journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.103-107 103 the effect of guided imagery on insomnia in the elderly in the jara mara pati technical implementation unit (upt) kab. buleleng grenda aprilyawan*, tri suryo wibowo rana wijaya high school of health sciences singaraja, indonesia corresponding author: grenda262@gmail.com abstract background: the aging process is a natural process faced by humans where there is a decrease or change in physical, emotional, psychosocial conditions which will certainly affect their productivity. this situation tends to have the potential to cause health problems, one of which is insomnia. there are some serious effects on sleep disorders such as excessive daytime sleepiness, impaired attention and memory, mood, depression, and decreased quality of life. purpose: this study aimed to determine the effect of giving guided imagery to insomnia in the elderly at the technical implementation unit (upt) jara mara pati kab. buleleng. methods: the research design used was pre-experimental with a one-group pre-test posttest design. the population in this study were all elderly people who experienced insomnia in the technical implementation unit (upt) of jara mara pati kab. buleleng with a sample size of 36 respondents, by using a simple random sampling technique. data collection using a checklist sheet. the data obtained were then coded, scored, tabulated, and analyzed with the wilcoxon test with a significant value of 0.05. results: the results of this study show the results of value < which means that there is an influence of guided imagery on insomnia in the elderly. conclusion: seeing the results of this study can be used as non-pharmacological therapy by the elderly in (upt) jara mara pati kab. buleleng to improve sleep quality which is done once a month on a scheduled basis. keywords: guided imagery, insomnia, lansia. received august 12, 2021; revised august 21, 2021; accepted september 17, 2021 doi: https://doi.org/10.30994/jnp.v5i1.158 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. http://thejnp.org/ mailto:grenda262@gmail.com https://doi.org/10.30994/jnp.v5i1.158 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.103-107 104 background sleep disorders are one of the health problems that are often faced by the elderly. this condition requires serious attention. poor sleep quality in the elderly is caused by increased sleep latency, reduced sleep efficiency and early awakening due to the aging process. the aging process causes a decrease in the function of neurotransmitters which is characterized by a decrease in the distribution of norepinephrine. this causes changes in circadian rhythms, where there is a change in elderly sleep in the 3rd and 4th nrem phases. so that the elderly have almost no phase 4 or deep sleep.1 the elderly need good quality sleep to improve their health and recover from illness. poor sleep quality can cause disturbances, among others, such as: a tendency to be more susceptible to disease, forgetfulness, confusion, disorientation and decreased ability to concentrate and make decisions. this certainly has a negative impact on the quality of life of the elderly. therefore, the problem of sleep quality in the elderly must be addressed immediately.2 about a quarter of the adult population has experienced sleep problems and 6% to 10% are estimated to have an insomnia disorder.3 the results of a warwick medical school survey from the uk on countries in africa and asia found that approximately 150 million adults experience sleep disorders. an average of 16.6% cases of insomnia among the countries surveyed. this figure is close to western countries, which is about 20%.4 in indonesia, in 2010 it was found that 36% of elderly men and 54% of elderly women complained of insomnia. only 26% of elderly men and 21% of elderly women reported having no difficulty sleeping.5 based on data from the central statistics agency for the province of bali, the results of the population census in 2020, the number of elderly people in bali province reached 535,449 people.6 from the results of a preliminary study at the technical implementation unit (upt) of jara mara pati, kab. buleleng obtained data on the number of elderly about 70 elderly. while the results of interviews from 15 elderly, 10 elderly said they had sleep disturbances and 5 people did not experience sleep disturbances. objective the main purpose of this study was to determine the effect of giving guided imagery to insomnia in the elderly at the technical implementation unit (upt) jara mara pati kab. buleleng. methods the design used in this study was a pre-experimental type of one group pre-test posttest. the population is all elderly who experience insomnia in the technical implementation unit (upt) jara mara pati kab. buleleng, a total of 40 people. sampling with simple random sampling technique. y using the slovin formula, it was found that the number of samples in this study was 36 respondents. the independent research variable is guided imagery. the dependent variable is insomnia. the data were collected using a checklist, then the data were analyzed using the wilcoxon test with a significance level of 0.05. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.103-107 105 results 1. general data table 1. characteristics of respondents based on elderly age at upt jara mara pati, buleleng regency age respondent percentage 55-65 years 7 19,4 66-74 years 15 41,7 75-90 years 14 38,9 total 36 100,0 from table 1 above, it can be seen that almost half of 15 respondents (41.7%) are 66-74 years old. table 2. characteristics of respondents based on the gender of the elderly at upt jara mara pati, buleleng regency gender respondent percentage male 7 19,4 female 29 80,6 total 36 100,0 from table 2 above, it can be seen that almost all 29 respondents (80.6%) are female. 2. special data table 3. incidence of insomnia before guided imagery treatment. insomnia guided imagery treatment before after yes 36 (100%) 8 (22,2%) no 28 (77,8%) total 36 (100%) 36 (100%) from table 3 above, it can be seen that before being given guided imagery, all respondents experienced insomnia, namely 36 (100%), while after being given guided imagery, most of the respondents did not experience insomnia, namely 28 (77.8%). table 4. wilcoxon test results ranks n mean rank sum of ranks after before negative ranks 28a 14,50 406,00 positive ranks 0b ,00 ,00 ties 8c total 36 a. after < before b. after > before c. after = before http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.103-107 106 test statisticsa sesudah sebelum z -5,292b asymp. sig. (2tailed) ,000 a. wilcoxon signed ranks test b. based on positive ranks. table 4. shows the results of the wilcoxon test with a value of 0.000 which means that there is an effect of guided imagery on insomnia in the elderly. discussion based on table 4 shows the results of the wilcoxon test with the results of value 0.000 which means that there is an effect of guided imagery on insomnia in the elderly. guided imagery is a relaxation technique by taking deep breaths and exhaling slowly so that the body becomes comfortable. this comfortable feeling is then transformed to the hypothalamus to produce corticotropin releasing factor which stimulates the pituitary gland to increase the production of proopioid melanocortin (pomc) so that the production of enkephalin by the adrenal medulla increases. the pituitary gland also produces endorphins as neurotransmitters that affect the mood to relax. guided imagery therapy is a relaxation method to imagine or imagine places and events related to a pleasant sense of relaxation.7 with this treatment, the elderly who previously experienced sleep problems after doing guided imagery relaxation had better sleep quality (no insomnia). the success of this relaxation depends on the response of the elderly who carry out relaxation seriously and cooperatively in following the instructions given by the researcher. this is in accordance with research conducted by hizkia (2019) which showed that guided imagery relaxation techniques had an effect on sleep quality in the elderly at the binjai elderly social service upt p=0.001, (<0.05).8 this study is also in line with dwi's research (2015) the results of this study indicate that there is a difference between before and after relaxation at upt pslu pasuruan, the significance value is p = 0.005 < 0.05.9 the relaxation given will be received as a stimulus and continued to the brain stem to the thalamus sensor and will reappear when there are stimuli in the form of images of things they like, so that the elderly become calmer and more comfortable to start sleeping. researchers argue that the use of mind power by imagining things that are interesting and liked by the elderly that is carried out continuously can grow and create a relaxed atmosphere so that it can increase feelings of pleasure, reduce muscle tension and the need for sleep can be fulfilled properly, due to increased encephalin and endorphins after getting guided imagery. conclusion based on the results of the discussion above, it can be concluded that there is an effect of giving guided imagery on insomnia in the elderly. the results of this study can be used as non-pharmacological therapy by the elderly in (upt) jara mara pati kab. buleleng to improve sleep quality which is done once a month on a scheduled basis. acknowledgments the authors would like to thank the ministry of research and technology/national research and innovation agency for providing researchers with the opportunity to obtain http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.103-107 107 grants under the beginner lecturer research (pdp) scheme. in addition, researchers also thank the upt jara mara pati kab. buleleng who has given research permission and all parties who helped during the research process that the author cannot mention one by one. conflicts of interest in the research proposal, the researcher writes that the results of this study will be published in a national journal with the status published in 2021. researchers hope that the results of this study can be accepted by the editors of health journals so that the output targets of this research can be achieved. references 1. khasanah, k dan hidayati, w. 2012. kualitas tidur lansia balai rehabilitasi sosial “mandiri” semarang. journal nursing studies, 1, 189-196. 2. oliveira. 2010. sleep quality of elders living in long term care institution. journal of brazilian university. 3. national sleep foundation. 2012. new research: identify and treat insomnia early to reduce risk of other illnesses. http://www.sleepfoundation.org/ alert/new-research identify-and-treatinsomnia-early-reduce-risk-other-illnesses. 4. prasetya, z. 2016. pengaruh terapi relaksasi otot progresif terhadap perubahan tingkat insomnia pada lansia. fakultas kedokteran dan ilmu kesehatan. universitas islam negeri alauddin makasar. 5. zeidler, mr, 2011. insomnia. http://www.emedcina.medscape.com/article. 1187829.com. 6. badan pusat statistik provinsi bali. 2020. hasil sensus penduduk 2020 provinsi bali. 7. kaplan & sadock, (2010). sinopsis psikiatri ilmu pengetahuan perilaku klinis. tangerang: bina rupa asara publisher. 8. hizkia, indra. 2019. pengaruh teknik relaksasi guided imagery terhadap kualitas tidur pada lansia di upt pelayanan sosial lansia binjai vol 4 no 2 (2019) : elisabeth health jurnal. stikes santa elisabeth medan. 9. dwi, nina, 2015. pengaruh terapi relaksasi guided imagery terhadap penurunan imsomnia pada lansia di unit pelayanan terpadu pelayanan sosial lanjut usia pasuruan. skripsi. universitas muhammadiyah malang. http://thejnp.org/ http://www.sleepfoundation.org/ http://www.emedcina.medscape.com/article http://www.emedcina.medscape.com/article journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.261-265 261 effect endorphin massage on anxiety labor levels of first stage anis nikmatul nikmah1*, dhita kris prasetiyanti1, eko winarti1, karima meireza2, hiromi ogasawara3 1faculty of sciences, kadiri university, kediri, indonesia 2midwifery study program, faculty of health sciences, kadiri university, indonesia 3nagoya city university, nagoya, japan *corresponding author: anisnikmatul@unik-kediri.ac.id abstract background: endorphin massage stimulates the body to release endorphin compounds; these hormones can create a sense of comfort thereby reducing anxiety. purpose: the purpose of this study was to prove the effect of endorphin massage on the anxiety level of the first stage of maternal i. pre-experimental research design with one group pretest-posttest design. the population of all mothers in childbirth i. methods: the sample size was 16 respondents, the accidental sampling technique. data collection uses observation sheets. endorphin massage by the husband for 10 minutes, massage performed for 20 minutes in 1 hour and every 10 minutes in 30 minutes at the time of contraction. data analysis using paired t test. results: the results showed that before giving endorphin massage, the average respondent experienced severe anxiety (30.00). whereas after being given an endorphin massage the average respondent experiences moderate anxiety (26,19). the value of p = 0,000 is the effect of endorphin massage on the level of anxiety of the first stage of labor. conclusion: massage through the skin surface during labor will improve the relaxed condition in the body so that it triggers a feeling of comfort. keywords: anxiety, endorphin massage, first stage, maternity mother received march 10, 2022; revised april 1, 2022; accepted april 29, 2022 doi: https://doi.org/10.30994/jnp.v5i2.219 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:anisnikmatul@unik-kediri.ac.id https://doi.org/10.30994/jnp.v5i2.219 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.261-265 262 background childbirth is a tense and worrying event, because in this event one of the most intense sources of pain that is known is mainly due to uterine contractions (cheung et al., 2007) (surucu et al., 2018). nearly 80% of women express worries and fears related to pregnancy or during labor (rondung et al., 2016). during labor emotional stress and pain can negatively impact physiological contractions and interfere with labor (boaviagem et al., 2016). this can trigger emotional stress and anxiety disorders (n et al., 1978). anxiety is an individual response to an unpleasant situation experienced by all living things in everyday life (fassaie & mcaloon, 2019). it is well known that emotional increases stimulate secretion of ketocolamine and cortisol (n et al., 1978) . the impact of excessive release of catecholamine and steroid hormones can cause increased blood pressure, unstable emotions, decreased uteroplacental circulation, reduced blood flow and oxygen to the uterus, the onset of uterine ischemia which causes more painful impulses and decreased uterine contractions (williams et al., 2019). if the impact is paused it will affect the welfare of the mother and fetus and result in death how to overcome anxiety in childbirth by using pharmacological and nonpharmacological therapies. pharmacologically through the use of drugs while nonpharmacologically without the use of drugs such as relaxation, acupressure, acupuncture, hot or cold compresses and massage (simkin & bolding, 2004). massage has been found to reduce anxiety in labor. massage is a physical manipulation of soft tissue, such as applying light pressure, fixed or moving, holding and moving muscles and body tissues (al-yousef et al., 2019). massage stimulates endorphin production and reduces blood pressure through effects on the parasympathetic system (bastard & tiran, 2009). endorphin reduces transmission of signals between nerve cells to reduce pain and reduce discomfort in the form of a decrease in the hormone cortisol (n et al., 1978). other benefits are obtained for pain relief, rehabilitation of sports injuries, stress reduction and overcoming psychological disorders, massage is the most common form of complementary and alternative therapy used throughout the world (sherman et al., 2010). research that shows massage therapy can be applied to overcome psychological well-being (williams et al., 2019). various techniques have been proposed to relieve anxiety and pain in labor including massage therapy. endorphin massage releases endorphin compounds which are a trigger for calmness and reduce pain; massage through the skin surface which is done during labor will improve the relaxed condition in the body so that it triggers a feeling of comfort. objective the purpose of this study was to prove the effect of endorphin massage on the anxiety level of the first stage of maternal i. methods this study uses pre-experimental design with the one group pretest-posttest design method. the population of all mothers in childbirth i. the sample size was 16 respondents, the accidental sampling technique. data collection uses observation sheets. this research was conducted by giving treatment to first-time mothers without complications of 16 maternal women. the treatment given was an endorphin massage conducted by a husband who had previously observed maternal anxiety levels before. endorphin massage is performed for 20 minutes every 1 hour and when the contraction is carried out for 10 minutes in 30 minutes then measures maternal anxiety. the analytical method used by the analysis to identify https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.261-265 263 differences in the level of anxiety of the first stage of maternal active phase before and after the administration of endorphin massage (in pairs) is a paired t analysis technique. results this study starts from identifying the anxiety level of the first stage of maternity mothers who have not been treated with endorphin massage, then identifying the level of anxiety after treatment. observation results are shown in the following table: table 1. level of anxiety of the first stage of maternal pregnancy before endorphin massage anxiety n minimum maximum mean std. device anxiety pre test 16 24 35 30.00 2.966 valid n (listwisw) 16 100% the average anxiety in the first stage of labor of the active mother before being given an endorphin massage is 30.00. this shows that the average maternity mothers experience severe anxiety. table 2. levels of anxiety in the first stage of maternity after an endorphin massage anxiety n minimum maximum mean std. device anxiety pre test 16 20 30 26.19 2.857 valid n (listwisw) 16 100% the average anxiety in the first stage of labor during the active phase after an endorphin massage was 26.19. this shows that on average mothers experience moderate anxiety. table 3. analysts' influence of maternal anxiety level i before and after endorphin massage variabel statistik pre post p-value anxiety mean 30.00 30 < 0.001 minimum 24 20 maximum 35 30 std. device 2.966 2.857 discussion endorphin massage is one of the non-pharmacological therapies to reduce or alleviate anxiety in women who will give birth. less pain will reduce anxiety (simkin & bolding, 2004) endorphin massage techniques can give individuals self-control when discomfort or anxiety, physical and emotional causes caused by anxiety. this happens because massage stimulates the body to release endorphin compounds which are natural pain relievers (maesaroh, 2019). endorphin massage carried out in the back of the direction of the right and left shoulders forming the letter v for 20 minutes can control the pain that persists, control the feeling of stress and boost the immune system (aprillia, 2010). states that endorphin can increase oxytocin, a hormone that facilitates labor so as to reduce pain. endorphin massage can control persistent pain, control feelings of stress and boost the immune system. endorphin levels differ from one person to another. this causes pain and anxiety every person is different. endorphin massage is a gentle and gentle way to help mothers feel more refreshed, more relaxed, and comfortable during labor. endorphin massage also helps mothers feel closer to the people caring for them (robert noah calvert, 2002). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.261-265 264 based on the research mentioned that massage can improve sleep quality and calmness in children (mindell et al., 2017). massage is used as an alternative treatment for anxiety (sherman et al., 2010). massage on the back in patients with liver transplant that positively influences vital signs, decreases the severity of pain and increases comfort (demir & saritas, 2019). endorphin can be trusted to produce four keys for the body and mind, namely increasing the immune system / immunity, reducing pain, reducing stress, and slowing down the aging process (aprillia, 2010). endorphin levels differ from one person to another. this causes everyone's anxiety to be different. but by giving endorphin massage at least it has given care for the love of maternity so that maternal anxiety levels can be reduced even if only using a simple method with a smaller risk. conclusion endorphin massage is one of the most important therapeutic touches or light massages given before delivery until delivery. endorphin compounds produced from the therapy is a pain reliever and can create a feeling of comfort. so that mothers can face a comfortable delivery process and mothers are not afraid and anxious about labor. endorphin massage that is performed on maternal will cause a sense of calm with the touch or massage of the tense nervous system will become more relaxed. this makes it possible to reduce the anxiety felt by the mother. references al-yousef, h. m., wajid, s., & sales, i. (2019). journal of ayurveda and integrative medicine short communication a community-based survey on massage therapy in saudi arabia. journal of ayurveda and integrative medicine, xxxx, 2–5. https://doi.org/10.1016/j.jaim.2019.10.002. aprillia, y. (2010). hipnostetri : rilek, aman dan nyaman saat hamil dan melahirkan ( sandra sabastian dan resita wahyu febiarti (ed.); pertama). transmedia. bastard, j., & tiran, d. (2009). complementary therapies in clinical practice reprint of : aromatherapy and massage for antenatal anxiety : its effect on the fetus q. complementary therapies in clinical practice, 15(4), 230–233. https://doi.org/10.1016/j.ctcp.2009.06.010. boaviagem, a., junior, e. m., lubambo, l., sousa, p., aragão, c., albuquerque, s., & lemos, a. (2016). sc. complementary therapies in clinical practice. https://doi.org/10.1016/j.ctcp.2016.11.004. cheung, w., registered, r. m., & ip, w. (2007). maternal anxiety and feelings of control during labour : a study of chinese first-time pregnant women. 