diri mereka dan mereka menganggap diabetes yang mereka derita tidak separah orang lain tersebut. menilai hasil (‘appraising the results’) setelah penderita diabetes membuat pilihan tentang rekomendasi mana yang akan mereka ikuti dalam pengelolaan diabetes mereka, mereka kemudian mengevaluasi hasilnya melalui ’appraising the result’ atau penilaian hasil. tindakan atau respon yang mereka pilih atau ti d ak pilih tersebut, dievaluasi pada fase ini. ‘penilaian hasil' mencakup tiga elemen: ‘pengukuran’, ‘kemajuan’ dan ‘tindakan selanjutnya’. dalam pengukuran, mereka mempertimbangkan bagaimana perasaan mereka dan mereka pun mengamati perubahan yang terjadi pada tubuh mereka, baik secara subjektif maupun obyektif. pengukuran secara subyektif pada perubahan tubuh mereka termasuk di antaranya mengukur perasaan nyaman atau tidak nyaman, melihat apakah penglihatan mereka jernih atau tidak, dan merasakan apakah mereka bertenaga. sedangkan pengukuran secara obyektif meliputi pengamatan luka yang mengalami penyembuhan, pengukuran berat badan dan pengukuran kadar gula darah yang stabil. saat 'menilai hasilnya', penderita diabetes juga mempertimbangkan ‘kemajuan’ penerapan tindakan yang dipilih. kemajuan terhadap tindakan penderita diabetes meliputi hasil yang positif dan negatif. produk dari ‘penilaian hasilnya’ disebut ‘experiential insight’ (wawasan/informasi yang diperoleh melalui sebuah pengalaman), yang mereka pelajari dari hasil mengevaluasi atau menilai respon mereka terhadap rekomendasi yang mereka terapkan. penderita diabetes ini menggunakan wawasan mereka untuk membuat keputusan selanjutnya yaitu: berbagi wawasan mereka dengan orang lain atau menggunakan wawasan mereka tersebut sebagai sebuah informasi yang mereka terima melalui pengalaman mereka. bila penderita diabetes memproses wawasan pengalaman mereka untuk disaring sebagai informasi yang berdasarkan pengalaman, mereka dapat memutuskan untuk memilih atau tidak memilih untuk melanjutkan rekomendasi atau terapi yang mereka aplikasikan sebelumnya. penderita diabetes yang memilih untuk menghentikan atau tidak mengikuti rekomendasi/terapi yang mereka terapkan, mereka kemudian memilih terapi lainnya, ataupun mere ka mencari rekomendasi/terapi lain yang berbeda. bila mereka percaya ada hasil positif baik yang diukur secara objektif maupun subyektif, mereka mempertahankan rekomendasi/terapi yang diterapkan karena itu dapat meningkatkan motivasi mereka untuk melanjutkannya. ketika mereka merasa mendapati hasil yang negatif atau tidak adanya kemajuan dalam pengobatan atau terapi yang telah mereka terapkan, mereka menghentikan terapi tersebut dan mulai mengubah tindakan mereka; misalnya dengan mengikuti rekomendasi dari tenaga kesehatan atau mencari rekomendasi lainnya. berbagi dengan yang lain (‘sharing with others’) pemahaman eksperiensial tidak hanya digunakan oleh penderita diabetes itu sendiri sebagai se bu ah wawasan/informasi yang diperoleh berdasarkan pengalaman, tapi juga dibagikan kepada orang lain. vol. 3 no. 1 juni 2019 17 berbagi wawasan ini dengan orang lain biasanya terjadi karena penderita diabetes sudah mengalaminya sendiri. terdapat berbagai hal untuk dibagikan dengan orang lain yaitu bagaimana mengenali gejala diabetes, manfaat manajemen diabetes dan bahkan kesalahan-kesalahan yang harus dihindari dalam pengelolaan perawatan diabetes. sedangkan informasi itu dibagikan kepada yaitu penderita diabetes yang lain, anggota keluarga mereka sendiri baik yang menderita diabetes maupun tidak, dan orang lain yang memiliki anggota keluarga yang mengalami diabetes. wawasan/informasi yang dibagikan dengan penderita diabetes dapat menjadi titik awal baginya untuk memulai proses 'mempelajari, memilih dan bertindak dalam manajemen diri diabetes'. keluarga memiliki peran penting bagi penderita diabetes. mereka terlibat dalam keseluruhan fase penting dalam proses ‘mempelajari, memilih dan bertindak dalam manajemen diri diabetes’. maka dari itu, penderita diabetes tidak dapat dipisah kan dari keluarga mereka, dan dengan demikian pengaruh anggota keluarga mendukung orangorang ini juga diidentifikasi pada proses ‘mempelajari, memilih dan bertindak dalam manajemen diri diabetes’. pembahasan saat seseorang didiagnosa sebagai penderita diabetes ataupun seseorang yang belum didiagnosa tetapi sudah merasakan gejala diabetes, ia kemudian merasa perlu mendapatkan informasi terkait dengan penyakitnya tersebut. penelitian i n i mengembangkan sebuat teori yang menunjukkan proses bagaimana penderita diabetes di indon e si a mempelajari mengenai penyakitnya. melalui proses yang dinamakan ‘learning, choosing, and acting: self-management of diabetes in indonesia’, penderita diabetes mulai mencari informasi melalui sumber-sumber yang ia percayai dapat membantunya dalam melakukan perawatan, pengelolaan dan penanganan diabetes. proses ‘learning, choosing, and acting: self management of diabetes in indonesia’ meru p akan proses di mana penderita diabetes mempelajari mengenai penyakitnya. proses ini terjadi melalui lima kategori: 1) mencari