123–130. https://doi.org/10.1016/j.midw.2006.05.001. demir, b., & saritas, s. (2019). effects of massage on vital signs , pain and comfort levels in liver transplant patients. explore, 000, 1–7. https://doi.org/10.1016/j.explore.2019.10.004. fassaie, s., & mcaloon, j. (2019). psychoneuroendocrinology maternal distress , hpa activity , and antenatal interventions : a systematic review. psychoneuroendocrinology, october, 104477. https://doi.org/10.1016/j.psyneuen.2019.104477. maesaroh, s. (2019). pengaruh endorphin massage terhadap tingkat kecemasan ibu bersalin multipara kala i. 1, 231–237. mindell, j. a., lee, c., leichman, e. s., & rotella, k. n. (2017). impact on sleep and mood in infants and mothers. sleep medicine. https://doi.org/10.1016/j.sleep.2017.09.010. n, r. p. l. r., ph, d., d, e. l. e., d, b. a. w. j. m., & d, d. s. m. p. (1978). the https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.261-265 265 relationship of maternal anxiety , plasma catecholamines , and plasma cortisol to progress in labor. the american journal of obstetrics and gynecology, 132(5), 495– 500. https://doi.org/10.1016/0002-9378(78)90742-1. robert noah calvert. (2002). the history of massage: an illustrated survey from around the world (2nd ed.). healing art press. rondung, e., thomtén, j., & sundin, ö. (2016). psychological perspectives on fear of childbirth. journal of anxiety disorders, 44, 80–91. https://doi.org/10.1016/j.janxdis.2016.10.007. sherman, k. j., ph, d. m. p. h., ludman, ã. e. j., ph, d., cook, a. j., ph, d., hawkes, r. j., roy-byrne, p. p., bentley, s., brooks, m. z., cherkin, d. c., & ph, d. (2010). generalized anxiety disorder : a randomized. 450, 441–450. https://doi.org/10.1002/da.20671. simkin, p., & bolding, a. (2004). update on nonpharmacologic approaches to relieve labor pain and prevent suffering. 489–504. https://doi.org/10.1016/j.jmwh.2004.07.007. surucu, s. g., ozturk, m., vurgec, b. a., alan, s., & akbas, m. (2018). ac. complementary therapies in clinical practice. https://doi.org/10.1016/j.ctcp.2017.12.015. williams, n. a., burn, j. m., springer, p., wolf, k., & buster, t. (2019). complementary therapies in clinical practice therapeutic massage to enhance family caregivers ’ well-being in a rehabilitation hospital. 35(november 2018), 361–367. https://doi.org/10.1016/j.ctcp.2019.03.020. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.266-270 266 the effect catheter care on length of catheter installation wardah fauziah1*, aat agustini2, novian mahayu adiutama1 1politeknik negeri subang, subang, indonesia 2stikes ypib majalengka, majalengka, indonesia *corresponding author: wardah.fauziah@polsub.ac.id abstract background: urinary tract infections may increase the prevalence of healthcare-associated infections, which reaches 40%. catheter associated urinary tract infections (cauti) can cause unnecessary postoperative morbidity, and increase the length of stay and mortality, which can lead to complications of urosepsis and even death. many interventions of evidence-based nursing are practiced by nurses to prevent cauti. one of them is catheter care based on evidence-based nursing. purpose: the study aimed to determine the effects of catheter care on the duration of catheter installment. methods: the research described a quantitative study with a quasi-experimental approach with post-test only design with control group. the samples were 66 patients, consisting of 33 patients in the intervention group and 33 patients in the control group. results: data were collected using observation sheets and analyzed using fisher e and mann whitney tests. conclusion: the duration of catheter installment in the control group and the intervention group was 5-11 days and 4-8 days, respectively. catheter of care could reduce the duration of catheter installment. keywords: catheter care, catheter duration, urinary tract infection received march 10, 2022; revised april 1, 2022; accepted april 29, 2022 doi: https://doi.org/10.30994/jnp.v5i2.214 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:wardah.fauziah@polsub.ac.id https://doi.org/10.30994/jnp.v5i2.214 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.266-270 267 background urinary tract infections (uti) due to installation, which is then referred to as catheter associated urinary tract infections (cauti). the impact of urinary tract infections (uti) will result in an increase in length of stay and an increase in urosepsis complications an also cause secondary diseases such as urethral structures, hematuria, bladder perforation, cystitis, pyelonephritis, prostatitis, bacteremia, and sepsis if not treated immediately. good infection control can reduce the risk of cauti by 17%-69% (ozden et al., 2015). the impacts are so many, it is important to act based on evidence based on nursing in catheterized patients, one of which is catheter care. the purpose of catheter care is to prevent infection in patients and reduce the length of catheter insertion in patients (chenoweth & saint, 2013; fauziah et al., 2022). previous research conducted in indonesia by perdana, haryani and aulawi regarding the implementation of catheter care treatment that focused on nursing interventions there was a relationship between the implementation of catheter care and the incidence of urinary tract infections (perdana et al., 2017). meanwhile, research conducted by susantiningdyah, kurniawati, and sriyono regarding the treatment of indwelling urinary catheters with 2% chlorhexidine gluconate in preventing urinary tract infections showed no difference in the incidence of urinary tract infections between treatment and control patients (susantiningdyah et al., 2019). another study conducted regarding the effect of urinary catheter care model of the american association of colleges of nursing (aacn) on bacteriuria results were significant compared to the control group (williams, 2016). the preliminary study carried out came from the results of observations and the application of catheter care on february 14 to february 28, 2022 at a subang hospital in west java, with 5 patients being applied and with significant results based on the length of catheter insertion, showing 4 out of 5 given the catheter treatment procedure did not show signs and symptoms of cauti and also the length of time it was different from the control group. then, the number of catheter installations in a hospital in west java reached an average of 94 installations per month. the high rate of catheter insertion leads to an increased risk of cauti (zingg et al., 2009). in hospitals, screening to determine and installation is carried out based on advice from medical personnel, for the selection of catheter numbers based on measurements on the patient, for catheter care based on standart operational procedure in hospitals not using the latest updates based on evidence-based practice. based on the description above, researchers are interested in conducting research on the effectiveness of catheter care for the length of catheter insertion. objective the study aimed to determine the effects of catheter care on the duration of catheter installment. methods this research is a quantitative study with a quasi-experimental approach with post-test only design. this study uses a quasi-experimental design research type, namely research by providing intervention to a group of research subjects. the design used was a posttest only design with control group where respondents were measured on the day when the catheter was removed after being given the application of catheter care. the population of the study was all patients indicated for indwelling urinary catheters at the subang district hospital, west java province during the study period. the sampling technique in this study used a non-probability sampling https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.266-270 268 technique with consecutive sampling type, namely patients indicated for catheter insertion by meeting certain inclusion criteria until the desired number of samples. samples were taken using the washout period method, namely using a certain period in accordance with the number of samples determined before the intervention was given, hereinafter referred to as the control group, then continued with the intervention and the group that was given the intervention was then called the intervention group. the researcher used the power and effect size method based on cohen (cohen, 1992). effect size in previous research conducted by magers was 0.65. in an effort to achieve 80% power, the sample size in this study used w=0.6, =3, and =0.05 with a sample of 30 respondents for each group. however, to prevent sample reduction due to drop out during the study, the number of samples was enlarged to become respondents for each group (total sample 33) with a drop out of 10%. the total sample obtained in this study for the control group was 35 respondents, but 2 respondents experienced a drop out, namely they died with the catheter not yet removed, and returned home with the catheter still attached. the intervention group, the total sample obtained was 36 respondents, but 4 respondents dropped out because the respondent died before the catheter removed and the patient went home with a catheter attached. results table 1. effect of catheter care on the length of catheter installation in the control group and intervention group respondent group mean standar 95% ci p a deviation control 7.64 day 1.319 7.17-8.10 (n=33) 0.001 intervention 6.09 day 1.042 5.72-6.46 (n=33) a maan whitney based on the statistical results, the p-value (0.001) showed less than 0.05. therefore, it can be concluded that statistically there is a significant difference in the length of installation in the intervention group (7.64 days) compared to the control group (6.09 days). thus, it can be concluded that there is a significant difference in the length of catheter insertion between the control group and the intervention group after being given catheter care. the results obtained effect size of 1.09%. the result means that the effect of catheter care on the length of catheter insertion in the control group and the intervention group has a large effect size. discussion the results of this study showed that the length of catheter insertion in the control group was 7.64 days. the duration in the control group is longer than the intervention group (6.09 days). the length of time a patient has a catheter greatly affected the incidence of urinary tract infections. if the catheter is inserted for no good reason and the catheter removal is not carried out even though the indications have expired. this is because the catheter can cause irritation of the urethral mucosa and as an entry points for microorganisms, so the longer the catheter is in place, the higher the risk of urinary tract infections (gould et al., 2017). the use of high urinary catheters is one of the causes of an increase in the incidence https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.266-270 269 of infection, causing an increase in health care costs and length of stay in hospital. the installation of a urinary catheter in the long term is a major risk factor for urinary tract infections (mody et al., 2017). there is an increased risk of bacteriuria related to the length of catheterization. the prevalence of urinary catheter insertion in hospitals in adults is 12-16% during hospitalization. the risk of bacteriuria increases by 5-10% per day after catheterization. microbiologically, uti is defined as significant bacteriuria (pathogenic microorganism 103/ml was found in mid-stream urine collected correctly) (fasugba et al., 2017). the prolonged of the catheterization greatly increases the risk of urinary tract infections, with daily use of a catheter increasing the risk of infection (letica-kriegel et al., 2019). the duration of urinary catheter insertion is a major risk for urinary tract infections. various preventive measures aimed at limiting the placement and early removal of urinary catheters have a significant impact on reducing infection (peter et al., 2018). the main risk factor for urinary tract infections is the prolonged use of catheters. therefore, the use should be minimized as much as possible. conclusion the duration of catheter insertion in the intervention group was lower than in the control group. catheter care significantly reduced the length of catheter insertion compared to the control group. conflicts of interest the authors declare there is no conflict of interest. references chenoweth, c., & saint, s. (2013). preventing catheter-associated urinary tract infections in the intensive care unit. critical care clinics, 29(1), 19–32. https://doi.org/10.1016/j.ccc.2012.10.005. cohen, j. (1992). a power primer. psychological bulletin, 112(1), 155–159. https://doi.org/10.1037/0033-2909.112.1.155. fasugba, o., koerner, j., mitchell, b. g., & gardner, a. (2017). systematic review and metaanalysis of the effectiveness of antiseptic agents for meatal cleaning in the prevention of catheter-associated urinary tract infections. journal of hospital infection, 95(3), 233–242. https://doi.org/10.1016/j.jhin.2016.10.025. fauziah, w., adiutama, n. m., & mandhatyi, f. a. (2022). karakteristik pasien dengan catheter urinary tract infections (cauti). jourkep : journal keperawatan, 1(1), 54–58. gould, d., gaze, s., drey, n., & cooper, t. (2017). implementing clinical guidelines to prevent catheter-associated urinary tract infections and improve catheter care in nursing homes: systematic review. american journal of infection control, 45(5), 471–476. https://doi.org/10.1016/j.ajic.2016.09.015. letica-kriegel, a. s., salmasian, h., vawdrey, d. k., youngerman, b. e., green, r. a., furuya, e. y., calfee, d. p., & perotte, r. (2019). identifying the risk factors for catheter-associated urinary tract infections: a large cross-sectional study of six hospitals. bmj open, 9(2), e022137. https://doi.org/10.1136/bmjopen-2018-022137. mody, l., greene, m. t., meddings, j., krein, s. l., mcnamara, s. e., trautner, b. w., ratz, https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.266-270 270 d., stone, n. d., min, l., schweon, s. j., rolle, a. j., olmsted, r. n., burwen, d. r., battles, j., edson, b., & saint, s. (2017). a national implementation project to prevent catheter-associated urinary tract infection in nursing home residents. jama internal medicine, 177(8), 1154. https://doi.org/10.1001/jamainternmed.2017.1689. ozden, s., iscimen, r., akalin, h., girgin, n., kahveci, f., & sinirtas, m. (2015). preventing catheter-related infections in icus: comparing catheter care techniques. critical care, 19(suppl 1), p72. https://doi.org/10.1186/cc14152. perdana, m., haryani, h., & aulawi, k. (2017). hubungan pelaksanaan perawatan indwelling kateter dengan kejadian infeksi saluran kemih. jurnal keperawatan klinis dan komunitas, 1(1), 17–27. https://doi.org/doi.org/10.22146/jkkk.29012. peter, s., devi, e. s., & nayak, s. g. (2018). effectiveness of clinical practice guidelines on prevention of catheter-associated urinary tract infections in selected hospitals. journal of krishna institute of medical sciences university, 7(1), 55–66. susantiningdyah, n. n., kurniawati, n. d., & sriyono, s. (2019). perawatan kateter urine indwelling dengan chlorhexidine gluconate 2 % dalam mencegah infeksi saluran kemih. critical medical and surgical nursing journal (cmsnj), 3(2), 8–14. https://doi.org/https://doi.org/10.20473/cmsnj.v3i2.12238. williams, l. (2016). zeroing in on safety: a pediatric approach to preventing catheterassociated urinary tract infections. aacn advanced critical care, 27(4), 372–378. https://doi.org/10.4037/aacnacc2016297. zingg, w., imhof, a., maggiorini, m., stocker, r., keller, e., & ruef, c. (2009). impact of a prevention strategy targeting hand hygiene and catheter care on the incidence of catheter-related bloodstream infections*. critical care medicine, 37(7), 2167–2173. https://doi.org/10.1097/ccm.0b013e3181a02d8f. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.255-260 255 the analysis of lateral violence among nurses in accredited hospital in riau province fitra mayenti1*, dilgu meri1, mfuh anita y. lukong2 1stikes al insyirah pekanbaru, riau, indonesia 2department of nursing, faculty of allied health sciences, ahmadu bello university, nigeria *corresponding author: fitramayenti19@gmail.com abstract background: violence in the workplace affects the performance of nurses in providing nursing care. in addition, it can increase absenteeism, influence nurses' personal and professional lives, increase administrative stress and distrust, and increase staff burnout and turnover. purpose: this study aims to analyze lateral violence in hospital nurses. methods: the type of research used in this research is quantitative research with a descriptive approach. this research was conducted at an accredited hospital in pekanbaru, in january 2019. results: the sample of the study was nurses in the room with a total of 50 respondents and the data were analyzed univariately. conclusion: the results of the study were obtained at petala bumi hospital, as many as 100% of respondents: often treated politely and respectfully by co-workers, lateral violence from co-workers in the hospital is not a problem, the seriousness of a problem regarding lateral violence by co-workers is very serious category, never lose patience and become rude to coworkers, workload is a major cause of stress related to inadequate staff and resources to deal with while at syafira hospital pekanbaru as many as 80% of respondents are often treated politely and respectfully by co-workers, 48% of respondents are lateral violence from co-workers in a large hospital or caused by many people, 36% of respondents are serious about a problem about lateral violence by co-workers very serious category, 48% of respondents sometimes lose their temper and become rude to coworkers, 64% of respondents workload the main cause of stress is related to inadequate staff and resources to deal. keywords: lateral violence, nurses, violence received march 10, 2022; revised april 1, 2022; accepted april 29, 2022 doi: https://doi.org/10.30994/jnp.v5i2.218 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:fitramayenti19@gmail.com https://doi.org/10.30994/jnp.v5i2.218 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.255-260 256 background nowadays violence in hospitals toward health care providers, especially nurses is a significant problem in every health setting in the world. workplace violence is defined by the national institute for occupational study and health as an act of violence directed against a person on the job (national institute for occupational safety and health, 2022). types of acts of violence experienced by emergency room nurses were verbal violence (79.6%), verbal threats (55.5%), physical violence (41.1%), and sexual harassment (15.9%). as many as 82.3% of nurses experienced verbal violence such as being shouted at, belittled, insulted and threatened. physical violence experienced such as being kicked, slapped, pushed and rejected (73.9%). sexual harassment such as sexually suggestive jokes, stories and questions that lead to sexuality, and indecent touching of private body parts were also experienced by nurses (51.2%) (gacki-smith et al., 2009; talas et al., 2011). several studies of violence experienced by nurses, namely the research of opie et al. (2010) found that the most frequently reported form of violence experienced by nurses in australia was verbal aggression (80%), followed by physical violence (28.6%) and sexual harassment (22.5%). most of these nurses were dissatisfied with the way they handled incidents of violence against nurses (oppie et al., 2010). in jordan as in many countries, physical and verbal violence has increased not only in the workplace but in all community settings. subsequently, many incidents were recorded and reported in the mass media. several studies were conducted to explore that problem among nurses. the prevalence of physical violence against 420 jordanian nurses who found that 22.5% of jordanian nurses were exposed to such abuse. they also found many different sources such as administration, staff, security, patients, families and the public, responsible for the attack (abualrub & al-asmar, 2011). violence in the workplace affects the performance of nurses in providing nursing care. in addition, it can increase absenteeism, influence nurses' personal and professional lives, increase administrative stress and distrust, and increase burnout and staff turnover. it can lead to dissatisfaction at work, resulting in decreased levels of general care (boafo & hancock, 2017). furthermore, workplace violence not only affects the victim, but it can also affect the victim's colleagues, friends and family (randle et al., 2007). the effects of workplace violence result in serious physical injury, psychological trauma, and even death. workplace violence also has negative organizational consequences such as low morale, increased worker turnover, a hostile work environment, and reduced trust from management and other co-workers. nurses who experience verbal abuses frequently did not report it because no action will be taken. due to abuse, they also experienced stress, low work performance, low job satisfaction, high absenteeism, and high turnover intentions (kennedy & julie, 2013; shahzad & malik, 2014). the consequence of the workplace violance is the employees will need medical attention or are unable to work because of workplace violence injuries can use workers' compensation to pay for the costs. however, workplace violence can be prevented and research shows that comprehensive workplace violence prevention programs can effectively reduce workplace violence (whelan, 2008). objective the study aimed to analyze lateral violence on nurses at an accredited hospital in pekanbaru city. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.255-260 257 methods the type of research used in this study is a quantitative study with a descriptive design, to determine nurses' perceptions of lateral violence. this research was conducted at petala bumi hospital and syafira hospital pekanbaru, in january 2019. the samples in this study were nurses at petala bumi hospital and syafira hospital pekanbaru city, with a sample of 50 respondents. the data collection instrument uses a structured questionnaire which includes the characteristics of the respondents and the quality of service. quantitative analysis uses univariate analysis to get a picture of the quality of health services. results overview of the lateral violence in petala bumi pekanbaru hospital table 1. lateral violence in petala bumi hospital pekanbaru (n = 25) no statement f % 1 treated with courtesy and respect by colleagues work a. often 25 100 b. sometimes 0 c. seldom 0 0 d. never 0 0 2 opinions about lateral violence from coworkers in the hospital a. extensive or caused by many people 0 0 b. limited to few people 0 0 c. no problem 25 100 3 the seriousness of an issue about violence laterally by colleagues in the hospital a. very serious 25 100 b. kinda serious 0 0 c. not too serious 0 0 d. not serious at all 0 0 4 losing patience and being impolite to your co-workers a. often 0 0 b. sometimes 0 0 c. seldom 0 0 d. never 25 100 5 stress related to staff and resource inadequate to handle a. main cause of workload 25 100 b. light workload 0 0 c. workload is not the cause 0 0 based on table 1, 100% of respondents stated that they were often treated politely and respectfully by co-workers, 100% of respondents stated that lateral violence from co-workers in the hospital was not a problem, 100% of respondents stated the seriousness of a problem regarding violence. laterally by colleagues at the hospital in the very serious category, 100% of respondents stated that they have never lost their temper and have been rude to their cohttps://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.255-260 258 workers, 100% of respondents stated that workload is the main cause of stress related to staff and inadequate resources to deal with: the overview of lateral violence at syafira hospital pekanbaru table 2. lateral violence at syafira hospital pekanbaru (n = 25) no statement f % 1 treated with courtesy and respect by colleagues work a. often 20 80 b. sometimes 5 20 c. seldom 0 0 d. never 0 0 2 opinions about lateral violence from coworkers in the hospital a. extensive or caused by many people 12 48 b. limited to few people 11 44 c. no problem 2 8 3 the seriousness of an issue about violence laterally by colleagues in the hospital a. very serious 9 36 b. kinda serious 6 24 c. not too serious 8 32 d. not serious at all 4 16 4 losing patience and being impolite to your co-workers a. often 3 12 b. sometimes 11 44 c. seldom 3 12 d. never 8 32 5 stress related to staff and resource inadequate to handle a. main cause of workload 16 64 b. light workload 9 36 c. workload is not the cause 0 0 based on table 2, it can be seen that of the 25 respondents, 80% of the respondents stated that they were often treated politely and respectfully by their co-workers, 48% of the respondents stated that lateral violence from co-workers in the hospital was widespread or caused by many people, 36% of respondents stated that it was serious. a problem regarding lateral violence by co-workers in a hospital is in the very serious category, 48% of respondents stated that they sometimes lose their temper and become rude to their coworkers, 64% of respondents said workload is the main cause of stress related to staff and resources inadequate to deal with. discussion the results of the research at the petala bumi pekanbaru hospital showed that often being treated politely and respectfully by co-workers lateral violence from co-workers at the hospital was not a problem, the seriousness of a problem about lateral violence by co-workers at the hospital was in the very serious category, never lost patience and being rude to your coworkers, workload is a major cause of stress related to staff and inadequate resources to deal with. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.255-260 259 the results of the study at syafira hospital pekanbaru found that they were often treated politely and respectfully by co-workers, 48% of respondents stated that lateral violence from co-workers in the hospital was broad or caused by many people, 36% of respondents stated the seriousness of a problem regarding lateral violence by colleagues. working in a hospital is in the very serious category, 48% of respondents stated that they sometimes lose their temper and become rude to their co-workers, 64% of respondents stated that workload is the main cause of stress related to inadequate staff and resources to deal with. stress can be interpreted as a stimulus that causes an imbalance in physiological and psychological functions. stress is a pattern of reactions to stressors that come from within the individual and from the environment (nasir & muhits, 2011). stress is the body's nonspecific response to any demands on it. for example, how a person's body respond when he or she experiences an excessive workload. if he is able to handle it, it means that there is no disturbance in the function of the body's organs, then it is said that the person concerned is not experiencing stress. but on the other hand, if it turns out that he has a disorder in one or more organs of the body so that the person concerned is no longer able to carry out his job functions properly, then he is called experiencing distress (alsulami et al., 2018). stress is a negative emotional experience caused by predictable changes in biochemical, physiological, cognitive, and behavioral, whose purpose is to change stressful events or accommodate the consequences. stress causes the body to produce the hormone adrenaline which functions to defend itself. stress is a part of human life. mild stress is useful and can spur someone to think and try to think more and try faster and harder so that they can answer the challenges of everyday life. mild stress can stimulate and give a sense of more excitement in a life that is usually boring and routine. but too much and continuous stress, if not addressed, will be harmful to health (nasir & muhits, 2011). conclusion the nurses were often treated politely and respectfully by co-workers and lateral violence from co-workers at the hospital was not a problem. workload was the main cause of stress related to staff and inadequate resources to handle, most of the respondents stated that they were often treated unfairly. lateral violence from co-workers in hospital widespread or caused by many people. references abualrub, r. f., & al-asmar, a. h. (2011). physical violence in the workplace among jordanian hospital nurses. journal of transcultural nursing, 22(2), 157–165. https://doi.org/10.1177/1043659610395769. alsulami, s., al omar, z., binnwejim, m. s., alhamdan, f., aldrees, a., al-bawardi, a., alsohim, m., & alhabeeb, m. (2018). perception of academic stress among health science preparatory program students in two saudi universities. advances in medical education and practice, 9, 159–164. https://doi.org/10.2147/amep.s143151. boafo, i. m., & hancock, p. (2017). workplace violence against nurses. sage open, 7(1), 215824401770118. https://doi.org/10.1177/2158244017701187. gacki-smith, j., juarez, a. m., boyett, l., homeyer, c., robinson, l., & maclean, s. l. (2009). violence against nurses working in us emergency departments. jona: the journal of nursing administration, 39(7/8), 340–349. https://doi.org/10.1097/nna.0b013e3181ae97db. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.255-260 260 kennedy, m., & julie, h. (2013). nurses’ experiences and understanding of workplace violence in a trauma and emergency department in south africa. health sa gesondheid, 18(1). https://doi.org/10.4102/hsag.v18i1.663. nasir, a., & muhits, a. (2011). dasar-dasar keperawatan jiwa: pengantar dan teori. jakarta: salemba medika. national institute for occupational safety and health. (2022). violence occupational hazards in hospital. https://www.cdc.gov/niosh/docs/2002-101/default.html. oppie, t., lenthal, s., dollard, m., wakerman, j., macleod, m., knight, s., dunn, s., & rickard, g. (2010). trends in workplace violence in the remote area nursing workforce. australian journal of advanced nursing, 27(4), 18–23. https://www.ajan.com.au/archive/vol27/27-4.pdf#page=19. randle, j., stevenson, k., & grayling, i. (2007). reducing workplace bullying in healthcare organisations. nursing standard, 21(22), 49–56. https://doi.org/10.7748/ns2007.02.21.22.49.c4517. shahzad, a., & malik, r. k. (2014). workplace violence: an extensive issue for nurses in pakistan—. journal of interpersonal violence, 29(11), 2021–2034. https://doi.org/10.1177/0886260513516005. talas, m. s., kocaöz, s., & akgüç, s. (2011). a survey of violence against staff working in the emergency department in ankara, turkey. asian nursing research, 5(4), 197– 203. https://doi.org/10.1016/j.anr.2011.11.001. whelan, t. (2008). the escalating trend of violence toward nurses. journal of emergency nursing, 34(2), 130–133. https://doi.org/10.1016/j.jen.2007.05.018. https://thejnp.org/ journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 17 23 17 perilaku bullying mahasiswa kesehatan lingga kusuma wardani , fajriansyah stikes surya mitra husada linggakusumawardani@gmail.com abstrak bullying behavior is an act of intimidation by a strong side against a weak side. bullying behavior can be grouped into four categories: physical bullying, verbal bullying, social bullying and cyber bullying. students are in the transition from adolescence to adult. the purpose of this study is to explore the behavior of bullying by healthstudents.the design of this research is qualitative with case study approach. using the snowball sampling technique obtained samplemostly students of nurse education program studyof the number 4 informants. data collection conductedindept interview, the result was analyzed using inductive thinking process.data analyzedshowed four themes of knowledge deficits, bullying awareness, repetitive behavior, and self impact.the results showed that students know what is bullying behavior, but bullying university still done by intimidating verbally and with physical strength. keywords: bullying behavior, student, intimidation received august 15, 2017; revised september 07, 2017; accepted october 01, 2017 how to cite: wardani, l.k & fajriansyah. (2017). perilaku bullying mahasiswa kesehatan. journal of nursing practice. 1(1). 17-23. the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-noncommercial-sharealike 4.0 international license. journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 17 23 18 latar belakang pendidikan adalah salah satu lembaga formal yang ditempuh oleh sebagian besar individu untuk memperoleh dan mengembangkan pengetahuan, keterampilan dan moral. lingkungan pendidikan seharusnya dapat menjadi sebuah wadah yang sehat, kondusif dan aman agar individu dapat bereksplorasi dan mengembangkan diri di dalamnya. akan tetapi akhir-akhir ini kerap terjadi berbagai perilaku dan aksi kekerasan yang mengkhawatirkan di lingkungan pendidikan, baik yang dilakukan guru terhadap siswa antar siswa maupun antar mahasiswa. salah satu fenomena yang banyak beredar di media adalah kasus kekerasan antar siswa atau mahasiswa yang terjadi di lingkungan sekolah atau kampus yang dikenal dengan istilah bullying.banyaknya fenomena bullying yang terjadi dalam institusi pendidikan karena ada beberapa karakteristik siswa atau mahasiswa yang membuatnya rentan menjadi korban bullying. berdasarkan survei yang dilakukan oleh latitude news di 40 negara. salah satu faktanya yang ditemukan adalah pelaku bullying biasanya para siswa atau mahasiswa laki-laki. sedangkan siswi atau mahasiswi lebih banyak menggosip ketimbang melakukan aksi kekerasan dengan fisik. dari survei tersebut juga terdapat negara-negara dengan kasus bullying tertinggi di seluruh dunia. lima negara dengan kasus bullying tertinggi, pada posisi pertama ditempati oleh jepang, indonesia, kanada, amerika serikat, dan finlandia (uniquepost, 2014). data komisi perlindungan anak (kpai) menyebutkan, sejak 2012 hingga 2015, sedikitnya dari 2 ribu anak di seluruh indonesia, sebanyak 87 persennya mengalami kasus kekerasan yang di dalamnya termasuk bullying.hasil survei yang dilakukan oleh yayasan semai jiwa amini (sejiwa, 2008) kekerasan bullying di tiga kota besar di indonesia, yaitu yogyakarta, surabaya, dan jakarta mencatat terjadinya tingkat kekerasan sebesar 67,9% di tingkat sekolah menengah atas (sma) dan 66,1% di tingkat sekolah menengah pertama (smp). kekerasan yang dilakukan sesama siswa tercatat sebesar 41,2% untuk tingkat smp dan 43,7% untuk tingkat sma dengan kategori tertinggi kekerasan psikologis berupa pengucilan. peringkat kedua ditempati kekerasan verbal (mengejek) dan kekerasan fisik (memukul). gambaran kekerasan di smp di tiga kota besar yaitu yogya: 77,5% (mengakui ada kekerasan); surabaya: 59,8% (ada kekerasan); jakarta : 61,1% (ada kekerasan). beberapa faktor yangterlihat dalam perilaku bullying, yaitu faktorpribadi anak itu sendiri, faktor keluarga, lingkungan, maupun sekolah atau kampus. fakor-faktortersebut baik yang bersifat individumaupun kolektif, memberi kontribusikepada seseorang anak sehingga akhirnya anak melakukan tindakanbullying. menurut ken rigby (2010) untuk mengatasi maraknya perilaku bullying dan dampaknya di dunia pendidikan dapat dilakukan dengan 6 cara berikut, yaitu : dukungan disiplin (traditional disciplinary approach), memberikan dukungan pada korban (strengthening the victim), mediasi antara korban dan pelaku (mediation),mengembalikan keharmonisan antara pelaku dan korban (restorasi practice), metode dukungan kelompok (support group method),dan metode kelompok peduli (method of shared concern).tujuan penelitian ini untuk mengeksplorasi perilaku bullyingmahasiswa kesehatan. journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 17 23 19 metode penelitian desain penelitian ini adalah kualitatif dengan pendekatan studi kasus. menggunakan teknik snowball sampling dengan sampel beberapa mahasiswa prodi ners stikes surya mitra husada kediri yang berjumlah 4 informan. pengumpulan data dilakukan dengan wawancara mendalam menggunakan wawancara semi-terstruktur, hasilnya dianalisis menggunakan proses berfikir induktif. hasil penelitian karakteristik subyek tabel 1. karakteristik informan dalam penelitian perilaku bullying mahasiswa kesehatan informan usia (th) semester informan 1 informan 2 informan 3 informan 4 21 23 22 22 6 10 8 8 sumber: hasil analisa data, tahun 2017 pembahasan defisit pengetahuan tema defisit pengetahuan yang dilakukan oleh mahasiswa adalah perkelahian, balas dendam pada orang lain, membicarakan orang lain baik secara verbal maupun melalui sosial media , serta menjelek-jelekan orang lain di lingkungan kampus. perkelahian yang dimaksudkan menggunakan kekuatan fisik pada orang lain dengan tujuan pribadi, membicarakan orang lain dilakukan pelaku berupa meyebarkan berita tidak benar (hoax) melalui kelompok diskusinya maupun melaui media sosial yang dimiliki. semua hal yang dilakukan dengan maksud pribadi dari pelaku. hal ini masih terjadi di lingkungan kampus. hal ini diperkuat oleh teori coloronso (2007) yang mengatakan perilaku bullying adalah tindakan intimidasi yang dilakukan pihak yang kuat terhadap pihak yang lemah. sedangkan menurut flynt & morton (2006) bullying adalah suatu perilaku agresif yang diniatkan untuk menjahati atau membuat individu merasa kesusahan, terjadi berulang kali dari waktu ke waktu dan berlangsung dalam suatu hubungan yang tidak terdapat keseimbangan kekuasaan atau kekuatan di dalamnya. bullying dapat terjadi di berbagai tempat, kapanpun, dan pada siapa saja. penelitian sebelumnya menunjukkan bahwa bullying dapat terjadi di rumah tangga, sekolah dan lingkungan kampus (syakrani & mafriana, 2005). dari hal diatas dapat disimpulkan bahwa perilaku bullying bukan merupakan hal asing bagi mahasiswa, namun masih marak terjadi di semua lini dunia pendidikan, baik itu tingkat dasar sampai tingkat perguruan tinggi. hal ini journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 17 23 20 dikarenakan mahasiswa masih termasuk dalam periode tengah kehidupan, yang mana mahasiswa masih mencari jati diri dan cenderung untuk mencoba hal-hal baru, baik itu yang positif maupun yang negatif. kesadaran tentang bullying tema kesadaran tentang bullying yang dilakukan oleh mahasiswa meliputi perilaku bullying yang disadari dan tidak. beberapa pelaku menyatakan bahwa mereka sadar melakukan perilaku bullying bahkan mengatakan hal itu sudah menjadi sebuah hal yang biasa untuk dilakukan. sedangkan ada pula pelaku yang menyatakan bahwa tidak pernah melakukan bullying walaupun tindakannya termasuk perilaku bullying. hal ini disebabkan bullying sudah dianggap menjadi hal yang biasa di lingkungan pelaku maupun pelaku itu sendiri. hal ini sesuai dengan pendapat ken rigby (dalam astuti, 2008) yang menyatakan bullying adalah aktifitas yang sadar, disengaja yang dimaksudkan untuk melukai, menanamkan ketakutan melalui ancaman agresi lebih lanjut serta dapat menjadi sebuah kebiasaan berulang-ulang. perilaku buruk yang dilakukan secara sadar dari waktu ke waktu apabila dibiarkan terus akan menjadi sebuah kebiasaan. sama seperti bullying, jika selalu dilakukan maka perilaku ini akan menjadi sebuah kebiasaan dan dianggap lumrah terjadi. padahal pada hakikatnya perilaku tersebut merupakan perilaku yang salah. apabila terus dibiarkan maka akan terlahir generasi yang membenarkan semua kesalahan yang dilakukan perilaku berulang tema perilaku berulang yang dilakukan oleh mahasiswa meliputi realisasi bentuk seperti mengejek, membicarakan orang lain, berkelahi, serta mengancam dengan frekuensi yang tidak kurang dari 2 kali, timer perilaku dilakukan di dalam maupun di luar kampus, dan akar masalah dari perilaku yang dilakukan adalah eksistensi dari pelaku. pelaku ingin menunjukan eksistensinya pada korban. hal ini diperkuat dengan teori priyatna (2010) yang menyatakan bentuk bullying yang secara umum dapat dikelompokkan ke dalam empat kategori: bullying fisik, bullying verbal, bullying sosial dan cyberbullying. teori bandura mengatakan bahwa perilaku manusia sebagian besar merupakan perilaku yang dipelajari. demikian halnya dengan perilaku kekerasan termasuk di dalamnya bullying. teori belajar sosial yang dipelopori oleh bandura menyatakan bahwa perilaku merupakan pengalaman yang dipelajari dari masa lalu, apakah melalui pengamatan langsung (imitasi), pengukuh positif, dan karena stimulus diskriminatif. pengamatan pada orang disekelilingnya yang berperilaku kekerasan atau mungkin mengontrol perilaku kekerasan dan kemudian menirukannya sertaa mengulangi hal tersebut di masa yang akan datang. (rigby & slee dalam boeree, 2006). simbolon (2012) mengatakan bullying dapat terjadi bukan hanya di asrama tetapi juga di lingkungan kampus terutama di tempat-tempat yang bebas dari pengawasan dosen. pelaku bullying bebas melakukan tindakannya ketika orang-orang yang dianggap memiliki kewenangan di kampus sedang tidak mengawasi mereka. tempat-tempat yang paling dianggap kondusif untuk melakukan bullying adalah kamar mandi, kamar kosong, bahkan kamar hunian korban ketika penghuni lainnya tidak ada di tempat. ia juga mengatakan beberapa journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 17 23 21 faktor penyebab terjadinya bullying berupa faktor internal dan eksternal. faktor internal adalah karakteristik kepribadian, kekerasan yang dialami sebagai pengalaman masa lalu, sikap keluarga yang memanjakan anak sehingga tidak membentuk kepribadian yang matang. faktor eksternal yang menyebabkan kekerasan adalah lingkungan, dan budaya. pada mahasiswa pria lebih menekankan keuatan fisik, sedangkan wanita lebih bermain dengan kata-kata atau dengan cyber bullying (melalui media social ). tidak menutup kemungkinan mahasiswa wanita bisa melakukan bullying fisik pada orang lain maupun sebaliknya mahasiswa pria menjadi tukang gosip dan tukang penyebar berita hoax. ada pengaruh tempat dimana pelaku melakukan bullying kepada korbannya. tempat sepi bisa menjadi pilihan utama. pelaku lebih memilih tempat yang tidak terlihat orang banyak. tapi berbeda konteksnya jika pelaku sudah merasa nyaman melakukan bullying. ruangan sepi atau tempat yang jarang terlihat sudah bukan menjadi persoalan. hal ini dapat terjadi pada social bullying, contohnya membicarakan gosip atau berita hoax. hal ini tidak memandang tempat sepi atau ruangan kosong, yang menjadi fokus pelaku adalah teman, karena pelaku butuh objek lain (teman) sebagai penyalur gosip atau berita hoax. latar belakang setiap orang tidaklah sama dalam melakukan sesuatu. perilaku bullying yang dilakukan oleh mahasiswa umumnya akan lebih cenderung mengarah pada balas dendam, ketakutan ataupun ingin menunjukan eksistensi pribadi pada orang lain. perilaku ini tidak dibenarkan karena berdampak negatif pada korban. pelaku bullying mendapatkan kepuasan tapi tidak halnya dengan korban bullying itu sendiri. korban akan merasa tertekan dan hal yang paling dikhawtirkan korban akan meniru perlakuan yang ia terima kepada orang. apabila hal tersebut terjadi, maka kasus ini akan menjadi rantai yang terus bersambung. self impact tema self impact yang dilakukan oleh mahasiswa meliputi hal positif dan negatif yang dirasakan oleh pelaku. hal positif yang diperoleh pelaku bullying adalah apa yang mereka inginkan terwujud, dalam hal ini adalah latar belakang pelaku melakukan bullying. sedangkan dampak negatif yang diperoleh oleh pelaku adalah pelaku kehilangan orang-orang terdekat, stigma sosial menjadi jelek dan harus berurusan di kantor polisi untuk mempertanggung jawabkan perbuatannya. hal ini diperkuat dengan pendapat andrew mellor (2000) yang mengatakan dampak bullyingbagi korban diantara adalah depresi, gelisah, rasa tidak aman saat berada di lingkungan sekolah, penurunan semangat belajar dan prestasi akademis, dalam kasus yang cukup langka anak-anak korban bullyingmungkin akan menunjukkan sifat kekerasan.tak hanya korban bullying, mereka yang melakukan bullying juga terkena dampaknya. orang-orang yang melakukan bullyingcenderung untuk berperilaku kasar/abusif, melakukan kriminalitas, tawuran, terlibat dalam vandalisme, penyalahgunakan obat-obatan dan alkohol, terlibat dalam pergaulan bebas. menurut simbolon (2012) bullyingmengakibatkan korbannya menjadi putusasa, menyendiri, tidak mau bergaul, tidakbersemangat, bahkan berhalusinasi. berbeda halnya dengan pelaku, mereka merasasemakin memiliki wibawa. pelaku jugamendapatkan kepuasan journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 17 23 22 setelah melakukan tindakan tersebut. tapi pada beberapa kasus pelaku mengaku ada akibatlain yang dirasakan setelah melakukanperbuatannya yaitu rasa malu dan minder.ungkapan ini menunjukkan bahwa lingkungan sosial menjadikan pelaku merasaterhukum atas perbuatannya. perilaku bullying memberikan dampak positif berupa wibawa yang meningkat, eksistensi yang muncul, dan dihormati orang lain. namun banyak hal negatif lain yang juga muncul dari hal tersebut, diantaranya pelaku akan mengalami over confidence (percaya diri berlebihan), memiliki harga diri yang tinggi dan terkesan sombong. pelaku juga seakan akan mengalami adiksi terhadap bullying, yaitu merasa kehilangan wibawa dan harga diri apabila tidak melakukan bullying. akibatnya, perilaku bullying akan selalu diulangi oleh pelaku untuk mempertahankan apa yang ia miliki. hal kedua yang akan di peroleh oleh pelaku adalah tercorengnya stigma sosial pelaku, dikarenakan dampak sosial yang menyebabkan pelaku dipandang buruk di mata masyarakat umum atas perbuatan yang ia lakukan. selain itu, pelaku juga akan dijauhi orang-orang sekitar karena merasa jenuh dengan sikap pelaku. kesimpulan dan saran kesimpulan 1. penelitian ini menghasilkan empat tema yaitu defisit pengetahuan, kesadaran tentang bullying, perilaku berulang, dan self impact. 