dan menerima info rmasi terkait diabetes; 2) memproses/mengolah informasi yang diterima; 3) merespon atau menanggapi rekomendasi-rekomendasi; 4) menil ai hasil; dan 5) berbagi dengan yang lain (ligita et al . , 2019). ligita et al. (2019) menekankan bahwa proses ini bersifat siklus artinya dari kategori empat ke kategori dua atau dari kategori tiga ke kategori satu, serta bersifat linier di mana penderita diabetes mengalami proses yang dimulai dari kategori satu hingga kategori lima. sumber-sumber informasi tersebut tidak hanya berasal dari tenaga kesehatan professional sep erti perawat, dokter, ahli gizi dan apoteker yang merupakan penyedia pelayanan kesehatan utama diabetes di indonesia (ligita, wicking, harvey, & mills, 2018), akan tetapi dapat berasal dari orang lain yang bukan tenaga kesehatan maupun melalu i media informasi. sumber informasi yang berasal dari tenaga kesehatan umumnya diberikan melalu i pendidikan atau edukasi kesehatan seperti program edukasi pengelolaan diabetes secara mandiri. sebagian besar program-program edukas i tersebut hanya berfokus pada aturan dan penatalaksaan yang memandu penderita di dalam mengelola diet dan olahraganya. selain itu, program tersebut umumnya hanya dapat mengevaluasi pencapaian hasil dalam jangka waktu yang singkat saja karena penderita diabetes sangat sulit mempertahankan kondisi sehatnya dalam keadaan kronis (klein, jackson, street, whitacre , & klein, 2013). penderita yang memiliki tingkat literasi kesehatan yang rendah ternyata berhubungan dengan rendahnya pengetahuan terhadap diabetes sehingga hal ini berpengaruh juga terhadap kurangnya kontrol mereka terhad ap kadar gula darah serta kurangnya melakukan aktifitas fisik (van der heide et al., 2014). tidak jarang penderita diabetes menggunakan terapi selain daripada terapi yang direkomendasikan oleh tenaga kesehatan profesional disebabkan oleh sangat bervariasinya sumber-sumber informasi yang mereka dapatkan tersebut. penderita diabetes dapat memperole h pengetahuan tentang diabetes dan mempelajari mengenai diabetes terutama tentang kondisi penyakitnya tersebut melalui buku-buku, brosur, surat kabar, majalah dan televisi, di mana sumb e r sumber ini, menurut javalkar, williamson, v aid y a, vaidya, and ferris (2016) terkait dengan hasil indikator positif seperti penurunan kadar gula darah, pengetahuan dan pengelolaan diabetes mandirinya. penderita diabetes pun dapat indonesian journal of nursing practices 18 memperoleh dan mencari informasi secara o n lin e. akan tetapi menurut studi crangle et al. (2017) sumber informasi online umumnya tidak memberikan jawaban yang memadai terhadap pertanyaan-pertanyaan penderita diabetes mengenai penyakit diabetesnya tersebut. tidak jarang penderita diabetes pun memanfaatkan jaringan sosial (social network), seperti anggota keluarga dan orang lain di sebuah komunitas tertentu (misal komunitas muslim), sebagai sumber informasi dan saran serta dukungan dalam pengelolaan diabetesnya (patel, kennedy, blickem, reeves, & chew-graham, 2016). penderita diabetes perlu mendapatkan dukungan psikososial di dalam mengelola diabetesnya dan aspek psikososial ini ternyata sangat kurang diberikan sehingga menjadi penghalang dalam pemberian perawatan diabetes yang efektif (stuckey et al., 2015). maka dari itu stuckey et al. (2015) menyarankan bahwa untuk medukung dan memperbaiki pengelolaan diabetes dengan lebih baik, diperlukan dukungan kepada penderita melalui strategi-strategi berikut ini: menjadi pendengar yang baik bagi si penderita, mengembangkan pendekatan perawatan yg berfokus pada masing-masing penderita sebagai individu, dan memotivasi penderita diabetes s e rta melibatkan keluarga dalam perawatan. penderita diabetes dapat menggunakan terapi diabetesnya baik dalam kurun waktu yang singkat maupun waktu yang lama. setelah itu, mereka biasanya akan melakukan penilaian terhadap terapi yang mereka gunakan tersebut. hal ini dilakukan untuk menentukan tindakan selanjutnya terh ad ap terapi yang mereka gunakan apakah perlu dipertahankan atau dihentikan sehingga perlu diputuskan terapi mana yang lebih tepat bagi mereka. program edukasi diabetes yang menunjukkan keberhasilan biasanya membutuhkan biaya besar sebab masing-masing penderita akan mendapatkan supervisi dari tenaga kesehatan yang terlatih serta dibutuhkan komitmen dari penderita diabetes dalam pengelolaan diabetes jangka panjangnya ini (klein et al., 2013). peran tenaga kesehatan dalam hal ini perawat, sangat krusial dalam memberikan masukan bagi penderita diabetes agar penderita diabetes dapat memilih, menggunakan dan memutuskan rencana pengelolaan diabetes yang lebih baik dan lebih tepat bagi dirinya. hal ini dapat dilakukan melalui edukasi diabetes yang lebih baik dan kreatif dengan memegang prinsip person-centered care (pcc). pada prinsip pcc, perawatan berfokus kepada penderita, dalam hal ini penderita diabetes. menurut australian college of nursing (acn) , p cc bermakna menangani penderita sebagai seorang individu, melindungi harga dirinya, menghargai hak dan pilihannya, mengembangkan