2. tema defisit pengetahuan yang dilakukan oleh mahasiswa adalah perkelahian, balas dendam pada orang lain, membicarakan orang lain baik secara verbal maupun melalui sosial media , serta menjelek-jelekan orang lain di lingkungan kampus. perkelahian yang dimaksudkan menggunakan kekuatan fisik pada orang lain dengan tujuan pribadi, membicarakan orang lain dilakukan pelaku berupa meyebarkan berita tidak benar (hoax) melalui kelompok diskusinya maupun melaui media sosial yang dimiliki. semua hal yang dilakukan dengan maksud pribadi dari pelaku. hal ini masih terjadi di lingkungan kampus. 3. tema kesadaran tentang bullying yang dilakukan oleh mahasiswa meliputi perilaku bullying yang disadari dan tidak. beberapa pelaku menyatakan bahwa mereka sadar melakukan perilaku bullying bahkan mengatakan hal itu sudah menjadi sebuah hal yang biasa untuk dilakukan. sedangkan ada pula pelaku yang menyatakan bahwa tidak pernah melakukan bullying walaupun tindakannya termasuk perilaku bullying. hal ini disebabkan bullying sudah dianggap menjadi hal yang biasa di lingkungan pelaku maupun pelaku itu sendiri. 4. tema perilaku berulang yang dilakukan oleh mahasiswa meliputi realisasi bentuk seperti mengejek, membicarakan orang lain, berkelahi, serta mengancam dengan frekuensi yang tidak kurang dari 2 kali, timer perilaku dilakukan di dalam maupun di luar kampus, dan akar masalah dari perilaku yang dilakukan adalah eksistensi dari pelaku. pelaku ingin menunjukan eksistensinya pada korban. tema self impact yang dilakukan oleh mahasiswa meliputi hal positif dan negatif yang dirasakan oleh pelaku. hal positif yang diperoleh pelaku journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 17 23 23 bullying adalah apa yang mereka inginkan terwujud, dalam hal ini adalah latar belakang pelaku melakukan bullying. sedangkan dampak negatif yang diperoleh oleh pelaku adalah pelaku kehilangan orang-orang terdekat, stigma sosial menjadi jelek dan harus berurusan di kantor polisi untuk mempertanggung jawabkan perbuatannya. daftar pustaka allen k, 2006. bullying and self-esteem: is there a connection?. impact training, inc. fitri, h. 2013. hubungan antara harga diri dan disiplin sekolah dengan perilakubullying pada remaja. jurnal penelitian humaniora, vol.14 no.1 hal 9-16. liow, c. j., & andriani, i. (2009). hubungan tindakan bullying di sekolah dengan self esteem, 3, 3–7. rigby, k. 2008. new perspectives on bullying. london : jessica kingsley saifullah, 2016. hubungan konsep diri dengan bullying pada siswa-siswi smp di smp 16 samarinda. jurnal psikologi unmul,vol. 4 no.2 hal 3-12 setiawati, r. o. 2010. waspadalah harga diri anak rendah karena bullying. psikologi plus. vol. iv no. 7 hal 12-16 januari 2012 spade ja, 2007. the relationship between student bullying behaviors and self esteem. a dissertation. college of bowling green state university yolan, 2012. negara-negara dengan kasus bullying tertinggi, indonesia diurutan ke-2. http://uniqpost.com. diakses 12 november 2016 yusuf, s. 2012. psikologi perkembangan anak dan remaja. bandung : pt.remaja rosdakarya journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.204-209 204 the effect of red betel leaves (piper crocatum) boiled water on the perineal wounds healing in public health center of karangpawitan of garut regency in 2021 triana indrayani*, rani septiani rahmawati, dewi kurniati universitas nasional, jakarta, indonesia corresponding author: trianaindrayani@civitas.unas.ac.id abstract background: based on the annual report of the karangpawitan health center in 2020 there were 231 cases of postpartum women (29.3%) who experienced perineal injuries from 786 mothers who gave birth. in the first trimester of 2021, there were 56 cases of postpartum women (21.2%) who experienced perineal injuries from 263 women who gave birth. meanwhile, cases of perineal wound infection in the first trimester of 2021 were 3 cases. perineal wound care is expected to prevent infection, increase comfort and accelerate healing. purpose: this study aimed to determine the effect of giving boiled red betel leaf water on perineal wound healing at the karangpawitan health center, garut regency. methods: this study was a quasi-experimental pretest posttest with control group design. the population in this study was 44 pregnant women in june 2021 who were divided into two groups, 22 experimental people and 22 controls, the sample technique used total sampling. the instrument used was a wound measurement questionnaire with the reeda scale. data analysis using wilcoxon test. results: the average perineal wound healing in the control group before the intervention was 6.86 and after the intervention was 1.86. while the experimental group before the intervention was 6.95 and after the intervention was 0.64. bivariate results showed a p-value of 0.000 <0.05, meaning that there was an effect of using boiled red betel leaf water on perineal wound healing. conclusion: there was an effect of using boiled red betel leaf water on perineal wound healing. keywords: perineal wound, post partum, red betel. received august 15, 2021; revised august 21, 2021; accepted september 22, 2021 doi: https://doi.org/10.30994/jnp.v5i1.173 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. http://thejnp.org/ mailto:trianaindrayani@civitas.unas.ac.id https://doi.org/10.30994/jnp.v5i1.173 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.204-209 205 background maternal death is caused by several direct causes, one of them is postpartum infection which is caused by perineal wound emerged due to the lack of perineal hygiene. in this case, efforts are needed to prevent the perineal infection by treating the wound. the treatment can be done by squatting or sitting using a bath seat and then washing the perineal wound using antiseptic liquid (satriani & st, 2021). according to the world health organization (who) there were 830 women died every day due to complications suffered during pregnancy or childbirth in 2017. therefore, the global maternal mortality risk needs to be reduced from 216,100,000 live births in 2015 to 70/100,000 live births in 2030 (hanum & liesmayani, 2020). in this case, the sustainable development goals (sdgs) needs a global annual reduction rate of at least 7.5%, which is more than three times the annual rate, achieved between 1990 and 2015. furthermore, the world maternal mortality rate in 2014 was 289,000, of which there were 9,300 people in the united states, 179,000 people in the north africa, and 16,000 in the countries of southeast asia. most maternal deaths can actually be prevented through medical intervention, which is actually well known. therefore, it is very important to increase women's access to quality care before, during, and after pregnancy (ministry of health of the republic of indonesia, 2017). indonesian demographic and population survey (idhs) has been conducted in 2016 and revealed that the maternal mortality rate in indonesia was 412 per 100,000 live births. this rate is directly caused by bleeding by 22%, preeclampsia and eclampsia by 45%, prolonged labor by 26%, and abortion complications by 18% (heriani, 2019). furthermore, in west java province, there were 416 maternal death cases in 2020. this rate is similar to the case that occurred in 2019 which is 417 cases and mostly caused by preeclampsia cases by 29%, bleeding by 28%, infection by 4%, metabolic disorders by 3%, blood disorders by 12%, and others by 24%. garut regency, particularly, is the third most contributor to maternal mortality cases in west java in 2020 with 31 cases after bogor regency and karawang regency (health office of west java, 2020). red betel leaf or piper crocatum extract, in this case, can be utilized since it contains antiseptic and anti-bacterial chemicals. red betel leaf contains twice higher the antiseptic effect than the green betel leaf since the chemical contained by red betel leaf includes essential oils, hydroxykavikol, chavicol, chavibetol, allylpyrocatechol, carvacol, eugenole, p-cymene, cineole, caryophyllene, codimen estragole, terpene, and phenyl propanol (damarini, eliana, & mariati, 2013). methods this research was conducted through quasy-experimental research using pretest posttest with control group design. furthermore, the research population involved is 44 postpartum mothers who have perineal wounds and give birth in public health center of karangpawitan of garut regency in july-august 2021. in this case, the sampling was carried out through total sampling. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.204-209 206 result univariate analysis table 1.1. mean of perineal wounds healing before and after intervention in public health center of karangpawitan of garut regency in 2021 experimental group mean differe nce control group mean difference n min max mean n min max mean pre-test 22 5 9 6.95 6.31 22 5 9 6.86 5 post-test 22 0 2 0.64 22 0 5 1.86 based on table 1.1 above, before the intervention in the forms of red betel leaves boiled water was given to the 22 respondents in the experimental group, the lowest score is 5, the highest score is 9, and the average score is 6.95. meanwhile, after the intervention was carried out, the lowest score is 0, the highest score is 2, and the average score is 0.64 with an average difference of 6.31. furthermore, in the case of the control group before intervention was carried out, the lowest score is 5, the highest score is 9, and the average score is 6.86. meanwhile, after the intervention was carried out in the control group, the lowest score is 70, the highest score is 5, and the average score is 1.86 with an average difference of 5. bivariate analysis table 1.2. normality test results results experimental group control group n p-value n p-value pre-test 22 0.003 22 0.002 post-test 22 0.000 22 0.000 table 1.2 above shows that the significance level of all data is < 0.05, indicating that the research data were not distributed normally. thus, the data analysis technique used was non-parametric test, which is wilcoxon signed ranks test and mann-whitney test with the following analysis results: table 1.3. difference on the provision of red betel leaves boiled water on perineal wound healing between experimental and control groups groups post-test p-value n mean std. dev experimental 0.64 0.902 0.005 22 control 1.86 1.612 based on table 1.3, the p-value obtained is 0.005 <0.05, indicating that there is a difference in the mean results of the perineal wound examination between those who obtained the intervention in the form of giving red betel leaves boiled water and those who did not obtain the intervention. therefore, it can be concluded that the red betel leaves boiled water affected the perineal wound healing at the public health center of karangpawitan, garut regency in 2021. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.204-209 207 discussion based on the results of the current research, it was revealed that in the case of the experimental groups, which contained 22 respondents before obtaining intervention in the form of red betel leaves boiled water, the lowest score is 5, the highest score is 9, and the average score is 6.95. meanwhile, after the group obtained intervention, the lowest score is 0, the highest score is 2, and the average score is 0.64 with an average difference of 6.31. furthermore, in the case of the control group before obtaining the intervention, the lowest score is 5, the highest score is 9 and the average score is 6.86. meanwhile, after the control group obtained intervention, the lowest score is 70, the highest score is 5, and the average score is 1.86 with an average difference of 5. the perineal wound is a condition where the continuity of body tissue is damaged, causing disruption on body functions and trauma which causes skin wounds, thus disturbing the daily activities (puspita fitriana, 2019). wounds are divided into two types, those are intentional wounds and unintentional wounds. intentional wounds are injuries exposed to radiation or surgery, while unintentional injuries are divided into closed wounds and open wounds (morison, 2004). in the field of midwifery, the wounds that often occur are episiotomy wounds, surgical wounds due to cesarean section, or wounds during the delivery process (rofiah, 2020). statistical test was also conducted in the current research in the forms of the wilcoxon signed ranks test, in which a p-value of 0.000 < 0.05 was obtained. this indicates that the provision of red betel leaves boiled water on perineal wound healing at the public health center of karangpawitan, garut regency in 2021. furthermore, in the case of the control group, the p-value obtained is 0.000 <0.05. therefore, it can also be concluded that there is a difference in the mean results of the respondent's perineal wound examination for both pre-test and post-test of the control group. in this case, midwives need to master wound treatment. the main principle in wound care management is infection control because infection inhibits the wound healing process, increasing the morbidity and mortality risk. postoperative wound infection is one of the main problems in surgical practice (puspitasari & sumarsih, 2011). based on the results discovered in the current research, these results are in line with the theory proposed that perineal wounds healing care can be done through both pharmacological and non-pharmacological methods (susilawati & ilda, 2019). in pharmacological method, it can be carried out by giving antiseptic drugs. however, antiseptic or antibiotic treatment for perineal wound care currently tends to be avoided. the reason is that some antibiotics should be avoided during lactation because the amount is very significant and risky (rostika, choirunissa, & rifiana, 2020). therefore, in this case, midwives advise postpartum mothers to use betel leaves as a medicine to accelerate the healing of perineal wounds (elisabet, 2017). betel leaf contains chavicol, which has the function of killing germs, as antioxidants, as fungicides, and as antifungals. moreover, the chavicol contained in betel leaves contains antiseptic which can accelerate the healing of perineal wounds (pratiwi kusuma, 2020). in addition, red betel leaves (piper crocatum) have a distinctive smell due to its content of 1-4.2% essential oil, water, protein, fat, carbohydrates, calcium, phosphorus, vitamins a, b, c, iodine, sugar, and starch. among these contents, there are natural phenols contained in essential oils whose antiseptic content is 5 times stronger than ordinary phenols (bactericidal and fungicidal). essential oils are volatile oils and contain a distinctive smell or fragrance. the essential oil of betel leaf contains 30% phenol and some of its derivatives. essential oils consist of hydroxyl chavicol, chavibetol, estragole, eugenol, methyl eugenol, carbachol, terpene, sesquiterpene, phenylpropane, and tannins. in this case, chavicol is the most abundant component in the http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.204-209 208 essential oil which has a distinctive smell of betel. according to manoi (2017) chavicol is easily oxidized and can cause color changes (ernawati, 2018). furthermore, the alkaloid compounds in red betel leaves have a function as antibacterial through the mechanism of peptidoglycan components in bacterial cells. therefore, it can cause the bacterial cell wall layer is not entirely formed and cause bacterial cell death. furthermore, tannin compounds are beneficial as an antibacterial with a tannin mechanism that can damage bacterial cell membranes. tannin astringent compounds can induce the formation of complex compounds binding to enzymes or microbial substrates. meanwhile, saponin compounds can trigger the formation of collagen by forming new tissue, namely structural proteins that take a role in the wound healing process. since saponin compounds are beneficial as an antiseptic, it is very effective for healing open wounds. therefore, it can be proven that red betel leaf can be used as an antibacterial to heal wound in rats infected with staphylococcus aureus. the results obtained in this research is in line with previous research conducted by mulyati (2017), showing that almost all postpartum mothers who did not use betel leaf extract experienced slow healing by 90% on their perineal sutures. meanwhile, those who used betel leaf extract were mostly experienced fast healing by 85% with a p value (0.000) < (0.05) based on the results of research in the field, researchers concluded that respondents who obtained red betel leaves boiled water had faster perineal wounds faster healing than those who did not obtain the red betel leaves boiled water. this is due to the chemical content of red betel leaf which can accelerate the wound healing process. conclusion the mean of perineal wounds healing on experimental group before obtained intervention is 6.95, while after the intervention is 0.64. meanwhile, on the control group, the value is 6.86 before obtaining the intervention, while after the intervention is 1.86. there is an effect of the use of red betel leaves boiled water on the perineal wound healing in public health center of karangpawitan of garut regency in 2020. acknowledgement the authors would like to thank the chancellor, the head of the institute for research and community service (lppm) at the national university, the head of the upt puskesmas karangpawitan, karangpawitan district, garut regency who has provided the opportunity to conduct research in his working area. references damarini, s., eliana, e., & mariati, m. (2013). efektivitas sirih merah dalam perawatan luka perineum di bidan praktik mandiri. kesmas: jurnal kesehatan masyarakat nasional (national public health journal), 8(1), 39-44. ernawati, o. (2018). pengaruh air rebusan daun sirih merah (piper crocatum) terhadap penurunan gejala fluor albus pada wanita usia subur (di desa kedunglosari kecamatan tembelang kabupaten jombang). stikes insan cendekia medika jombang. hanum, r., & liesmayani, e. e. (2020). efektivitas air rebusan daun binahong dengan kesembuhan luka perineum pada ibu nifas di klinik sri diana lubis tahun 2019. jurnal kesehatan almuslim, 6(11), 12-21. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.204-209 209 heriani, j. (2019). penerapan terapi rendam kaki air hangat pada ibu nifas dengan riwayat reeklamsi berat di ruangangan kebidanan rsam bukittimnggi tahun 2018. universitas perintis indonesia. morison, m. j. (2004). manajemen luka. pratiwi kusuma, s. d. (2020). perawatan luka perineum dengan menggunakan air rebusan daun binahong pada ibu postpartum. poltekkes tanjungkarang. puspita fitriana, r. (2019). efektivitas daun sirih dan madu terhadap lamanya penyembuhan luka perineum pada ibu nifas di bpm eka santi prabekti dan sulistiyo rahayu lampung tengah. poltekkes tanjungkarang. puspitasari, h. a., & sumarsih, t. (2011). faktor-faktor yang mempengaruhi penyembuhan luka post operasi sectio caesarea (sc). jurnal ilmiah kesehatan keperawatan, 7(1). rofiah, n. (2020). hubungan ambulasi dini (early ambulation) dengan kesepatan kesembuhan luka perineum pada ibu nifas di puskesmas kedungadem kabupaten bojonegoro. stikes insan cendekia medika jombang. rostika, t., choirunissa, r., & rifiana, a. j. (2020). pemberian penggunaan air rebusan daun sirih merah terhadap waktu penyembuhan luka perineum derajat i dan ii di klinik aster kabupaten karawang. jurnal ilmiah kesehatan, 12(2), 196-204. satriani, g., & st, s. (2021). asuhan kebidanan pasca persalinan dan menyusui: ahlimedia book. susilawati, e., & ilda, w. r. (2019). efektifitas kompres hangat dan kompres dingin terhadap intensitas nyeri luka perineum pada ibu post partum di bpm siti julaeha pekanbaru. jomis (journal of midwifery science), 3(1), 7-14. http://thejnp.org/ journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 33 39 33 pemberian motivasi orang tua dalam menggosok gigi pada anak usia prasekolah terhadap timbulnya karies gigi 1 avi dian sari, 2 intan fazrin, 3 heri saputro stikes surya mitra husada kediri fazrin_smile@yahoo.co.id abstract dental caries is a disease found in dental hard tissues, namely email, dentin, cementum which experienced chronic regressive process. the cause of dental caries are lazy or wrong in brushing teeth. the purpose of this study was to determine the relationship of giving motivation by parents in brushing tooth in preschool children on the rise of dental caries in dharma wanita i kindergarten singonegaran kediri. the study design was cross sectional. the study population were all parents of preschool students as much as 85 respondents. the sample size of 70 respondents taken with stratified random sampling technique. the independent variable is giving motivation by parents, while the dependent variable was the rise of dental caries. results of analysis using the spearman rho. the results were obtained mostly parents motivation lacking as many as 42 respondents (60%), and observations obtained 64 children (91%) experienced caries. results spearman rho value 0,000 known ρ < 0,05 then h0 is rejected, which means there is a significant correlation of giving motivation by parents with the rise of dental caries. keywords: motivation by parents, dental caries, preeschool children received august 15, 2017; revised september 07, 2017; accepted october 01, 2017 how to cite: sari, a.d., fazrin, i & saputro, h. (2017). pemberian motivasi orang tua dalam menggosok gigi pada anak usia prasekolah terhadap timbulnya karies gigi. journal of nursing practice. 1(1). 