hubungan terapeutik antara tenaga kesehatan dan pende rita berdasarkan asas saling kepercayaan dan saling pengertian (australian college of nursing, 2014) . dengan memberikan pelayanan berbasis pcc, penderita diabetes dapat terlibat dalam pelayan an kesehatan secara tepat dan efisien sehingga mereka dapat membuat keputusan yang terbaik bagi dirinya dan ikut serta dalam pengelolaan diabetes yang disetujui tenaga kesehatan dan penderita (rice, 2016). karena setiap penderita diabetes itu unik dan tidak memiliki kondisi yang sama persis dengan penderita lainnya dikarenakan pengaruh latar belakang yang berbeda baik itu budaya dan sosialnya dan hal ini dapat juga mempengaruhi keberhasilan hubungan penderita dan tenaga kesehatan serta terhadap tingkat kepatuhan penderita terhadap pengelolaan diabetes (caballero, 2007). dalam hal ini perawat hendaknya memiliki kompetensi kultural (cultural competency). praktisi kesehatan sangat perlu mempertimbangkan dengan hati -hati terhadap penderita diabetes yang memiliki kebutuhan y an g berbeda sesuai dengan sistem pendukung yang bervarasi yang dimilikinya serta bagaimana pengelolaan diabetes beserta kondisi penyerta dalam merencanakan pedekatan yang terbaik di dalam menangani penderita diabetes (hackel, 2013). maka dari itu pemberian perawatan dan pengelolaan diabetes termasuk di antaranya adalah pemberian edukasi diabetes pun harus disesuaikan dengan kondisi dan situasi yang dihadapi oleh masing-masing penderita tersebut. kelebihan dan keterbatasan penelitian studi ini melibatkan partisipan dari berbagai disiplin ilmu kesehatan. selain itu, artikel ini merupakan yang pertama kali menyampaikan hasi l penelitian melalui storyline/alur cerita dalam vol. 3 no. 1 juni 2019 19 bahasa indonesia dan sesuai dengan target pembaca yang terdiri dari peneliti, akademisi dan juga penderita diabetes beserta keluarganya. sedangkan keterbatasan pada penelitian ini adalah, keterlibatan pastisipan dari salah satu provinsi di indonesia sehingga tidak dapat mewakili seluruh populasi di indonesia. implikasi penelitian melalui penelitian ini, tenaga kesehatan te ru tama perawat perlu mengembangkan pendekatan yang kreatif terhadap edukasi kesehatan pada penderita diabetes. hal ini dilakukan melalui pengkajian yan g cermat terhadap aspek seperti pengetahuan sebelumnya yang dimiliki penderita, pengalaman yang dimiliki terkait pengelolaan diabetes saat ini dan yang pernah ia terapkan, kemudian pendapat pribadi termasuk mitos terkait perawatan diabetes yang penderita miliki. hal ini dikarenakan aspek tersebut dapat mempengaruhi pengambilan keputusan penderita diabetes terhadap pengelolaan diabetesnya. adanya keterbatasan waktu dalam setiap konsultasi kesehatan, menyebabkan perlu kiranya pembuat kebijakan menetapkan aturan bahwa setiap konsultasi yang pertama kali bagi penderita diabetes, akan diberikan waktu yang lebih lama oleh tenaga kesehatan sehingga kebutuhan penderita yang akan mempelajari penyakit diabetesnya dapat dianalisa dengan tepat. selain itu, tenaga kesehatan perlu melakukan perawatan tindak lanjut secara teratur ( follow up care) untuk meninjau ulang apakah pemberian informasi termasuk diantaranya rekomendasi terhadap pengelolaan diabetes penderita sudah benar-benar diaplikasikan. hal ini dapat di l ak u k an melalui kunjungan rumah atau home review visit. penderita diabetes perlu mendapatkan akses y an g mudah terhadap informasi kesehatan terkait diabetes melalui sumber yang benar dan dapat dipercaya. untuk itu, organisasi diabetes setingk at nasional, misalnya, perlu mengembangkan situs web yang berisi tentang informasi diabetes yang benar, terpercaya, dalam bentuk yang bervariasi (brosur atau leaflet berupa gambar atau simbol) dan menggunakan bahasa yang interaktif dan mudah dipahami oleh penderita diabetes dengan latar belakang pengetahuan yang bervariasi. kesimpulan penderita diabetes mengalami proses di mana mereka mempelajari penyakitnya melalui learning, choosing, and acting: self-management of diabetes. melalui proses tersebut, penderita diabetes mencari dan menerima informasi terkait diabetes kemudian mereka menerima dan memilih mana yang akan mereka terapkan di dalam pengelolaan diabetesnya. setelah menerapkan terapi pilihannya tersebut, penderita diabetes akan menilai sejauh mana terapi yang ia gunakan berhasil atau berdampak positif bagi kondisi diabetesnya. hal i n i diperlukan agar penderita diabetes dapat menentukan tindakan selanjutnya. pengalaman akan penggunaan terapi atau perawatan diabetes biasanya akan dibagikan ke orang lain baik yang menderita diabetes maupun yang tidak. adanya proses mempelajari, memilih dan bertindak d al am manajemen diri diabetes tersebut dapat digunakan oleh tenaga kesehatan professional perlu menggunakan pendekatan perawatan yang memang disesuaikan dengan kebutuhan masingmasing penderita diabetes baik itu melalui edukasi kesehatan maupun pengelolaan perawatan diabetes. penelitian selanjutnya dibutuhkan u n tu k mengembangkan model perawatan diabetes y an g saling disepakati oleh tenaga kesehatan dan perawat yang disesuaikan dengan kondisi penderita per individu dan mengevaluasi model tersebut. referensi australian college of nursing. 