33-39. the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-noncommercialsharealike 4.0 international license. journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 33 39 34 pendahuluan kesehatan gigi dan mulut bagi usia prasekolah merupakan hal yang perlu mendapat perhatian serius bagi orang tua, tenaga kesehatan baik dokter maupun perawat, sebab karies gigi masih merupakan masalah utama kesehatan mulut di berbagai negara. perawatan gigi yang kurang baik atau tidak adekuat menyebabkan masalah yang paling umum dari seluruh masalah kesehatan gigi pada masa kanak-kanak. penyakit gigi masih sering diabaikan oleh banyak orang tua, mereka menganggap kerusakan gigi merupakan hal yang biasa terjadi pada anak. rendahnya motivasi orang tua menyebabkan kegiatan menggosok gigi pada anak menjadi kurang maksimal. kurangnya motivasi yang diberikan membuat anak tidak memperhatikan ketika orang tua memberikan perintah untuk gosok gigi 5 . karies gigi merupakan penyakit yang terdapat pada jaringan keras gigi yaitu email, dentin dan sementum yang mengalami proses kronis regresif. karies gigi terjadi karena adanya proses interaksi antara bakteri pada permukaan gigi. komponen karbohidrat yang dapat difermentasikan oleh bakteri plak menjadi asam,terutama asam laktat dan asam asetat, kondisi asam seperti ini sangat disukai oleh bakteri kariogenik yang berada di rongga mulut dikenal dengan nama streptococcus mutans (sm). proses ini ditandai dengan adanya demineralisasi jaringan keras gigi dan rusaknya bahan organik akibat terganggunya keseimbangan email dan sekelilingnya, menyebabkan terjadinya invasi bakteri yang dapat berkembang ke jaringan periapeks sehingga dapat membentuk mineral disebut dengan karang gigi yang meningkatkan resiko karies gigi dan menimbulkan rasa sakit dan nyeri (sugeng, 2008). karies gigi dapat disebabkan oleh beberapa faktor pencetus. faktor yang menyebabkan terjadinya karies gigi yaitu hospes (saliva dan gigi), mikroorganisme, substrat, sebagai faktor tambahan yaitu waktu 5 . berdasarkan hasil studi pendahuluan yang dilakukan peneliti tentang pemberian motivasi orang tua dalam menggosok gigi pada anak usia prasekolah dengan timbulnya karies gigi di tk dharma wanita singonegaran i pada 28 oktober 2015 didapatkan 37 anak mengalami karies gigi. dari hasil wawancara yang dilakukan terhadap 12 orang tua didapatkan bahwa beberapa anak mengalami permasalahan pada giginya. tujuh orang tua diantaranya mengatakan anak mereka masih jarang-jarang untuk menggosok gigi. bahkan jika tidak diingatkan dan disuruh anak cenderung malas dan tidak menggosok gigi. dan lima orang tua yang lain mengemukakan bahwa anaknya mengalami karies gigi, tetapi mereka menganggap bahwa karies gigi bukan merupakan masalah serius bagi kesehatan mulut anak dan akan sembuh dengan sendirinya. akibat karies gigi yang berkepanjangan pada anak akan menyebabkan banyak masalah kesehatan, tentunya masalah infeksi pada gigi. jika tidak ditangani, penyakit ini akan meyebabkan nyeri, gangguan tidur, penanggalan gigi, infeksi, berbagai kasus berbahaya dan bahkan kematian. penyebab penyakit tersebut karena malas atau salah dalam menyikat gigi, kurangnya perhatian dalam kesehatan gigi dan mulut, bahkan tidak ada dukungan orang tua untuk menyikat gigi (listono, 2012). orang tua sebagai orang terdekat dan memiliki tanggung jawab yang besar bagi anak merupakan pendukung utama dalam pelaksanaan kesehatan gigi dan mulut. bukan hanya memfasilitasi dengan menyediakan sikat gigi dan pasta gigi saja, tetapi orang tua juga memiliki peranan dalam memberi dukungan agar anak termotivasi untuk menggunakan dan melaksanakannya 11 . motivasi adalah kecenderungan yang timbul pada diri seseorang secara sadar maupun tidak sadar melakukan tindakan dengan tujuan tertentu atau usaha-usaha yang menyebabkan seseorang atau kelompok orang tergerak melakukan sesuatu karena ingin mencapai tujuan yang dikehendaki 9 . journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 33 39 35 berbagai faktor penyebab karies, pelaksanaan orang tua dapat dilakukan yaitu dengan memberikan motivasi kepada anak agar anak mau untuk menggosok gigi.menggosok gigi adalah cara yang dikenal umum oleh masyarakat untuk menjaga kebersihan gigi dan mulut dengan maksud agar terhindar dari penyakit gigi dan mulut 1 . untuk itu peran orang tua sangatlah penting dalam memotivasi anak menggosok gigi dengan menciptakan suasana gosok gigi yang menyenangkan agar anak menggosok gigi dengan senang hati, membuat kegiatan gosok gigi dengan permainan supaya dapat merangsang keinginan anak untuk gosok gigi, ataupun memberikan pujian maupun hadiah bagi anak apabila dia telah berhasil untuk rajin gosok gigi 10 . metode penelitian dalam penelitian ini menggunakan desain kuantitatif penelitian korelasional dengan menggunakan metode cross sectional. populasi penelitian ini adalah semua orang tua siswa prasekolah di tk dharma wanita singonegaran i kota kediri yang berjumlah 85 responden. teknik pengambilan sampel dalam penelitian ini adalah stratified random sampling. jumlah sampel yang didapatkan sebesar 70 responden. instrumen penelitian ini menggunakan kuesioner untuk mengetahui pemberian motivasi orang tua yang diberikan, dan observasi untuk mengetahui status gigi pada anak usia prasekolah. proses selanjutnya yaitu analisa data yang diuji perangkat lunak spss dengan uji statistik spearman rho α = 0,05 untuk mengetahui apakah ada hubungan pemberian motivasi orang tua dalam menggosok gigi pada anak usia prasekolah terhadap timbulnya karies gigi di tk dharma wanita singonegaran i kota kediri. hasil dan pembahasan a. hasil penelitian a. data umum dalam pembahasan hasil penelitian ini, peneliti akan menjabarkan data-data yang diperoleh dari responden melalui penyebaran kuesioner. data umum merupakan data responden yang mengacu kepada identitas atau karakteristik responden. dalam hal ini peneliti mengumpulkan data berupa status dalam keluarga, umur orang tua, pendidikan, status pekerjaan , usia anak, jenis kelamin anak, kelas, status gigi. b. data khusus data khusus akan menyajikan karakteristik pemberian motivasi orang tua dalam menggosok gigi dengan timbulnya karies gigi pada anak usia prasekolah. tabel 1 distribusi frekuensi responden berdasarkan motivasi orang tua di tk dharma wanita singonegaran i kota kediri kategori jumlah presentase (%) baik cukup kurang 7 21 42 10 30 60 jumlah 70 100 berdasarkan tabel 1 dapat diketahui bahwa sebagian besar responden memiliki motivasi kurang terhadap timbulnya karies gigi pada anak yaitu ebanyak 60% (42 responden). tabel 2 distribusi frekuensi responden berdasarkan timbulnya karies gigi pada anak di tk dharma wanita singonegaran i kota kediri status gigi jumlah presentase(%) journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 33 39 36 karies tidak karies 64 6 91% 9% jumlah 70 100 berdasarkan tabel 2 dapat diketahui bahwa sebagian besar anak yang mengalami karies gigi adalah tinggi yaitu sebanyak 91% (64 responden). tabel 3 hasil uji statistik korelasi pearman rho antara motivasi orang tua dengan timbulnya karies gigi anak usia prasekolah di tk dharma wanita singonegaran i kota kediri. correlations motivasi _orang_ tua karies _gigi spearm an's rho motivasi _orang_ tua correlation coefficient 1,000 ,753 ** sig. (2tailed) . ,000 n 70 70 karies_ gigi correlation coefficient ,753 ** 1,000 sig. (2tailed) ,000 . n 70 70 **. correlation is significant at the 0.01 level (2tailed). berdasarkan tabel 3 dapat diketahui hasil uji statistik yang dilakukan dengan menggunakan uji spearman rho kepada 70 responden pada tanggal 29 april 2016 di tk dharma wanita singonegaran i kota kediri didapatkan ρ value = 0,000 dengan koefisien korelasi sebesar 0,753 dan α = 0,05 karena nilai ρ value 0,000 < 0,05 maka h0 ditolak yang berarti adal hubungan yang signifikan pemberian motivasi orang tua dengan timbulnya karie gigi pada anak usia prasekolah di tk dharma wanita singonegaran i kota kediri. pembahasan pemberian motivasi orang tua dalam menggosok gigi pada anak usia prasekolah di tk dharma wanita singonegaran i kota kediri berdasarkan hasil penelitian yang telah dilakukan pada tanggal 29 april 2016 di taman kanak-kanak dharma wanita singonegaran i kota kediri didapatkan orang tua yang memberikan motivasi baik sebanyak 7 responden (10%), sedangkan motivasi cukup 21 responden (30%), dan motivasi kurang 42 responden (60%). hal ini menunjukkan bahwa kurangnya pemberian motivasi orang tua dalam menggosok gigi terhadap timbulnya karies gigi pada anak usia prasekolah. hal tersebut dikarenakan motivasi orang tua merupakan faktor yang penting bagi anak dalam melakukan kegiatan baik di rumah maupun di luar rumah. orang tua sebagai tokoh sentral dalam tahap perkembangan seorang anak, maka diwajibkan selalu membimbing dan mendukung kegiatan anak di dalam maupun luar sekolah, sehingga orang tua perlu menguasai berbagai pengetahuan ketrampilannya 12 . orang tua memiliki tanggung jawab yang sangat besar dalam menjaga kesehatan anggota keluarganya. orang tua harus selalu memperhatikan perkembangan anak baik makanan dan kebersihan serta kesehatan anak. orang tua memberikan pengaruh yang sangat besar tehadap perilaku anak, sebab orang tua merupakan figur pertama yang menjadi contoh bagi anak-anaknya. orang tua berkewajiban memberikan bimbingan, perhatian, pengawasan dan mengajarkan hal-hal positif serta kasih journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 33 39 37 sayang bagi anak-anaknya. hal yang dapat dilakukan antara lain membantu anak dalam kegiatan menggosok gigi terutama pada anak di bawah usia 10 tahun, karena anak belum memiliki kemampuan motorik yang baik untuk menggosok gigi terutama jika dilakukan mandiri 6 . menurut uno (2008) setiap individu memiliki kondisi internal, dimana kondisi tersebut ikut berperan dalam aktivitas dirinya sehari-hari. salah satu kondisi internal tersebut adalah “motivasi”. motivasi adalah dorongan dasar yang menggerakkan seseorang untuk bertingkah laku. dorongan tersebut berada pada diri seseorang yang menggerakkan untuk melakukan sesuatu yang sesuai dengan dorongan dalam dirinya. waktu menggosok gigi yang tepat adalah pagi setelah sarapan dan malam sebelum tidur. waktu tidur produksi air liur berkurang sehingga menimbulkan suasana asam di mulut. sisa-sisa makanan pada gigi jika tidak dibersihkan, maka mulut semakin asam dan kuman pun akan tumbuh subur membuat lubang pada gigi. sifat asam ini bisa dicegah dengan menggosok gigi. menggosok gigi adalah cara yang dikenal umum oleh masyarakat untuk menjaga kebersihan gigi dan mulut dengan maksud agar terhindar dari penyakit gigi dan mulut 4 . timbulnya karies gigi pada anak usia prasekolah di tk dharma wanita singonegaran i kota kediri dari hasil observasi menggunakan lembar odontogram yang dilakukan oleh dokter gigi pada tanggal 29 april 2016 di tk dharma wanita singonegaran i kota kediri menunjukkan bahwa mayoritas anak memiliki status gigi karies, dengan jumlah anak dengan gigi karies sebesar 64 anak (91%) dan 6 anak (9%) bebas karies. sumber kuman paling besar adalah di dalam mulut. anak usia prasekolah sangat rentan terkena karies, hal-hal yang dapat menyebabkan karies diantaranya susunan gigi, umur, jenis kelamin, orang tua, makanan 8 . gigi susu lebih mudah terserang karies daripada gigi tetap, hal ini dikarenakan gigi susu lebih banyak mengandung bahan organik dan air daripada mineral, dan secara kristalografis mineral dari gigi tetap lebih padat bila dibandingkan dengan gigi susu. alasan mengapa susunan kristal dan mineralisasi gigi susu kurang adalah pembentukan maupun mineralisasi gigi susu terjadi dalam kurun waktu 1 tahun, sedangkan pembentukan dan mineralisasi gigi tetap 7-8 tahun 2 . dari faktor penyebab karies, terdapat 64 anak yang mengalami karies disebabkan motivasi orang tua yang kurang karena pendidikan orang tua yang rendah dan usia orang tua menyebabkan keterhambatan dalam menangkap informasi secara cepat serta penurunan iq orang tua. pekerjaan wiraswasta yang menyita waktu menyebabkan kehadiran orang tua di rumah menjadi berkurang. sedangkan untuk 6 anak yang berstatus tidak karies memiliki orang tua dengan pendidikan sma dan perguruan tinggi. semakin tinggi tingkat pendidikan orang tua, maka semakin mudah untuk menangkap informasi yang diterima. status pekerjaan sebagai pns akan membuat orang tua lebih peka dan intensif untuk mencari tahu tentang bagaimana caranya menggosok gigi agar anak tidak mengalami karies. untuk status orang tua yang tidak bekerja akan memiliki waktu yang lebih banyak di rumah untuk menjalani kegiatan sehari-hari bersama dengan anak, sehingga pengawasan dalam menggosok gigi lebih optimal. namun dalam tabel 4.7 didapatkan untuk status orang tua yang tidak bekerja terdapat 12 orang tua yang memiliki motivasi kurang, hal ini disebabkan karena sebagian besar orang tua memiliki pendidikan dasar. orang dengan pendidikan yang rendah cenderung memiliki pengetahuan yang kurang, sehingga mereka kurang peka terhadap informasi-informasi yang diterima dan menganggap kurang penting akan hal menggosok gigi. journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 33 39 38 pemberian motivasi orang tua dalam menggosok gigi pada anak usia prasekolah terhadap timbulnya karies gigi di tk dharma wanita singonegaran i kota kediri hasil uji statistik yang dilakukan dengan menggunakan uji spearman rho kepada 70 responden pada tanggal 29 april 2016 di tk dharma wanita singonegaran i kota kediri didapatkan ρ value = 0,000 dengan koefisien korelasi 0,753 dan α = 0,05, karena nilai ρ value = 0,000 < 0,05 maka h0ditolak yang berarti ada hubungan yang signifikan antara pemberian motivasi orang tua dalam menggosok gigi terhadap timbulnya karie gigi di tk dharma wanita singonegaran i kota kediri. cukup kuat hubungan berdasarkan nilai koefisien korelasi yang didapatkan hubungan terbentuk dari kedua variabel dikategorikan kuat yang berarti pemberian motivasi orang tua dalam menggosok gigi pada anak usia prasekolah terhadap timbulnya karies gigi saling berkaitan dan penting. anak akan dapat menyadari apa gunanya menggosok gigi itu, jika diberi perangsang atau motivasi. maka motivasi orang tua merupakan faktor yang memegang peran penting terhadap keberlangsungan kesehatan gigi anak 3 . menurut peneliti pentingnya keluarga dalam mendukung kegiatan anak dalam menggosok gigi, mengingat hal ini maka tanpa adanya motivasi orang tua yang kuat seorang anak akan malas untuk menggosok gigi. dari uraian di atas dapat disimpulkan bahwa pemberian motivasi orang tua yang kurang khususnya pemberian bimbingan, penyediaan fasilitas, pemberian hukuman, pengawasan, dan pemberian hadiah yang dapat mempengaruhi kegiatan gosok gigi dan kejadian karies gigi yang tinggi. kesimpulan dan saran a. kesimpulan ada hubungan atara pemberian motivasi orang tua dalam menggosok gigi pada anak usia prasekolah terhadap timbulnya karies gigi di tk dharma wanita singonegaran i kota kediri. b. saran diharapkan dapat dijadikan gambaran bagi tk dharma wanita singonegaran i kota kediri untuk lebih dapat meningkatkan kerja sama melibatkan orang tua untuk meningkatkan motivasi yang baik, membuat jadwal kegiatan menggosok gigi dan screening 6 bulan sekali di taman kanak-kanak untuk meminimalkan timbulnya karies gigi. daftar pustaka alpers, ann. 2006. buku ajar pediatri rudolph, edisi 20 volume 2. jakarta: egc. arep, ishak, dkk. 2003. manajemen motivasi. jakarta: pt. gramedia widiasarana indonesia. budiman, c, m. 2009. manfaat berbagai jenis pasta gigi, available from: http://wwwfajar.co.id/news.php?n ewsid=12984 edwina, sally joyston. 2013. dasar-dasar karies penyakit dan penanggulangan. egc: jakarta. http://wwwfajar.co.id/news.php journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 33 39 39 halimsyah, dkk. 2008. perkembangan motorik halus prasekolah https://docs.google.com diakses 10 mei 2016. hamzah b, uno. 2008. model pembelajaran. jakarta : bumi aksara. listiono, b. 2012. kesehatan gigi dan mulut. diakses pada tanggal 24 januari2016pukul15.10.http://ww w.litbang.tangerangkota.go.id/ind ex.php/detail_kesehatan_gigi_m ulut poerwadarminta. w. j. s. 2006. kamus umum bahasa indonesia. jakarta: pn balai pustaka. riyanti, eriska. 2005. pengenalan dan perawatan kesehatan gigi anak sejak dini. disajikan dalam seminar sehari kesehatan.psikologi anak. minggu 29 mei 2005 di gedung lab klinik utama pramita. santoso, soegeng. 2009. materi pokok kesehatan dan gizi. universitas terbuka: jakarta. wahyu, dkk. 2013. “hubungan dukungan keluarga terhadap perilaku menjaga kesehatan gigi anak usia prasekolah di taman kanak-kanak ar-ridlo kecamatan blimbing kota malang. diakses pada 10 mei 2016. http://old.fk.ub.ac.id journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.176-181 176 the effect of exercises pursed lips breathing (plb) changes to scale of breathlessness and oxygen saturation in copd patients at hospital dr. soedarso pontianak christianus eko purwanto widoroni*, florensius andri, eben haezar kristian nursing academy of dharma insan, pontianak, indonesia corresponding author: christianus.eko@gmail.com abstract background: chronic obstructive pulmonary disease (copd) is a narrowing of the air flow caused by inflammation in the airways resulting in the shortness of breath and reduced oxygen levels in the blood thereby affecting patients’ quality of life. purpose: the purpose of this study was to determine the effect of exercise on the plb to scale of breathlessness and oxygen saturation (sao2) in copd patients. methods: the research method utilized quasi experimental design with randomized pretestposttest control group. sample of 68 respondents (60 respondents plb group, and 8 respondents control group) was recruited through total sampling technique. result: independent t-test showed difference of decreasing scale of breathlessness (p=0.018) & increasing of sao2 (p=0.023) between plb & control group. the results of multiple linear regression test showed an effect of plb on a scale of breathlessness (p=0.030) and sao2 (p=0.002). conclusion: it can be concluded that the plb exercises influenced changes in the value scale of breathlessness and sao2. keywords: copd, oxygen saturation, pursed lip breathing exercises, scale of breathlessness. received august 15, 2021; revised august 20, 2021; accepted september 19, 2021 doi: https://doi.org/10.30994/jnp.v5i1.169 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. http://thejnp.org/ mailto:christianus.eko@gmail.com https://doi.org/10.30994/jnp.v5i1.169 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.176-181 177 background chronic obstructive pulmonary disease (copd) is a progressive and irreversible respiratory tract disorder in the form of obstruction or narrowing of the respiratory tract caused by inflammation or inflammation resulting from the inhalation of harmful gases or particles such as cigarette smoke which will eventually cause shortness of breath. copd can cause several other diseases associated with airway obstruction such as chronic bronchitis and emphysema. patients with copd have symptoms including dyspnea, chronic cough, and chronic sputum production (lewis, dirksen, heitkemper, bucher, & camera, 2011). copd and related respiratory diseases are estimated to affect 24 million adults and are the third leading cause of death in the united states. copd affects more than 5% of the adult population in the united states. it is estimated that 27 million adults have copd, 14 million have been diagnosed with copd and more than 12 million adults have not been diagnosed with copd (hinkle & cheever, 2014). the incidence of copd in indonesia in 2013 was 4.2% in men and 3.3% in women. west kalimantan province has a copd incidence rate of 3.5% and maluku province has a copd incidence rate of around 4.3% (riskesdas, 2013) copd will have a major impact on clients starting from dyspnea which has become a common symptom in clients with copd. usually dyspnea is progressive, draining, and can occur every day. gradually, dyspnea can interfere with daily activities, for example, patients cannot walk as fast as their partners or friends, this will affect behavior changes. in addition, dyspnea can also occur at rest. patients with severe copd may also experience chronic anemia, anxiety, depression, and an increased incidence of cardiovascular disease (lewis, et al, 2011). research conducted by (monteagudo, et al., 2013) states that copd with symptoms of shortness of breath are chronic, progressive, irreversible and have an impact on limited activity which will ultimately affect the quality of health. this is supported by the results of a study conducted by (raherison, leblond, prudhomme, & taille, 2014) on 430 copd patients, showing that copd affects a decrease in quality of life in 50.6% of respondents with a p value < 0.02. compliance with oxygenation is a serious concern for copd patients, especially those with dyspnea or severe shortness of breath. oxygenation is a basic human need that plays an important role in the continuity of the body's cell metabolism processes, maintaining life and the activities of various organs. the presence of oxygen is one of the gas components and a vital element in the metabolic processes and functions of all body cells (andarmoyo, 2012). one of the pulmonary rehabilitation measures in copd clients is breathing exercises. all clients with copd benefit from a breathing exercise program, namely the client shows improvement in the form of tolerance exercises and decreases dyspnea and fatigue. exercise does not improve lung function more effectively, but rather has an impact on strengthening the respiratory muscles. breathing exercises include diaphragmatic breathing and pursed-lips breathing (black & hawks, 2009). the benefits of this rehabilitation include increased exercise capacity, reduced perceived intensity of shortness of breath, improved health-related quality of life, reduced number of hospitalizations and days in hospital, and reduced anxiety and depression associated with copd. this pulmonary rehabilitation can be performed in copd patients with grades ii to iv within an effective time span of 6 weeks (hinkle & cheever, 2014). breathing techniques, such as pursed-lips breathing, can help control dyspnea. this exercise has the effect of reducing the amount of residual air in the lungs, the client also http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.176-181 178 gains confidence in controlling and managing dyspnea. this breathing exercise technique should be taught when the patient is free from dyspnea (ignatavicius & workman, 2010). based on the above background, by looking at the tendency of copd patients to experience shortness of breath which results in a decrease in oxygen saturation values, the authors are interested in conducting a study entitled: " the effect of exercises pursed lips breathing (plb) changes to scale of breathlessness and oxygen saturation in copd patients at hospital dr. soedarso pontianak”. methods this study is a quasi-experimental design study with a randomized pretest-posttest control group design. the population in this study were 68 respondents. this research was conducted in hospital dr. soedarso pontianak in april 2020. in this study, the sampling technique used was exhaustive sampling or total sampling. the inclusion criteria of respondents in this study were patients suffering from copd based on the mrcs dyspnea scale assessment on a scale of 2 to 4, oxygen saturation <95%. the instrument in this study is a calibrated oximetry used to measure oxygen saturation and the medical research council dyspnea scale is one of the scales to assess the degree of shortness of breath during activities. this dyspnea scale consists of a range of 0 (zero) to 4 (four) based on activity level, where a scale of 0 (zero) is no shortness of breath except with strenuous activity, a scale of 1 (one) is that shortness of breath begins when walking fast or climbing stairs. level, a scale of 2 (two) is walking slower because of feeling short of breath, a scale of 3 (three) is shortness of breath when walking 100 m or after a few minutes, a scale of 4 (four) is shortness of breath when bathing or dressing (gold, 2015). in this study, data analysis was carried out using the spss 22 statistical application. the analysis used included independent t-test analysis. this analysis was used to see the comparison value between the intervention group and the control group. and multivariate analysis of multiple linear regression this analysis is used to see the effect of the independent variable on the dependent variable. results univariate analysis table 1. distribution of respondents by age in hospital dr. soedarso pontianak age max min mean total plb 86 25 59 68 control 66 24 51 source: 2016 primary data table 2. distribution of respondents by gender in hospital dr. soedarso pontianak gender plb control total n % n % n % man 42 70 4 50 46 67,6 women 18 30 4 50 22 32,4 total 60 100 8 100 68 100 source: 2016 primary data http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.176-181 179 table 3. distribution of respondents based on history of exposure to pollutants at hospital dr. soedarso pontianak history of exposure to pollutants plb control total n % n % n % frequent exposure to pollutants 41 68,3 5 62,5 46 67,6 not exposed to pollutants 19 31,7 3 37,5 22 32,4 total 60 100 8 100 68 100 source: 2016 primary data table 4. average scores before and after intervention for the respondent's shortness of breath scale by group at hospital dr. soedarso pontianak group n mean difference pre post plb 60 3,13 1,60 1,53 control 8 3.38 2,13 1,25 source: 2016 primary data table 5. average scores before and after intervention for oxygen saturation of respondents by group at hospital dr. soedarso pontianak group n mean difference pre post plb 60 87,68 95,50 7,82 control 8 88,75 93,63 4,88 source: 2016 primary data independent test table 6. differences in the scale of breathlessness and oxygen saturation between the intervention group pursed lip breathing and the control group at hospital dr. soedarso variabel plb control group pvalue scale of breathlessness 1,60 2,13 0,018 oxygen saturation 95,50 93,63 0,023 source: 2016 primary data multivariate analysis table 7. the effect of pursed lip breathing exercises on changes in scale of breathlessness and oxygen saturation values in hospital dr. soedarso pontianak variabel sig. scale of breathlessness oxygen saturation plb p 0,030 p 0,002 source: 2016 primary data http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.176-181 180 discussion comparison between the pursed lip breathing exercise intervention group and the control group in table 6, it can be seen that the results of the independent t-test analysis showed that the shortness of breath scale value p value was 0.018, and oxygen saturation p value was 0.023, it can be concluded that there was a significant difference in the value of the shortness of breath scale and oxygen saturation between the pursed lip breathing intervention group. and control group. so it can be concluded that the intervention of pursed lip breathing exercise has a better effect on decreasing the shortness of breath scale and increasing oxygen saturation when compared to the control group. pursed lip breathing is a breathing exercise technique that aims to prolong expiration and increase air pressure so as to delay airway compression and reduce trapped air. pursed lip breathing breathing exercises can also significantly reduce dyspnea (lewis, et at., 2011) the results of this study are supported by the results of research conducted by (bakti, rosella, & sugiono, 2015) that the pursed lip breathing exercise in the intervention group gave a more significant effect (p = 0.002) than the control group (p = 0.014) in reducing the level of hard to breathe. the effect of pursed lip breathing exercise on changes in the scale of breathlessness and oxygen saturation based on table 7 above, the p-value of the scale of breathlessness is 0.030 <0.05 and the p-value of oxygen saturation is 0.002 <0.05 so that statistically pursed lip breathing exercise significantly affects changes in the shortness of breath scale and oxygen saturation. so it can be concluded that pursed lip breathing exercise can reduce the scale of shortness of breath and increase oxygen saturation in copd patients. pursed lip breathing is a breathing exercise that emphasizes the expiration process with the aim of facilitating the process of expelling air trapped in the airways. through this technique, the air that comes out will be blocked by both lips, and will cause the pressure in the oral cavity to be more positive this reduces the resistance of the airways to the release of air and consequently lowers the residual volume and facilitates the entry of air during the inspiration process and affects the increase in gas exchange. and ventilation. this will result in an increase in oxygen saturation (sao2) and partial pressure of oxygen in the blood (pao2), and a decrease in the partial pressure of carbon dioxide in the blood (paco2) as well as an increase in tidal volume, greater recruitment of expiratory muscles and a decrease in respiratory rate (rr). (hinkle & cheever, 2014). research conducted by (visser, ramlal, dekhuijzen, & heijdra, 2011) showed that pursed lip breathing exercise significantly increased respiratory capacity (p = 0.006), oxygen saturation increased by 1% (p = 0.005), carbon dioxide and frequency respiration decreased significantly (p < 0.0001, for both). research conducted by (izadi-avanji & adib-hajbaghery, 2011) said that pursed lip breathing exercise can significantly reduce respiratory rate (p < 0.001), significantly increase oxygen saturation value (p < 0.05), decrease paco2 ( p<0.05), as well as an increase in daily activities (p<0.05) conclusion from the results of this study, it was found that the most frequent decrease in the shortness of breath scale was found in the pursed lip breathing exercise group from an average of 3.13 before the intervention to an average of 1.60 after the intervention with a http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.176-181 181 difference of 1.53 changes. in the average oxygen saturation, the difference in the increase in oxygen saturation values was mostly found in the pursed lip breathing exercise group from an average of 87.68 before the intervention to an average of 95.50 after the intervention with a difference of 7.82 changes. based on the results of multiple linear regression analysis for the effect of pursed lip breathing exercise on changes in the scale of breathlessness and oxygen saturation, the p-value of the shortness of breath scale is 0.030 <0.05 and the p-value of oxygen saturation is 0.002 <0.05 so it can be concluded that plb exercise has a significant effect on changes in scale of breathlessness and oxygen saturation. acknowledgments thank you to the nurse from dr. soedarso general hospital references andarmoyo, s. (2012). kebutuhan dasar manusia (oksigenasi). yogyakarta: graha ilmu. bakti, a. k., rosella, d., & sugiono. (2015). pengaruh pursed lip breathing exercise terhadap penurunan tingkat sesak napas pada penyakit paru obstruksi kronik (ppok) di balai besar kesehatan paru masyarakat bbkpm surakarta. universitas muhammadiyah surakarta. black, j. m., & hawks, j. h. (2009). medical surgical nursing; clinical management for positive outcomes. singapore: saunders; elsevier. gold. (2015). pocket guide to copd diagnosis, management, and prevention. hinkle, j. l., & cheever, k. h. (2014). brunner & suddarth's textbook of medical surgical nursing. philadelphia: lippincott williams & wilkins. ignatavicius, d. d., & workman, m. (2010). medical surgical nursing ;patient centered collaborative care. st. louis, missouri: saunders; elsevier. izadi-avanji, f. s., & adib-hajbaghery, m. (2011). effects of pursed lip breathing on ventilation and activities of daily living in patients with copd. webmed central. lewis, s. l., dirksen, s. r., heitkemper, m. m., bucher, l., & camera, i. m. (2011). medical surgical nursing; assessment and management of clinical problems. st. louis, missouri: elsevier; mosby. monteagudo, m., rodriguez-blanco, t., liagostera, m., valero, c., bayona, v., ferrer, m., & miravitlles, m. (2013). factors associated with changes in quality of life of copd patients: a prospective study in primary care. respir med. raherison, c., leblond, i. t., prudhomme, a., & taille, c. (2014). clinical characteristics and quality of life in women with copd: an observational study . bmc women's health. riskesdas. (2013). riset kesehatan dasar. kementerian kesehatan ri. visser, f. j., ramlal, s., dekhuijzen, p. r., & heijdra, y. f. (2011). pursed-lip breathing improves inspiratory capacity in copd . respiration. http://thejnp.org/ journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 1 8 1 pengaruh lingkungan keluarga terhadap perkembangan psikososial pada anak prasekolah heri saputro 1 , yufentri otnial talan 2 1,2 stikes surya mitra husada kediri intelsehat@gmail.com abstract the number of disorders in children such as lack of socialization, lack of initiative and a lot of silence for fear of doing an act indicates a psychosocial problem in children, and one of the factors that can affect the development of psychosocial disorders of children is the family environment. the purpose of this study to determine the influence between the family environment on psychosocial development in children aged 4-6 years in tosaren village.the study design was observational with cross sectional approach. respondents were taken using simple random sampling technique. population in this study all children aged 4-6 years in tosaren village as many as 147 respondents, a sample of 108 respondents. the independent variable is the family environment, the dependent variable of psycho-child development. results of analysis using logistic regression statistical testαs α=0.05. the results showed that almost all children aged 4-6 in tosaren sub-district with authoritarian family environment were 90 (83,3%) respondents, mostly children aged 4-6 in tosaren with guilt psychocic development that was 75 (69,4% ) of respondents from a total of 108 respondents. the results of data analysis showed that the level of significance value of p value = 0,000 so the h1 accepted which means there is influence of family environment on the psychosocial development of children aged 4-6 years in the village tosaren.a good family environment is a very supportive situation in optimizing the personal social development of pre school children. therefore, parents as those who are closest to the child should be able to be role models, show good examples and can guide and provide direction to children in a good way without having to force children to follow all the rules of parents. keywords: family environment, psychosocial development, pre-school children received august 15, 2017; revised september 07, 2017; accepted october 01, 2017 how to cite: saputro, h & talan, y.o. (2017). pengaruh lingkungan keluarga terhadap perkembangan psikososial pada anak prasekolah. journal of nursing practice. 1(1). 1-8. the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 1 8 2 pendahuluan banyaknya gangguan pada anak seperti kurang bersosialisasi, kurang inisiatif dan banyak diam karena takut salah dalam melakukan sebuah tindakan menandakan adanya masalah psikososil pada anak, apabila gangguan tersebut berlangsung secara menerus akan berdampak kurang baik bagi perkembangan kepribadian anak, yang berbahaya pada tahap ini adalah tidak tersalurkannya energi yang mendorong anak untuk aktif (dalam rangka memenuhi keinginannya), karena mengalami hambatan atau kegagalan sehingga dapat memperberat rasa bersalah pada anak. rasa bersalah inilah yang akan berdampak kurang baik bagi perkembangan kepribadian anak, dia bisa menjadi nakal atau pendiam (kurang bergairah), salah satu faktor yang dapat mempengaruhi terjadinya gangguan perkembangan psikososial anak yaitu lingkungan keluarga. lingkungan keluarga merupakan aspek yang pertama dan utama dalam mempengaruhi perkembangan anak. anak lebih banyak menghabiskan waktunya di lingkungan keluarga, sehingga keluarga mempunyai peran yang banyak dalam membentuk perilaku dan kepribadian anak serta memberi contoh nyata kepada anak. karena di dalam keluarga, anggota keluarga bertindak seadanya tanpa dibuat-buat. dari keluarga inilah baik dan buruknya perilaku dan kepribadian anak terbentuk. walaupun ada juga faktor lain yang mempengaruhi. orang tua merupakan contoh yang paling mendasar dalamkeluarga. apabila orang tua berperilaku kasar dalam keluarga, maka anak cenderung akan meniru. begitu juga sebaliknya, orang tua yang berperilaku baik dalam keluarga, maka anak juga cenderung akan berperilaku baik. menurut biro pusat statistik (bps) provinsi jawa timur tahun 2015 penduduk jawa timur berjumlah 38.052.950 jiwa, dengan jumlah anak pra sekolah sebanyak 2.196.856. data yang diperoleh dari dinas kesehatan kota kediri menyebutkan bahwa di kota kediri mempunyai jumlah balita dan anak prasekolah sebanyak 24.523,yang dilakukan deteksi dini hanya 7.622 balita dan anak prasekolah. hal ini menunjukan bahwa belum dilakukan deteksi dengan tepat sehingga tidak bisa diketahui jumlah anak yang sesungguhnya. kelurahan tosaren kota kediri terdiri dari 16 rw dan 46 rt. berdasarkan studi pendahuluan yang dilakukan di kelurahan tosaren pada tanggal 6 ferbruari, 2017 didapatkan jumlah anak usia 4-6 tahun pada tahun 2015 tercatat ada 117 anak. sedangkan pada tahun 2016 jumlah anak usia 4-6 tahun dikelurahan tosaren tercatat ada 148 anak. hasil wawancara dengan dengan 8 orang tua yang memiliki anak usia 4-6 tahun, 5 orang tua mengatakan tidak memberikan kesempatan kepada anak untuk melakukan apa yang anak inginkan dan semua keputusan yang dibuat berdasarkan kemauan orang tua, dan semua itu harus diikuti oleh anak. tiga orang tua mengatakan memberikan kebebasan kepada anak untuk menetukan pilihannya tetapi harus sesuai dengan norma dan aturan yang berlaku dalam keluarga dan masyarakat. sebagai calon generasi penerus bangsa, kualitas tumbuh kembang anak perlu mendapat perhatian serius, journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 1 8 3 karena perkembanga individu terjadi secara simultan antara dimensi fisik, kognitif, psikososial, moral dan spiritual. pencapaian tugas perkembangan psikososial agar tidak terjadi hambatan yang serius pada anak prasekolah, perlu diperhatikan faktor psikososial ysng dapat mempengaruhi tumbuh kembang anak antara lain; stimulus, motifasi belajar, ganjaran atau hukuman, kelompok sebaya, stress, sekolah, cinta dan kasih sayang serta pola asuh orang tua. anak prasekolah biasanya akan meniru apa yang di ajarkan oleh orang tua, baik secara langsung maupun tidak langsung. sehingga orangtua harus mampu meningkatkan pengetahuan dan kemampuan dalam menciptakan lingkungan dan kondisi keluarga yang kondusif guna menunjang proses perkembangan anak. tujuan penelitian ini adalah untuk mengetahui pengaruh antara lingkuangan keluarga terhadap perkembangan psikososial pada anak usia 4–6 tahun di kelurahan tosaren metode penelitian desain penelitian adalah observasional dengan pendekatan cross sectional. responden diambil dengan menggunakan teknik simple random sampling. populasi dalam penelitian ini semua anak usia 4-6 tahun di kelurahan tosaren sebanyak 147 responden, sampel sebanyak 108 responden. variabel independen adalah lingkungan keluarga, variabel dependen perkembangan psikosoial anak. hasil analisis dengan menggunakan uji statistik regresi logistic α=0,05. hasil penelitian karakteristik subyek tabel 1. karakteristik responden dalam penelitian ini meliputi usia orang tua, pendidikan, pekerjaan, usia anak, jenis kelamin anak, lingkungan keluarga dan perkembagan psikologi anak. no karakteristik σn σ% 1 usia orang tua (th) <25 18 17 25-30 59 55 31-35 27 25 >35 3 3 2 pendidikan smp 44 41 sma 52 48 pt 12 11 3 pekerjaan irt 22 20 swasta 38 35 wiraswasta 40 37 pns 9 8 4 usia anak (th) 4 39 36 5 54 50 6 15 14 5 jenis kelamin anak laki-laki 74 69 perempuan 34 31 6 lingkungan keluarga otoriter 90 83,3 demokratis 18 16,7 7 perkembangan psikologi anak journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 1 8 4 bersalah 75 69,4 inisiatif 33 30,6 total 108 100 sumber: hasil analisa data, tahun 2017 berdasarkan tabel 1 diatas dari total108 responden sebagian besar respondenberusia 20-35 tahun yaitu sebanyak 59 responden (55%), berpendidikan sma yaitu sebanyak 59 responden (48%), bekerja di bidang wiraswasta/berdagang yaitu sebanyak 59 responden (48%), usia anak responden yaitu 5 tahunsebanyak 54 responden (50%), berjenis kelamin laki-laki yaitu sebanyak 74 responden (69%), hampir seluruh anak usia 4–6 di kelurahan tosaren dengan lingkungan keluarga otoriter yaitu sebanyak 90 responden (83,3%) dan perkembangan psikosial bersalah yaitu sebanyak 75 responden (69,4%). tabel 2.pengaruh lingkungan keluarga terhadap perkembangan psikososial pada anak usia 4 – 6 tahun di kelurahan tosaren (tanggal 20-29 juli 2017) . variabel nilai signifikan pengaruh lingkungan keluarga terhadap perkembangan psikososial pada 0.000 anak usia 4 – 6 tahun di kelurahan tosaren. berdasarkan hasil uji statistik regresi logistikyang telah dilakukan diketahui bahwa nilai pvalue = 0,000< α 0,05 sehingga h1 diterima yang artinya terdapat pengaruh lingkungan keluarga terhadap perkembangan psikososial pada anak usia 4 – 6 tahun di kelurahan tosaren. pembahasan lingkungan keluarga anak usia 4-6 di kelurahan tosaren kota kediri. hasil penelitian menunjukan bahwa 90 (83.3%) responden dengan lingkungan keluarga otoriter, 18 (16.7%) responden dengan lingkungan keluarga demokratis dari total 108 responden di kelurahan tosaren kota kediri. lingkungan keluarga yaitu lingkungan yang bertanggung jawab atas kelakuan, pembentukkan kepribadian, kasih sayang, perhatian, bimbingan, kesehatan dan suasana rumah. dari lingkungan keluarga yang baik yang mampu memancarkan keteladanan kepada anak-anaknya, akan lahir anak-anak yang memliki kepribadian dengan pola yang mantap. menurut hurlock (2007), jenis lingkungan keluarga ada 3 yaitu otoriter, otoriter merupakan jenis lingkungan keluarga yang mengekang dan tidak memberi kebebasan sama sekali, semua peraturan dari orang tua harus ditaati, tidak memperhatikan kemauan dan kemampuam yamg dimiliki oleh anak, sehingga anak kurang bisa mengembangkan potensi yang dimiliki, 2) demokratis, demokratis merupakan jenis lingkungan keluarga yang memberi kebebasan kepada anak untuk mengembangkan potensi yang dimiliki, tanpa mengabaikan peraturan dan norma journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 1 8 5 norma yang harus ditaati, 3) bebas, bebas merupakan jenis lingkungan keluarga dimana orang tua tidak memberikan aturan dan norma-norma yang harus ditaati oleh anak, sehingga anak merasa bebas, dan kebanyakan mereka terjebak dalam hal-hal yang negatif karena kurangnya perhatian orang tua. perilaku pola asuh dalm lingkungan keluarga yang diterapkan pada anaknya dipengaruhi oleh faktor tingkat pendidikan, lingkungan, dan social budaya. hasil penelitian menunjukan hampir seluruh keluarga menerapakan lingkungan keluarga otoriter. hal ini menunjukan bahwa keluarga dengan sikap yang otoriter di kelurahan tosaren tosaren sangat tinggi karena angkanya mencapai 83,3%. sikap otoriter yang diterapakan orang tua kepada anak usia 4-6 tahun di kelurahan tosaren disebabkan karena masih kurangnya pemahaman orang tua tentang bagaimana cara memperlakukan anak pada jaman sekarang ini, mereka masih menganut kebiasaan lama yang diterapkan oleh orang tua mereka dulunya, serta masih kurangnya pemahaman orang tua akan dampak dari sikap otoriter mereka terhadap anak, dimana anak harus selalu mengikuti segala sesuatu yang telah ditetapkan orang tua. berdasarkan hasil wawancara dengan dengan pada orang tua dengan sikap otoriter, mereka mengatakan bahwa semua aturan yang telah dibuat harus diikuti oleh anak, orang tua juga mengatakan bahwa alansan mereka memperlakukan anak dengan sikap otoriter supaya membiasakan anak mengikuti aturan yang telah dibuat dan tidak membengkang setelah sudah besar nanti, dan ini juga merupakan kebaikan untuk anak. pada hasil penelitian juga menunjukan bahwa sebagian kecil keluarga menerapkan sikap demokratis pada anak, hal ini terjadi karena orang tua telah mengetahui dan memahami akan manfaat dari sikap yang demokratis, dimana orang tua tidak selalu memaksakan kehendak dan sesekali mendengarkan permintaan anak apabila permintaan anak tersebuat baik dan bermanfaat. perkembangan psikososial pada anak usia 4–6 tahun di kelurahan tosaren kota kediri. hasil penelitian menunjukan bahwa 75 anak (69.4%) dengan perkembangan psikososial bersalah dan 33 anak (30.6%) dengan perkembangan psikososial inisiatif dari total 108 responden di kelurahan tosaren kota kediri. perkembangan untuk mencapai manusia dewasa, seorang anak sejak lahir akan melalui berbagai tahap perkembangan, salah satunya adalah masa prasekolah yaitu antara usia 4-6 tahun dengan perkembangan psikososialnya. pada masa prasekolah usia 4-6 tahun merupakan masa dimana anak mulai mengeksplorasi tingkah lakunya dan keinginan-keingannya serta anak mulai aktif melakukan aktivitasnya, dan apabila anak usia 4-6 tahun gagal melalui tahap ini akan berdampak pada perkembangan anak. tahap prasekolah menurut erikson merupakan tahap dimana anak memasuki fase inisiatif vs kesalahan, pada tahap ini tugas yang harus diemban seorang anak adalah untuk belajar punya gagasan (inisiatif) tanpa banyak terlalu melakukan banyak kesalahan. tekanan yang berlebihan ataupun pengharapan yang terlalu tinggi melampaui kapasitas membuat anak untuk berbohong atau berbuat curang agar dapat diterima dikelompok sosialnya. faktor-faktor yang mempengaruhi perkembangan sosial personal anak prasekolah antara lain faktor keluarga dan kematangan anak. kondisi dan tata cara kehidupan keluarga merupakan lingkungan yang kondusif bagi sosialisasi anak. masalah sosial emosional sering terjadi pada anak, sekitar 9,5-14,2% anak mengalami gangguan sosial emosional yang nantinya akan berdampak negatif pada pertumbuhan, perkembangan dan kesiapannya untuk bersekolah. hasil penelitian journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 1 8 6 menunjukan bahwa sebagian besar anak usia 4-6 di kelurahan tosaren dengan perkembangan psikososial bersalah, hal ini akan berdampak pada perkembangan anak menuju soerang remaja dan dewasa. pada anak dengan psikososial bersalah akan menyababkan kurangnya kemampuan anak dalam melakukan eksplorasi dirinya, karena anak takut berbuat salah dalam melakukan sesuatu, sehingga anak lebih banyak pasif. adapun faktor yang mempengaruhi tingginya masalah psikososial pada anak di kelurahan tosaren karena orang tua selalu melarang dan memarahi anak ketika melakukan sesuatu. dari fakta dan teori di atas dapat dilihat bahwa faktor yang paling utama dalam mempengaruhi perkembangan sosial personal anak adalah keluarga. ketika orang tua memberikan kebebasan kepada anak untuk banyak bergaul dengan teman sebayanya maka mereka akan lebih terbuka untuk menerima dunia luar, lebih mandiri, dan mempunyai perkembangan sosial yang lebih baik. sebaliknya jika orang tua selalu