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(2014). indonesia: country profile. global health observatory (gho) data: indonesia. retrieved from http://www.who.int/gho/countries/idn/co untry_profiles/en/ yacoub, t. g. (2014). combining clinical judgment with guidelines for the management of type 2 diabetes: overall standards of comprehensive care. postgrad med, 126(3), 85-94. doi:10.3810/pgm.2014.05.2758. http://www.who.int/gho/countries/idn/country_profiles/en/ http://www.who.int/gho/countries/idn/country_profiles/en/ indonesian journal of nursing practices 50 ijnp (indonesian journal of nursing practices) vol 4 no 2 december 2020 : 50-58 tutur irfantoro1, dwi kartika rukmi1 1universitas jenderal achmad yani yogyakarta corresponding author: tutur irfantoro email: alikairfan123@gmail.com hiv disclosure and quality of life in people living with hiv/aids in yogyakarta article info online issn doi : http://journal.umy.ac.id/index.php/ijnp : 2548 4249 (print) : 2548 592x (online) : 10.18196/ijnp.v4i2.6989 abstract background: victory plus foundation is a non-government organization that helps the population directly affected by hiv/aids in yogyakarta. status disclosure’s research on people living with hiv/aids (plwha) in victory plus foundation is scarce. even though the status disclosure is one of hiv spreading prevention, it has twosided effects, both negative and positive, so its result can affect the quality of life despite plwha having tried to find a support system. therefore, it is essential to know how the quality of life of plwha has opened up their status. objective: this study aimed to determine the relationship between hiv status disclosure and the quality of life of plwha in the victory plus foundation, yogyakarta. method: this descriptive-analytic correlation study with a crosssectional approach was conducted in june-july 2019 on 68 plwha at the victory plus foundation. purposively, samples were asked to fill out a disclosure questionnaire and whoqol-bref. univariate data presented in descriptions and chi-square tested bivariate data. result: most of the hiv status disclosure of plwha in the victory plus foundation was classified into a moderate category (77.9%) and low quality of life (64 %). the bivariate test result found a significant relationship between the hiv status disclosures with the quality of life in general (p = 0.001) with a moderate relationship closeness (r=0.403). conclusion: consequently, there is a relationship between the hiv status disclosures with the quality of life of plwha in the victory plus foundation in yogyakarta. keywords: plwha, disclosure, status, hiv, quality of life introduction a relatively recent but rapidly growing in some key populations is a new description of the current indonesia hiv epidemic. the number of hivinfected individuals increased by at least threefold between 2009 and 2014, based on the indonesian aids commission (rahmalia et al., 2015). among aids prevention programs, the recommendations relating to hiv status disclosure hold a crucial place beside other strategies for preventing hiv transmission (yaya et al., 2015). disclosure of hiv status is an hiv patient's decision to reveal their personal information related to the illness they experienced to others (evangeli & wroe, 2017). when someone is infected with hiv, they have to consider several matters, such as death or the decision to inform others, whether friend, colleagues, family and most importantly, their sexual partners, of their illness (minson, 2014). 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://dx.doi.org/10.18196/ijnp.v4i2.6989 http://dx.doi.org/10.18196/ijnp.v4i2.6989 vol. 4 no. 2 december 2020 51 based on the meta-analysis results, it was found that status disclosure was mostly carried out by people living with hiv/aids (plwha), especially with their sexual partners than other people such as family, friends, priests/imam, and colleagues (adeoye-agboola, evans, hewson, & pappas, 2016). things that influence plwha undisclosing their status was fear of stigma and the possibility of being excluded from social life (adeoyeagboola et al., 2016). the seropositive hiv status disclosure has two opposite effects. on the one hand, the hiv status disclosure can motivate sexual partners to undergo voluntary counseling and test (vct), reduce risky behavior, and increase support to abide art (anti-retroviral therapy) treatment. on the other hand, the seropositive hiv status disclosure caused the hiv/aids patients to experience various unpleasant matters such as blame, discrimination, rejection, depression, loss of economic support and familial relationship disintegration (atuyambe et al., 2014; larkins, reback, shoptaw, & veniegas, 2005; stirratt et al., 2006). the seropositive hiv status disclosures also prompt anxiety in patients because they cannot predict the feelings, thoughts, and