melarang anak dalam melakukan dan mengikuti suatu kegiatan maka akan menyebabkan anak selalu tergantung dengan keptusan orang tua dan akan berpengaruh pada perkembangan psikososal anak kearah yang negatif yaitu makin meningkatnya rasa bersalah yang dialami oleh anak. pengaruh lingkungan keluarga terhadap perkembangan psikososial pada anak usia 4 – 6 tahun di kelurahan tosaren kota kediri berdasarkan hasil uji statistik regresi ordinal yang telah dilakukan diketahui bahwa nilai p value = 0,000 sehingga h1 diterima yang artinya terdapat pengaruh lingkungan keluarga terhadap perkembangan psikososial pada anak usia 4 – 6 tahun di kelurahan tosaren. sedangkan tabulasi silang antara lingkungan keluarga dengan perkembangan psikososial anak menunjukan bahwa sebagian besar anak di kelurahan tosaren dengan lingkungan keluarga otoriter memiliki perkembangan psikososial bersalah yaitu sebanyak 75 responden (69,4%) dari total 108 responden. perkembangan psikososial merupakan perkembangan yang membahas tentang perkembangan kepribadian manusia, khususnya yang berkaitan dengan emosi, motifasi dan perkembangan kepribadian. sikap lingkungan yang suka melarang dan menyalahkan membuat anak kehilangan inisiatif. pada saat dewasa anak akan mudah mengalami rasa bersalah bila melakukan kesalahan dan tidak kreatif. sebagai calon generasi penerus bangsa, kualitas tumbuh kembang anak perlu mendapat perhatian serius, karena perkembanga individu terjadi secara simultan antara dimensi fisik, kognitif, psikososial, moral dan spiritual. masing-masing dimensi mempunyai peran yang sama pentingnya untuk membentuk kepribadian yang utuh. pencapaian tugas perkembangan psikososial agar tidak terjadi hambatan yang serius pada anak prasekolah, perlu diperhatikan faktor psikososial yang dapat mempengaruhi tumbuh kembang anak antara lain; stimulus, motifasi belajar, ganjaran atau hukuman, kelompok sebaya, stress, sekolah, cinta dan kasih sayang serta pola asuh orang tua. anggota keluarga merupakan lingkungan pertama anak dan orang yang paling penting selama tahun-tahun formatif awal. hubungan dengan anggota keluarga menjadi landasan sikap terhadap orang, benda, dan kehidupan secara umum. mereka juga meletakan landasan bagi pola penyesuaian dan belajar berpikir tentang diri mereka sebagai mana dilakukan anggota keluarga mereka. tingkat pendidikan yang dimiliki oleh orangtua yaitu sederajat sangat berpengaruh terhadap kepribadian. kepribadian baik yang dimiliki oleh orangtua memiliki pengaruh positif journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 1 8 7 terhadap lingkungan sekitar, karena orangtua sebagai panutan di dalam keluarga, termasuk anak. anak prasekolah biasanya akan meniru apa yang di ajarkan oleh orang tua, baik secara langsung maupun tidak langsung. sehingga orangtua harus mampu meningkatkan pengetahuan dan kemampuan dalam menciptakan lingkungan dan kondisi keluarga yang kondusif guna menunjang proses perkembangan anak. pola kepribadian merupakan suatu penyatuan struktur yang multidimensi. konsistensi, artinya sifat diharapkan dapat menjadi perilaku. perkembangan sifat dipengaruhi oleh dua faktor, yaitu hereditas (bawaan) dan belajar, bentuk belajar antara lain, karena pengasuhan orangtua dan imitasi (peniruan) anak terhadap idolanya. berdasarkan hasil penelitian dan teori yang telah dijabarkan diatas peneliti berpendapat bahwa lingkungan keluarga memiliki pengaruh yang besar terhadap perkembangan psikososial anak. dimana semakin baik lingkungan keluarga dalam hal ini lingkungan keluarga yang demokratis maka akan semakin baik perkembangan psikososial anak menuju kearah yang lebih kreatif, karena anak memiliki kebebasan dalam mengeplorasikan dirinya tanpa adanya aturan-aturan yang terlalu membatasi anak dalam melakukan kegiatan yang diinginkan oleh anak. begitupun sebaliknya pada lingkungan keluarga yang kurang baik akan menyababkan perkembangan psikososoal anak terganggu dimana anak akan menjadi soerang pemalu, pendiam, bahkan menjadi hiperaktif. lingkungan keluarga yang baik merupakan suatu keadaan yang sangat mendukung dalam mengoptimalkan perkembangan sosial personal anak usia pra sekolah. oleh sebab itu, orang tua sebagai orang yang paling dekat dengan anak harus dapat menjadi panutan, menunjukan contoh-contoh yang baik serta dapat membimbing dan memberikan arahan kepada anak dengan cara yang baik dan benar tanpa harus memaksakan anak untuk mengikuti semua aturan orang tua, sehingga perkembangan psikososial anak berjalan dengan baik tanpa adanya masalah yang akan berpengaruh pada pertumbuhan dan perkembangan anak selanjutnya. kesimpulan dan saran 1. hampir seluruh anak usia 4–6 di kelurahan tosaren dengan lingkungan keluarga otoriter yaitu sebanyak 90 responden (83,3%) dari total 108 responden. 2. sebagian besar anak usia 4–6 di kelurahan tosaren dengan perkembangan psikosial bersalah yaitu sebanyak 75 responden (69,4%). 3. ada pengaruh lingkungan keluarga terhadap perkembangan psikososial pada anak usia 4 – 6 tahun di kelurahan tosaren, dengan nilai p value = 0,000. daftar pustaka bkkbn. (2009). pengasuhan dan pembinaan tumbuh kembang anak. jakarta. hidayat t (2010). agar anak tak pendek akal. jakarta: salemba medika. hurlock b.e, 2007. psikologi perkembangan suatu pendekatan sepanjang rentang kehidupan. penerbit erlangga. jakarta. journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 1 8 8 keliat. (2011). pola asuh orang tua dan komunikasi dalam keluarga. jakarta : rineka cipta. nelson. (2012). ilmu kesehatan anak. jakarta: egc. petantro i. (2011). rasa percaya diri anak adalah pantulan pola asuh orang tua. http://www.dampakpolaasuh.co.uk/ [diakses tanggal 4 februari 2017] ramli.2011. perkembangan anak jilid 2edisi keenam.alih bahasa oleh meitasari tjandarasa. jakarta: erlangga. setyowati sri. s.kep dkk.(2008).asuhan keperawatan keluarga, konsep dan apilkasi kasus; editor handokoriwidikdo, skp dkkjogjakarta : mitra cendikia soekanto, soerjono. 2007. sosiologi suatu pengantar. jakarta: p.t.raja grafindo. soetjiningsih. (2010). tumbuh kembang anak. jakarta: egc. shocib. (2010). pola asuh orang tua. jakarta: rineka cipta. supartini (2011). buku ajar konsep dasar keperawatan anak. jakarta. egc santrock, john w. (2013). masa perkembangan anak. jakarta: salemba medika. http://www.dampakpolaasuh.co.uk/ journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 26 32 26 description of ecg recycle and coronary angiography in coronary heart disease patients in catheries heart of dr. iskak tulungagung karmiati 1 , sutrisno 2 1 dr iskak hospital, tulungagung, east java, indonesia 2, stikes surya mitra husada, kediri, indonesia) corresponding author : alyamila7@gmail.com abstract background: coronary heart disease is a major health problem in almost every country in the world and contributes to about 30% of all deaths worldwide. proper diagnosis in patients with coronary heart disease will determine the accuracy of the procedure and will affect the patient's healing and prognosis. purpose : this study aims to describe the picture of ecg and coronary angiography in patients with coronary heart disease. methods : the design of this study was descriptive with the patient population of coronary heart disease in the cardiac catheterization room of rsud dr. iskak tulungagung. the sample size was 35 respondents taken with acidental sampling. the variables in this study are ecg image and coronary angiography results. methods of data collection using observation sheet. the results showed 13 respondents (37.14%) results of ecg image injuri. while the results of angiography showed 27 (77.14%) of respondents there was a significant stenosis. result : the result of research also got difference of result between ecg image and coronary angiography where the respondent that picture ecg and coronary angiography fit as many as 23 respondent whereas between ecg picture and coronary angiography not suitable as much 12 respondents. conclusion : in accordance with the number of accuracy of ecg in diagnosing coronary heart disease patients who ranged between 55% while in angiography accuracy rate 99% then can be drawn conclusion diagnostic patients with coronary heart disease using ekg can be a mistake of diagnosis by 45% compared angiografi which only 1%. keywords : coronary angiography, coronary heart disease, electrocardiogram received: february 03, 2018; revised february 24, 2018; accepted march 10, 2018 how to cite: karmiati., & sutrisno. (2018). description of ecg recycle and coronary angiography in coronary heart disease patients in catheries heart of dr. iskak tulungagung. journal of nursing practice. 1(2). 26-32 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 26 32 27 background cardiovascular disease, especially coronary heart disease, is a major health problem in almost every country in the world and contributes to about 30% of all deaths worldwide. the prevalence of national coronary heart disease based on riskesdes 2013 is 1.5%. riskesdes 2013 results show the prevalence of coronary heart disease based on doctor diagnosis of 5%, while based on symptoms of 1.5%. the mortality rate from coronary heart disease in indonesia reaches 53.5 per 100,000 population. (www.depkes.go.id). the incidence of coronary heart disease found in hospitals dr. iskak tulungagung through the er in 2016 as many as 374 cases, where patients entered with diagnosis uap 54 cases, nstemi 120 cases and stemi 200 cases. (medical record rsud dr. iskak, 2016) coronary heart disease is a narrowing or blockage of coronary artery blood vessels called coronary blood vessels. as with any body organ, the heart also needs nutrients and oxygen to pump blood throughout the body, the heart will work well if there is a balance between supply and expenditure. if the coronary arteries are blocked or narrowed, the blood supply to the heart will decrease, resulting in an imbalance between the need and supply of nutrients and oxygen, the greater the percentage of coronary artery narrowing the reduced blood flow to the heart, resulting in chest pain. (upt information center for lipi food & health technology, 2009). early diagnosis of coronary heart disease based on risk stratification approach including history of disease, physical examination and investigation is needed for diagnosis to determine the accuracy of the procedure and will ultimately improve patient outcome and prognosis. investigations of coronary heart disease may be non invasive and invasive. the non invasive examination such as ekg, treadmill, laboratory, nuclear and mri. while invasively performed with coronary angiography. ecg is an important diagnostic tool for diagnosing disorders such as atrial and ventricular hypertrophy, myocardial ischemia and infarction, pericarditis, the effects of several treatments, especially digitalis and anti-arrhythmias, and for assessing pacemaker function. the use of ekg is still the most important and fastest way of examination for both the initial diagnosis and evaluation of clinical course of coronary heart disease. ecg is important in the identification and management of coronary heart disease especially in patients with acute myocardial infarction. a detailed analysis of the st segment elevation pattern may influence the patient's treatment decision. early and accurate identification of arteries associated with infarction of the ecg can help predict the number of myocardium at risk and assist in making decisions about the urgency of patient revascularization and therapy. tamine-tamda reperfusion ecg is an important marker of coronary blood flow and patient prognosis. ekg is also important to identify the emergence of conduction abnormalities and arrhythmias that affect both short-term and long-term patient outcomes. coronary angiography is a standard gold in identifying constriction of coronary arteries associated with coronary heart disease. the purpose of coronary angiography is to determine the anatomy and degree of coronary artery lument obstruction so that it can assess the severity of coronary heart disease. this examination may also be performed in patients with an unclear diagnosis of coronary heart disease and can not be excluded by non-invasive testing. invasive coronary angiography also facilitates the determination of therapy in which intervention therapy (percutaneous coronary intervention) can be done in conjunction with diagnostic procedures. invasive coronary angiography is highly recommended in patients with acute myocardial infarction with st segment elevation or without elevated st elevation. thus high-risk patients can be identified quickly so that no delay in handling. in patients with stemi diagnostic coronary angiography should be journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 26 32 28 done immediately followed by percutaneous coronary intervention. percutaneous coronary action procedures rapid intervention can restore heart muscle to its original state, shorten treatment time and improve patient prognosis. in 2016, coronary diagnostic coronary angiography patients were 234 patients. (medical record rsud dr. iskak, 2016) based on the above description, the formulation of this research problem is "overview of ecg record and coronary angiography in coronary heart disease patients in cardiac catheterization room of rsud dr. iskak tulungagung ". objective knowing the overview of ecg record and coronary angiography results on coronary heart disease patients in cardiac catheterization room of rsud dr. iskak tulungagung. methods the research design used is descriptive research to get an overview of the results of ecg reading and angiography results in patients with coronary heart disease in the cardiac catheterization room hospital dr. iskak tulungagung. the samples of this study were all patients of coronary heart disease performed by ecg and coroner angiography in the cardiac catheterization room of dr. iskak tulungagung on 1 to 30 june 2017 as many as 35 respondents. the sampling technique used in this research is accidental sampling technique. results this research was conducted in cardeter catheterai heart hospital dr. iskak tulungagung on june 1 to june 30, 2007, with the number of respondents 35. the characteristic of respondents based on general data can be explained as follows: characteristic of respondents by sex is found most of the respondents of male gender is as much as 27 respondents or 77%, characteristics of respondents by age is found most of the respondents umumrnya> 50 years as many as 23 respondents or 66%, characteristics of respondents based on education obtained almost half of respondents with high school education as many as 15 respondents or 43%, characteristics of respondents based on medical history obtained almost half of the respondents have a smoking health history of 24 respondents or 48%, characteristics of respondents based on previous illnesses obtained most respondents ever went to the heart poly with coronary heart disease complaints that is as much as 22 respondents or 65%. while the characteristics of respondents based on variables can be explained as follows: a results of ecg picture 1. degree of ecg degree of ecg in coronary heart disease patients in idik rsud dr. iskak tulungagung obtained most of the degree of ekg is injury that is as much as 13 respondents or 37.14%. 2. location of ecg disorder location of ecg abnormalities in coronary heart disease patients in idik rsud dr. iskak tulungagung obtained most of the location of ecg abnormalities is the interior of 12 respondents or 40%. b coronary angiography results 1. degree of stenosis journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 26 32 29 degree of stenosis in coronary heart disease patients in idik rsud dr. iskak tulungagung obtained most degree of stenosis> 50% which means significant as much as 27 respondents or 77.14%. 2. the location of stenosis locations of stenosis in coronary heart disease patients in idik rsud dr. iskak tulungagung obtained most of the location of the stenosis is lad (left artery descenden) that is as much as 23 respondents or 54.76%. 3. number of stenosis locations number of stenosis locations in coronary heart disease patients in idik rsud dr. iskak tulungagung obtained most of the number of stenosis location is svd (single vesel desease) that is as much as 16 respondents or 45.71%. c comparison of ecg results and coronary angiography 1 respondents who described ecg and coronary angiography as many as 23 respondents or 65.71% 2 respondents who describe ecg and coronary angiography does not match as many as 12 respondents or equal to 34.28% discussion overview of ecg in coronary heart disease patients in idik room rsud dr. iskak tulungagung the results of the study in table 4.1 shows that the picture of ecg in patients with coronary heart disease in idik rsud dr. iskak tulungagung obtained most of the degree of ekg is injury that is as much as 13 respondents or 37.14%. the basic feature of injury is the typical st segment elevation (upward convex) (pratana, 2006). the presence of st segment elevation is a major sign of acute myocardial injury. in a normal ecg, the st segment should not be elevated more than 1 mm in standard leads or over 2 mm in a precordium lead. in acute injury, the st segment on the leads facing the injured area is elevated. the st segment elevation also has a downcrop or cove shape and joins invisibly with t waves (hudak and gallo, 2012). according to aha (american heart associaton) major risk factors for coronary heart disease include smoking, hypertension, elevated cholesterol levels, diabetes mellitus, increasing age, obesity and family history of coronary heart disease. based on medical history in this study obtained almost half of respondents ie sebayak 24 respondents or 48% of smoking. smoking is the most important risk factor for coronary heart disease. smoking has a major impact on myocardial infarction and all causes of death. the loose thromboses in the coronary arteries will lead to implantation of the arteries so that the patient has acute myocardial infarction. patients with acute myocardial infarction of the ecg image will be found in st segment elevation. overview of coronary angiography results in coronary heart disease patients in idik rsud dr. iskak tulungagung the results of the study in table 4.3 shows that the degree of stenosis in patients with coronary heart disease in idik rsud dr. iskak tulungagung obtained most degree of stenosis> 50% which means significant as much as 27 respondents or 77.14%. as mentioned above, according to aha (american heart associaton) major risk factors for the occurrence of arterisklerotik in patients with coronary heart disease include journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 26 32 30 smoking, hypertension, elevated cholesterol levels, diabetes mellitus, increasing age, obesity and family history of coronary heart disease. from the results of research based on age, most of the respondents were 50 years old as many as 20 respondents or 66%. according to yani (2015) the most important risk factor in the incidence of heart and blood vessel disease is age with research results in the age above 55 years have a statistically proven risk associated with heart disease and blood vessels. this is in line with the theory that age is an irreversible risk factor in heart and blood vessel disease. comparison of ecg results and coronary angiography results on coronary heart disease patients in idik rsud dr. iskak tulungagung based on table 4.7 on the comparison of ecg and coronary aillography on the coronary heart disease patients in idik rsud dr. iskak tulungagung obtained most (65.71%) or as many as 23 respondents according to the ecg picture and angiography results. coronary artery is divided into two namely right coroner artery (rca) and left coroner artery (lca). lca is divided into 2 namely left artery descenden (lad) and left circumflex (lcx). lad supplies the heart muscle anterior ventricular septum, anterior left ventricle and heart apek. if there is a blockage in the lad and resulting damage to the heart muscle will look kelianan on the ecg in v1-v4. lcx supplies the left atrial heart muscle, left ventricular lateral wall, posterior wall of the left ventricle. if there is damage to the heart muscle will be seen abnormalities of ecg on v4-v6 and i, avl. the right coronary artery supplies the heart muscle in the right atrium, right ventricle, the posterior ventricle septum, the left inferior wall of the left ventricle. if there is damage to the heart muscle will look eccentric ekg pad ii, iii, avf (hudak and gallo, 2012). based on table 4.7 also found a small number (12 respondents) or as much as 34, 28% not fit between the ecg picture and angiography results. research data obtained 2 respondents who diagnosed coronary heart disease but obtained normal ecg results and angiografinya also normal. this is probably because non-coronary clinical causes can be other disorders in the thoracic wall structures such as muscle, bone, nerve or lung. in patients with hypertension chest pain can be caused by non hypertension angina due to high afterload so that heart work increases. it may also be due to spasm of the coronary arteries. in patients with diabetes mellitus can occur neuropathy so that there is a sensation of chest pain that can be caused by the neuropathy. research data obtained 3 respondents normal ekg whereas angiografinya results obtained significant stenosis. ekg shows functional activity of the heart. while angiography indicates the state of coronary artery anatomy. if a normal ecg is found whereas significant stenosis is obtained in angiography it is possible that blood supply to heart cells is good so there is no damage to cardiac cell or heart perfusion disorder despite significant stenosis in the coronary artery, to obtain a normal ecg picture. the research data obtained 6 responders ecg picture is not normal but normal angiografinya results. in accordance with the number of accuracy of ecg in diagnosing coronary heart disease accuracy ranges between 55%. while the angiography accuracy of 99%. so it can be concluded that the diagnosis of coronary heart disease by using ekg can occur a misdiagnosis of 45% while the diagnosis of coronary heart disease by using angiography can be a fault diagnosis of only 1%. the sensitivity of an ekg may be influenced by non coronary factors such as ber, infection or non coronary arrhythmias. in cases of infections such as pericardiosynthesis, there may be a change in ecg picture although angiography is normal. likewise with non coronary arrhythmia, ecg in patients can be obtained ischemic images without a blockage journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 26 32 31 in the coronary arteries. likewise in patients who experience spasm in the coronary arteries at the time of ecg will get abnormalities in the picture of ecg. conclusion based on the results of research and discussion about ecg recording and coronary angiography images on coronary heart disease patients in idik rsud dr. iskak tulungagung can be concluded: 1. most of the respondents (37.14%) or as many as 13 respondents from coronary heart disease patients get the picture of injury ekg. 2. almost all respondents (77.14%) or as many as 27 respondents from coronary heart disease patients who performed angiography got stenosis more than 50% (significant). 