reactions of the people in their environment regarding their status (liamputtong & haritavorn, 2016). all of those effects indicate that hiv/aids can affect the plwha’s quality of life. quality of life (qol) is an essential component in evaluating the welfare of plwha. plwha must get special attention from a preventive, promotive, curative, and rehabilitative perspective to reduce morbidity and mortality and improve the qol of plwha. the quality of life of plwha must receive attention and must be improved because hiv / aids incidence is increasing every year (kurniasari, murti & demartoto, 2016). the plwha's quality of life is influenced by many factors, both external and internal. along with the development of hiv in the body, plwha will often face physical, psychosocial, psychological, and mental problems, both directly and indirectly, which will impact the quality of life of plwha (rina, 2013). based on previous research on the quality of life of plwha and the disclosure of plwha status, it was found that plwha in yogyakarta had a mediocre quality of life (53.95%) and had high disclosure of status to sexual partners (79.4%) (farillahsari & yasin, 2014; rukmi & darussalam, 2018). however, research on the disclosure of status to non-sexual partners such as the nuclear family, extended family, close friends, work colleagues, the community’s environment, and its relation to the quality of life at the victory plus foundation have not been explored further. despite that, disclosing their hiv status to others like partners, family, and friends is essential to reduce the incidence of hiv infection and improve hiv treatment and care (xu et al., 2017). this research intended to identify the relationship between the hiv disclosure status and their quality of life among plwha at the victory plus yogyakarta foundation. the benefit of this research is strengthening theoretical support related to the development of hiv / aids research, where research on this topic is still rare. this study could become a reference for further actions regarding plwha holistically, both from a medical and psychosocial perspective by the family, government and society so that the quality of life of plwha will be improved. method this research was a quantitative study with a descriptive correlational analytic method and a cross-sectional approach. the research was conducted in june july 2019 at the victory plus yogyakarta foundation. a total of 68 plwha were taken by purposive sampling with inclusion criteria aged> 18 years, can read and write and have opened their status. data were collected using two questionnaires. the first questionnaire contains 20 questions about status disclosure consisting of 19 questions about adoption from a previous study (leung, 2002) and one additional question regarding whom plwha has opened their status to. after being tested for validity, seven items failed and 13 questions were left with the validity test result showed r count of > 0.514 and the alpha cronbach reliability test was 0.862. the questionnaire used likert scale with a “strongly disagree” range (1) to “strongly agree” (5). the category of the disclosure of the status then calculated using the ideal mean and standard indonesian journal of nursing practices 52 deviation formula so that the range of values for low disclosure was <30.3, moderate was 30.347.6, and high was > 47.6. the second questionnaire was the indonesian whoqol-bref to measure the quality of life of plwha, which was adopted from previous research (kusuma, 2016). the second questionnaire has been tested for its validity and reliability (ch salim, sudharma, kusumaratna, & hidayat, 2007), so it was not retested. with the standard transformation set by who, the qol score was then categorized as low (score<79) and high (score≥80). data analysis was performed by univariate and bivariate analysis. the univariate data analyzed using frequency distribution and percentage, while the bivariate used the chisquare test. this research has received permission from the general achmad yani university of yogyakarta and the victory plus foundation yogyakarta. it also has passed the ethical clearance from general achmad yani university of yogyakarta with ethical number skep / 088 / kepk / vi / 2019. results table 1 shows the average age of the respondents is 34.22 ± 9.28 years, most of them are male (72.1%), have private occupation (42.6%), single (64.7%), muslims (85.3%), have senior high school education backgrounds (66.2%), live with their family (58.8%), and all undergo arv therapy (100.0%). the results of overview regarding the status disclosure and quality of life can be seen in table 1, where most of the respondents have moderate disclosure (77.9%) and have a low quality of life (64.7%). the bivariate test results are presented in table 2, where the chi-square test results for disclosure of status and quality of life in general, found a significant relationship (p=.001) with a moderate relationship closeness (r=.403). for the physical (p=.01), psychological (p=.004), social (p=.001), and environmental (p=.008) domains, it was also found that there was a significant relationship with a low level of closeness except for the social domain which was categorized in moderate closeness range (r=.416). table 1. respondent’s characteristics among plwha in victory plus foundation yogyakarta characteristic f(n) % mean ± sd age 68 100 34.22 ± 9.28 gender male female 49 19 72.15 27.9 occupation unemployed private employee student staff officer everyday worker housewives 20 29 3 6 6 4 29.4 42.6 4.4 8.8 8.8 5.9 marriage status married never married widow widowed 16 44 5 3 23.5 64.7 7.4 4.4 religion christian catholic hinduism buddhism islam 5 1 3 1 58 7.4 1.5 4.4 1.5 85.3 education background illiterate elementary school junior high school senior high school academic/university 1 5 3 45 14 1.5 7.4 4.4 66.2 20.6 living with family relatives friends alone 40 3 9 16 58.8 4.4 13.2 23.5 antiretroviral therapy yes no 68 0 100 0 hiv disclosure high moderate low 9 53 6 13.2 77.9 8.8 quality of life high low 44 24 64.7 35.3 vol. 4 no. 2 december 2020 53 table 2. bivariate analysis of hiv disclosure and quality of life among plwha in victory plus foundation domain hiv disclosure qol pv coef. low high total n % n % n % general high moderate low 1 39 4 1.5 57.4 5.9 8 14 2 11.8 20.6 2.9 9 53 6 13.2 77.9 8.8 0.001 0.403 total 44 64.7 24 35.3 68 100 physical high moderate low 5 48 6 7.4 70.6 8.8 4 5 0 5.9 7.4 0.0 9 53 6 13.2 77.9 8.8 0.010 0.345 total 59 86.8 9 13.2 68 100 psychological high moderate low 4 46 6 5.9 67.6 8.8 5 7 0 7.4 10.3 0 9 53 6 13.2 77.9 8.8 0.004 0.372 total 56 82.4 12 17.6 68 100 social high moderate low 3 45 6 4.4 66.2 8.8 6 9 0 8.8 11.8 0 9 53 6 13.2 77.9 8.8 0.001 0.416 total 54 79.4 14 20.6 68 100 environment high moderate low 4 45 6 5.9 66.2 8.8 5 6 0 7.4 11.8 0 9 53 6 13.2 77.9 8.8 0.008 0.353 total 55 80.9 13 19.1 68 100 discussion the results of the data analysis showed a relationship between the disclosure of hiv status and the general quality of life in plwha in a moderate closeness (r=.403) (table 2). most plwha in this research has moderate status disclosure (77.9%) and has a low quality of life (64.7%). these results are in line with rwanda's research, which stated that the lack of disclosure of status is associated with poor physical and mental conditions in plwha (biraguma, mutimura, & frantz, 2018). meanwhile, other studies in tanzania and thailand show that disclosure of status is strongly associated with improving the quality of life of plwha patients (bulali, kibusi, & mpondo, 2018; bunjoungmanee, chunloy, tangsathapornpong, khawcharoenporn, & apisarnthanarak, 2014). somewhat a different research results were obtained in america, which stated that disclosure of status would decrease with age and there is no significant difference from the quality of life of plwha before and after they disclose their status to others (butler et al., 2009). the disclosure of status is indeed a complex issue like a double-edged sword for plwha, producing positive or adverse effects. one positive example of disclosure of status that can increase life quality is research conducted in china. this study stated that hiv patients usually (81.3%) revealed their hiv seropositive status to the family before receiving art and it increase to 96.7% at the 24month mark (xu et al., 2017). among those who disclosed their status to their family, they stated that most of them were satisfied with their decision because they got the support of their family, which increased from 90.4% at baseline, 91.8% at six months, 95.5% in a year, and 94.3% at 24 months. most patients also received encouragement from their family in term of psychological, financial, and physical support and it increased significantly in 24 months (55.2% vs. 84.5%)(xu et al., 2017). evidence also showed a relationship between status disclosure and social support, where individuals who receive social support will have more self-esteem, better coping and a healthier lifestyle (biraguma et al., 2018). the individual could avoid the anxieties of hiding their hiv seropositive status, thus lowering their stress and lowering risky behaviors (mkize, 2009). however, there are also some examples of adverse outcomes from the disclosure of status that will reduce the quality of life of plwha. for indonesian journal of nursing practices 54 example, plwha in nigeria disclosed their status to at least one person within their social networks because the stigma was still the biggest obstacle for them. plwha in nigeria was found to experience a lot of stigma and discrimination, such as rejection by the religious community in the form of accusations of infidelity, violations of trust and the assumption that these conditions are a punishment from god (adeoye-agboola et al., 2016). one qualitative study in india stated that most participants revealed hiv status to their sexual partners because the partners also had hiv, but they were afraid to open up to family, children or friends (lakshmi, 2017). they felt that they had bad experiences related to their hiv status, such as difficulty getting sufficient food and unable to work to earn money like before being diagnosed with hiv. they also get stigmatized by health workers when they are sick (lakshmi, 2017). these study results seem to underline that the fear of stigma and exclusion i related to the disclosure of status of plwha. stigmatization of hiv in yogyakarta is still high (mawarni, 2017), and this stigma is not only obtained from the community but also from health workers (hati, shaluhiyah, & suryoputro, 2017; maharani, 2014; shaluhiyah, musthofa, & widjanarko, 2015). the results of mentioned studies support the results of this study. the high stigma in yogyakarta could be one of the reasons for the relationship between hiv status disclosure and the quality of life of plwha in yogyakarta, where the disclosure of status in plwha is mostly in the moderate category, but the quality of life is mostly in the low category. the relationship between hiv status disclosure and quality of life in this research is not only seen from general qol but also seen through 4 other domains: physical, psychological, social and environmental domain. based on the p-value and closeness, the physical domain has the lowest p-value and closeness among the other domains (table 2). most plwha with moderate openness (77.9%) had a low quality of life in the physical domain (70.6%) (table 2). it is consistent with indonesia's research (handayani, ratnasari, husna, marni, & susanto, 2019). however, it is somewhat different from the results of two studies conducted in south africa, where the physical domain is in the third and fifthlowest positions in the quality of life domain (cronje, williams, steenkamp, venter, & elkonin, 2017; tesemma, abate, abebo, & madebo, 2019). the higher plwha disclosure gets, the more opportunity the plwha get to do more physical activities akin to ordinary people. disclose hiv status can facilitate hiv care access and mobilize existing support networks (fifield et al., 2015). disclosing hiv status to others like sexual partners, family and friends is vital in decreasing hiv infection incidence and improving hiv treatment and health care (xu et al., 2017). by adhering to art treatment, the health of plwha will also improve, so that the ability to do physical activity will also increase. however, in this study, the physical domain's quality of life was mostly in the low category (table 2). plwha in this research could have difficulty to perform some daily physical activities while managing their illness. it is per with the research result which stated that plwha was challenged to attend their daily living tasks, participate in high physical activities, or have sufficient energy or vitality to engage in an active social life while managing hiv/aids (basavaraj, navya, & rashmi, 2010). pain, fatigue, poor nutrition, lack of rest and low cd4 cells are associated with physical limitations and disabilities from plwha (basavaraj et al., 2010; cronje et al., 2017; handayani et al., 2019; tesemma et al., 2019). plwha who have cd4above 500 and normal nutritional status have qol of 1.96 and 2.66 compared to their counterparts (tesemma et al., 2019). the second-lowest outcome of the quality-of-life domain based on status disclosure is the environmental domain (p = .008; r = .353) (table 2). this research differ from research in north africa, where the environmental domain is the highest (tesemma et al., 2019). openness can have a good impact on the environment; health care service is one example. high honesty of plwha will provide accurate information about their symptoms and conditions, making it easier to provide health care services. maximum health vol. 4 no. 2 december 2020 55 care services for plwha will raise patient satisfaction and has an impact on improving the quality of life of plwha (mkize, 2009). however, the opposite will happen if plwha is not open to their disease. the other issues related to the environmental domain are work and income issues. plwha should be able to adapt their life to their chronic diseases like the ability to work and employment status. working plwha sometimes experiences difficulties due to several reasons like fatigue, routine medical appointment, medication, episodic illness, physical and cognitive limitations and side effects of art (basavaraj et al., 2010). plwha who disclosed their status, said they had difficulty getting a job and often felt tired due to art's effects (lakshmi, 2017). most plwha in this study worked in the private sector (42.6%) and did not work (29.4%). it could be one cause of the low quality of life in the environmental domain because people who do not have a job are prone to experience depression, anxiety, isolation, and low self-esteem (basavaraj et al., 2010). plwha with depression 9.4 times will have an impaired qol, and social isolation will make plwha 6 times have a worse qol (tesemma et al., 2019). the third lowest domain in this study is the psychological domain (p=.004; r=.372). these results are consistent with previous research in indonesia and south africa (cronje et al., 2017; handayani et al., 2019). based on the previous study, status disclosure decreased the adverse effects of the status hiding may induce, including anxiety and depression (mkize, 2009). disclosure of a positive hiv diagnosis can also reduce stress and improve psychological health (deribe, woldemichael, wondafrash, haile, & amberbir, 2008). openness of the plwha can encourage behavior in seeking appropriate medical treatment and gain social support to help them reach a better deal and cope with the implications of living with hiv (mkize, 2009). however, the result showed that 66.7% of the 77.9% plwha with moderate status disclosure had a low quality of life. the low quality of life of plwha in the psychological domain could happened since this study did not dig deeper into possible conditions that could reduce the qol in psychological domain, such as stigma, health status, depression score, or nutritional status. plwha could have a variety of problems that worsen their psychological condition apart from depression such as ineffective coping, lack of social support, stigma, hiv-related work problems, body image problems, negative feelings, low self-esteem, and reduced ability to think, learn, memory and concentration (biraguma et al., 2018; cronje et al., 2017). the highest scored domain in this study is the social domain (p=.001; r=.416). previous research showed that the social domain occupied the highest score of all quality of life domains in plwha (cronje et al., 2017; handayani et al., 2019). this result is different from the results obtained in nigeria, which found the social domain as the lowest one (akinboro et al., 2014). disclosure in plwha could improve their social domain in the quality of life. the more open the plwha gets, the more positive impact they can get in terms of the personal or social relation of the plwha. the reason behind this is because the plwha who reveal themselves well and correctly, in addition to giving detailed information to others, can lead others to understand the condition of plwha and offer their support. the support provided by others helps the plwha be more confident in interacting with others. other positive effects of revealing a positive hiv status were the decrease in social isolation and an increase in social support (mkize, 2009). it is possible for plwha to seek information and care for their medical, social and mental health services (mkize, 2009). the study result indicated that out of 77.9% of plwha with moderate disclosure, most of them have a low quality of life in the social domain (66.2%) (table 2). the low qol in the social domain could be caused by plwha’s age. the average age of plwha in this study was 34.22 ± 9.28 years and according to pieter and lubis, the early adulthood stage, i.e., at 31 40 years of age, are respecting as the time to get a new social life like a role as a husband or wife, parents, worker, or breadwinner (handayani et al., 2019) and this is certainly not easy when someone is infected with hiv. another thing that can exacerbate the social domain is a indonesian journal of nursing practices 56 lack of social support and high stigma. based on previous research, people with good social support will have a better qol of 6.18 than those who lack social support. likewise, stigmatized people will have a qol of 2.75 lower than those who are not stigmatized (tesemma et al., 2019). although the qol in this domain is mostly low, the social domain has the highest pv value and closeness with status disclosure. it could be the case since the plwha in this study is under the same institution, namely the victory plus foundation. hanging out with the same fated could improve the social domain because they could open up, support each other and get information and psychosocial services. it is consistent with previous research, which stated that disclosure of status has always been an essential factor in hiv prevention programs. factors that could increase openness in plwha were general factors associated with the quality of life, such as living amongst friends and relatives, good social support, access to psychosocial services, and suitable financial condition (zaidi et al., 2012). conclusion the hiv status disclosure of plwha has a significant relationship with the general quality of life and quality of life in physical, psychological, social, and environmental domains. most of the hiv status disclosure for plwha in victory plus is in the moderate category (77.9%) and has a low quality of life (64%). the low quality of life of plwha that disclose their status in this study requires further follow-up from policymakers, health workers and plwha. policies are needed to help increase the disclosure of status to plwha, such as education regarding the stigma of plwha in the general public, counseling 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