3. comparison of ecg and coronary angiograi images in patients with coronary heart disease: a corresponding ecg and coronary angiography as many as 23 respondents or 65.71%. b an inappropriate ecg and coronary angiography of 12 respondents or 34.28%. references dharma, s. (2010). sistematika interpretasi ekg : pedoman praktis. jakarta. egc gabriel.j.f. (2001). fisika lingkungan. jakarta. hipokrates hampton, j.r. (2006). dasar-dasar ekg edisi 6. alih bahasa a. samik wahab. jakarta. egc hastono, s.p. dan sabri, luknis. (2010). statistik kesehatan. jakarta. raja grafindo persada. hendy. (2009). penyakit jantung koroner. http://heqrisonline.blogspot.com. diakses tanggal 23 januari 2017. hudak, c.m. dan gallo, b.m. (2010). keperawatan kritis. jakarta. penerbit buku kedokteran. james, j.baker. c and sivain.h. (2008). prinsip-prinsip sains untuk keperawatan. jakarta.erlangga karim, s & kabo, p. (2006). ekg dan penanggulangan beberapa penyakit jantung untuk dokter umum.jakarta. balai penerbit fkui. morton, p.g., fontaine, dorrie, hudak, c.m. dan gallo, b.m. (2012). keperawatan kritis. jakarta. penerbit buku kedokteran. munawar, m dan sutandar, h. (2002). buku ajar kardiologi. jakarta. egc muttaqin, arif. (2008). asuhan keperawatan klien gangguan sistem kardiovaskuler. jakarta. salemba merdeka http://heqrisonline.blogspot.com/ journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 26 32 32 muttaqin, arif. (2009). asuhan keperawatan klien gangguan sistem kardiovaskuler.jakarta. salemba merdeka oktaviono, h.y., subagjo, a., lefi, a. pratanu, i. (2013). manajemen komprehensif penyakit jantung koroner. surabaya. universitas airlangga ppni. (2009). penyakit jantung di indonesia. http://www.inna-ppni.or.id. diakses tanggal 15 januari 2017 pratanu, s. (2004). kursus elektrokardiografi. surabaya.karya pembina swajaya. soeharto, iman. (2004). penyakit jantung koroner dan serangan jantung. jakarta.gramedia pustaka utama. tiani, et al. (2015). determinan penyakit jantung dan pembuluh darah pasien poli jantung pembuluh darah pasien rawat jalan poli jantung dan poli penyakit dalam rsd dr. soebandi jember. e-jurnal kesehatan, vol. 3. http://www.inna-ppni.or.id/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.248-254 248 the effect of psychoreligy dzikir intervention on self efficacy and blood pressure on hypertension adivtian ragayasa1*, sylvina rahmawati2, emdat suprayitno3 1politeknik kesehatan surabaya, surabaya, indonesia 2akademi kebidanan aifa husada madura, madura, indonesia 3fakultas ilmu kesehatan, universitas wiraraja, sumenep, indonesia *corresponding author: adivtianragayasa@gmail.com abstract background: hypertension is a chronic disease condition that causes impaired self-efficacy and increased blood pressure. one of the non-pharmacological therapies that can do is dzikir or dhikr therapy. purpose: this study aimed to determine the effect of remembrance therapy on self-efficacy and blood pressure in hypertension. the study was an experimental study using a randomized pre test-post test control group design in hypertensive patients receiving psycho religious therapy. the subjects in this study were all hypertensive patients in the working area of the teja pamekasan health center, as many as 20 people. methods: the selected sample in this study was some hypertensive patients taken by simple random sampling. blood pressure measurements were carried out twice before psycho religious therapy and two weeks after psycho religious therapy. psychoreligious therapy is a series of dhikr and prayer by saying the letter "al-fatihah" 7 times, then "istighfar" 100 times, followed by solawat "allahumma shall 'ala muhammad wa ali muhammad" as much as 100 (solawat "ya sayyidi ya rasulullah " as much as 1000 times) which does once every day. mann whitney u test analyzed data. results: the results of calculations using the mann whitney u test statistical test showed a difference in blood pressure at the time of pre and post. the significance values indicate this at pre and post are 0.002 and 0.005. conclusion: psychoreligious therapy in remembrance can increase self-efficacy and reduce blood pressure in hypertensive patients in the elderly posyandu in the working area of the teja pamekasan health center. keywords: dzikir therapy, hypertension, pshychoreligious received march 10, 2022; revised april 1, 2022; accepted april 29, 2022 doi: https://doi.org/10.30994/jnp.v5i2.217 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:adivtianragayasa@gmail.com https://doi.org/10.30994/jnp.v5i2.217 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.248-254 249 background hypertension increases systolic blood pressure above 140 mmhg and diastolic blood pressure above 90 mmhg when measured twice at 5-minute intervals with sufficient rest or rest (indonesia ministry of health, 2013). according to the age limit for hypertension patients, it is estimated that 23% of women and 14% of men aged over 65 years suffer from hypertension (indonesia ministry of health, 2014). the prevalence of high blood pressure in indonesia became 25.8% of the whole populace of indonesia (indonesia ministry of health, 2013). moreover, the second one purpose of dying after stroke is cardiovascular ailment, so this ailment is an ailment that desires to be discovered and endeavored for its treatment, each promotive, preventive, curative, and rehabilitative. high blood pressure may be due to numerous factors, along with lifestyle (smoking, ingesting alcohol), pressure or anxiety, obesity, loss of exercising and heredity (suprayitno & wahid, 2019). stress is associated with high blood pressure due to the fact pressure is a bodily and mental strain which could stimulate the kidneys and launch the hormone adrenaline (hanefa, 2019). treatment of high blood pressure does not rely solely on doctors' medications and diets. it's also important to stay relaxed at all times. a calm state is required to activate the parasympathetic nervous system. the parasympathetic nervous system acts on the sympathetic nerves to reduce the body's production of stress hormones (damayanti et al., 2019). in general, people suffering from illness are followed by feelings of anxiety and an uneasy soul. in addition to taking medicine, praying and dhikr can calm the individual's soul (suprayitno & wahid, 2019). as dhikr means remembering, it is a practice associated with other ritual worship. dhikr can also be said as a form of awareness that a person has in establishing a relationship with the creator. dhikr has a relaxing power to reduce tension and bring peace of mind. every dhikr reading contains a profound meaning that can prevent tension (setiyani, 2018). objective this study aimed to determine the effect of remembrance therapy on self-efficacy and blood pressure in hypertension. methods this research is classified as an experimental study using a randomized pre test-post test control group design in hypertensive patients receiving psycho religious therapy. the subjects in this study were all hypertensive patients in the working area of the teja pamekasan health center, as many as 20 people. the selected sample in this study was some hypertensive patients taken by simple random sampling. the sample was selected by simple random sampling on patients who voluntarily were willing to become research subjects with an experimental unit of 10 patients per group identified from secondary data at the teja pamekasan public health center. giving informed consent from patients by signing a letter of consent as research subjects to conduct interviews, fill out questionnaires, and measure self-efficacy. the provision of informed consent was based on explaining the aims and objectives of the study to understand the information. blood pressure measurements were carried out twice before psycho religious therapy and two weeks after psycho religious therapy. psychoreligious therapy is a series of dhikr and prayer by saying the letter "alfatihah" 7 times, then "istighfar" 100 times, followed by solawat "allahumma shalli 'ala muhammad wa ali muhammad" as much as 100 (solawat "ya sayyidi ya rasulullah " as much as 1000 times) which is done once every day. data were analyzed using software (computer software) description of data with mean and standard deviation for normally https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.248-254 250 distributed data. changes in anxiety and self-efficacy variables were analyzed with the mannwhitney u test. results table 1. frequency distribution of gender and age of hypertension patients in the elderly posyandu in the working area of teja pamekasan health center in november 2021 characteristic group gender intervention % control % female 6 60% 7 70% male 4 40% 3 30% total 10% 100% 10% 100% age 50 – 60 3 30% 2 20% 61 – 70 6 60% 7 70% 71 – 80 1 10% 1 10% total 10 100% 10 100% based on the study results, the sex of hypertension patients in the treatment group mainly was female 6 (60%), and the rest were male as much as 4 (40%). in the control group, it was more significant for 7 (70%), and the rest were for men as much as 3 (30%). the age of hypertensive patients in the treatment group was 61-70 years old (60%), 71-80 years old (10%) and 50-60 years 3 (30%). in the control group, seven were greater, aged 61-70 years (70%), aged 50-60 years were 20%, and the rest were aged 71-80 years were 10%. table 2. test results differences in self-efficacy with mann-whitney u test and effects before and after being given psychoreligious actions in the form of remembrance at the elderly posyandu in the work area of teja pamekasan health center self-efficacy group intervention control pre post pre post low 2 0 10 10 20% 0% 100% 100% high 8 10 0 0 80% 100% 0% 0% total 10 10 10 10 100% 100% 100% 100% sig pre 0.004 sig post 0.000 sig 0.008 0.14 https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.248-254 251 table 3. test results of differences in systolic blood pressure measurement variables with mann whitney u test and effects before and after being given psychoreligious actions in the form of remembrance at the elderly posyandu in the work area of the teja pamekasan health center in november 2021. mean ±sd sistole intervention control mean pre ± sd 164 ± 17.68 140 ± 6,77 mean post ± sd 133 ±9.5 153 ±17,1 sig. pre 0.002 sig. post 0.005 sig. 0.005 0.41 the results of calculations using the mann whitney u test statistical test showed a difference between pre and post. the significance value indicates this at pre and post-time is 0.002 and 0.005 ≤ 0.05, which means that there is a difference before and after being given psycho religious action in the form of remembrance. from the calculation of the difference above, to determine the effect, using the wilcoxon statistical test, it was found that there was an influence of psycho religious actions in the treatment group. a significance value indicates this in the treatment group of 0.005 ≤ 0.05, which means that there is an effect of decreasing systolic blood pressure. table 4. test results differences in diastolic blood pressure measurement variables with mann whitney u test and the effect before and after being given psychoreligious actions in the form of remembrance at the elderly posyandu in the work area of the teja pamekasan health center in november 2021. mean ±sd diastole intervention control mean pre ± sd 92.8 ±9.19 82.1 ± 10.53 mean post ± sd 86 ±8.2 89 ±9.4 sig. pre 0.021 sig. post 0.519 sig. 0.286 0.153 the results of calculations using the mann whitney u test statistical test found a difference at the time of pre. there is a significant value of 0.021 < = 0.05, which means a difference before being given psycho religious action in the form of remembrance in the treatment and control groups. at the time of the post, there was no difference. this was indicated by a significance value of 0.519 > = 0.05, which means no difference in the treatment or control groups. from the calculation of the difference above, to determine the effect, using the wilcoxon statistical test, it was found that there was no effect of psycho religious actions in the treatment group. a significance value indicates this in the treatment group of 0.286 > = 0.05, which means that there is no effect of decreasing diastolic blood pressure in the treatment group. for more details, see the blood pressure table. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.248-254 252 discussion the study results prove an effect of psycho religious therapy in the form of remembrance on self-efficacy. this indicated by the results of calculations in the treatment group that ten hypertensive patients had a post-self-efficacy category higher than pre. the results of this study form the basis that psycho religious therapy with the remembrance of prayer can use to increase self-efficacy. dhikr has a relaxing power to reduce tension and bring peace of mind. each recitation of dhikr contains a profound meaning that can prevent tension (pertiwiningrum & kamalah, 2021). every dhikr reading contains the meaning of an acknowledgment of trust and belief only in allah swt. individuals who have high spirituality have a strong belief only in allah, and this belief can lead to solid control and direct the individual in a positive direction (anggraieni & subandi, 2014). this study's results found differences between the treatment and control groups on the self-efficacy variable. after doing psycho-religious action in the form of remembrance in the treatment group, there was a 100% effect. in line with research conducted by kumala et al. (2017) regarding the effectiveness of dhikr training in increasing mental calm in patients with hypertension, the results showed that there were differences in the level of mental calm in research respondents after being given dhikr relaxation training. the results of the different wilcoxon rank test scores of z = -2.673 and p = 0.008 (p <0.05) showed a significant difference in mental calm in the research respondents between before and after giving dhikr training. the average score of peace of mind on the respondents between before and after the dhikr training showed an increase from 78.56 to 98.33. these results indicate that dhikr training affects increasing mental calm and reduces the blood pressure of control respondents (kumala et al., 2017). the study results prove that there is an effect of lowering blood pressure after psycho religious actions in the form of remembrance are carried out (kumala et al., 2017). the results of this study form the basis that psycho religious therapy in the form of remembrance can reduce blood pressure on the condition that it is practiced every time, either after worship or when there is no activity (annisafitri, 2020). dhikr functions as a beta-blocker drug (beta-receptor blocker) in the work of the sympathetic nerves (purnika & roesmono, 2019). dhikr, on the other hand, can make the brain wave flow into alpha waves when a person becomes very creative and highly reclusive so that every time the brain thinks (works), it produces biochemical reactions that react more strongly than others, depending on the emotional intensity of the mind and body (biology) closely connected (aini & astuti, 2020). thoughts give rise to emotions that evoke chemical reactions. some reactions are beneficial, and other reactions are impaired (suprayitno & huzaimah, 2020). this is in line with the research intending to reduce the use of drugs in treating hypertension and normalizing blood pressure. in this study, there were 40 respondents divided into two groups, namely the intervention group of 20 people and the control group of 20 people. the study results prove that there is an effect of lowering blood pressure after psycho religious actions in the form of remembrance is carried out. the results of this study form the basis that psycho religious therapy in the form of remembrance can reduce blood pressure on the condition that it is practiced every time, either after worship or when there is no activity. in general, people suffering from illness are followed by feelings of anxiety and an uneasy soul (hakim & ananingtyas, 2020). in addition to taking medicine, praying and dhikr can calm the individual's soul. as dhikr means remembering, it is a practice associated with https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.248-254 253 other ritual worship. dhikr can also be said as a form of awareness that a person has in establishing a relationship with the creator (setiyani, 2018). conclusion psychoreligious therapy in the form of remembrance can increase self-efficacy and reduce blood pressure in hypertensive patients in the elderly posyandu working area of teja pamekasan health center. acknowledgments the authors would like to thank the participants of this study. conflicts of interest there is no conflict of interest. references aini, l., & astuti, l. (2020). pengaruh terapi relaksasi dzikir terhadap penurunan tekanan darah pada penderita hipertensi. jurnal kesehatan: jurnal ilmiah multi sciences, 10(01), 38–45. anggraieni, w. n., & subandi, s. (2014). pengaruh terapi relaksasi dzikir untuk menurunkan stress pada penderita hipertensi essencial. jurnal intervensi psikologi (jip), 6(1), 81–102. https://doi.org/10.20885/intervensipsikologi.vol6.iss1.art6. annisafitri, f. n. (2020). pengaruh zikir terhadap tingkat stres dan tekanan darah pada penderita hipertensi di puskesmas gamping i [universitas ’aisyiyah yogyakarta]. http://digilib.unisayogya.ac.id/4949/. damayanti, c. n., hannan, m., fatoni, a. f., & suprayitno, e. (2019). efektifitas pendidikan kesehatan terhadap tekanan darah pada lansia. wiraraja medika: jurnal kesehatan, 9(2), 46–51. hakim, m. h., & ananingtyas, r. s. a. (2020). pengaruh dzikir terhadap potensi menurunkan tingkat stres mahasiswa dengan indikator tekanan darah dan detak jantung. briliant: jurnal riset dan konseptual, 5(2), 384. https://doi.org/10.28926/briliant.v5i2.468. hanefa, g. a. (2019). pengaruh dzikir terhadap penurunan tingkat stres pada lansia dengan hipertensi di kelurahan gedung johor medan [universitas sumatera utara]. https://repositori.usu.ac.id/bitstream/handle/123456789/23697/151101057.pdf?sequen ce=1&isallowed=y. indonesia ministry of health. (2013). riset kesehatan dasar. https://pusdatin.kemkes.go.id/resources/download/general/hasil riskesdas 2013.pdf. indonesia ministry of health. (2014). infodation hipertensi. https://pusdatin.kemkes.go.id/resources/download/pusdatin/infodatin/infodatinhipertensi-si-pembunuh-senyap.pdf. kumala, o. d., kusprayogi, y., & nashori, f. (2017). efektivitas pelatihan dzikir dalam meningkatkan ketenangan jiwa pada lansia penderita hipertensi. psympathic : jurnal ilmiah psikologi, 4(1), 55–66. https://doi.org/10.15575/psy.v4i1.1260. pertiwiningrum, d. a., & kamalah, a. d. (2021). gambaran self efficacy pada pasien hipertensi: literature review. prosiding seminar nasional kesehatan, 1, 2148–2156. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.248-254 254 https://doi.org/10.48144/prosiding.v1i.990. purnika, r., & roesmono, b. (2019). pengaruh meditasi dzikir terhadap perubahan tekanan darah pada pasien hipertensi. jurnal ilmiah kesehatan diagnosis, 14(4), 338–342. setiyani, n. f. (2018). pengaruh terapi relaksasi dzikir terhadap tingkat kecemasan pada lansia hipertensi [stikes insan cendikia medika jombang]. http://repo.stikesicmejbg.ac.id/id/eprint/931. suprayitno, e., & huzaimah, n. (2020). pendampingan lansia dalam pencegahan komplikasi hipertensi. selaparang jurnal pengabdian masyarakat berkemajuan, 4(1), 518– 521. suprayitno, e., & wahid, a. (2019). pendampingan tentang penyakit hipertensi dan perawatan keluarga dengan hipertensi. seminar nasional hasil pengabdian kepada masyarakat, 3(1), 104–106. https://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.1-7 1 distal hypospadias, treated or untreated? a case report agus santosa* universitas muhammadiyah purwokerto, indonesia corresponding author: agussantosa@ump.ac.id abstract background: treatment for distal hypospadias is a controversy among the experts. some argue that it does not require any surgery if it does not interfere with the patient's urinary and sexuality. purpose: this study aimed to determine whether patients with distal hypospadias need treated or untreated. methods: the method used is a case study. participants in this study is a 10-year-old male with distal hypospadias—location of the study in purwokerto city, banyumas district, central java. participants were interviewed and physically examined by a doctor and nurse. the results of interviews and physical examinations are recorded and analyzed based on a literature review to determine the decision, treatment, or untreated. results: a 10-year-old patient with hypospadias and the pediatric urologist do not give surgery advice, because the urethral opening is still close to the glans penis, and there are no symptoms of urinary dysfunction. conclusion: patients with distal hypospadias may be untreated as long as they do not interfere with urinary function. keywords: child, hypospadias, urologists, sexuality, reconstructive surgical procedures. received april, 30, 2020; revised june 6, 2020; accepted july 28, 2020 doi: https://doi.org/10.30994/jnp.v4i1.100 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:agussantosa@ump.ac.id https://doi.org/10.30994/jnp.v4i1.100 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.1-7 2 background hypospadias is a congenital abnormality at birth, where the urethral opening's location is below the penis (djakovic, nyarangi-dix, ozturk, & hohenfellner, 2008). around 70% of hypospadias identified are the distal hypospadias (van der horst & de wall, 2017). the exact prevalence of hypospadias in the world is difficult to estimate. a study reported the prevalence of hypospadias in the word 20.9 per 10,000 live births (yu et al., 2019). distal hypospadias is often regarded as "normal function," and the surgery for improvement is still being debated. the goal of hypospadias reconstruction surgery is to improve penis appearance and the urinary function. the reconstruction surgery can be done at any age but is recommended to do in 6-18 months old. as seen as a reasonable condition, the parents usually do not think of any immediate operation; they will then fall to the thought as their child has grown up (bhandarkar & garriboli, 2019). some opinions of pediatric urologist doctors also confirm that if the hypospadias is not expected to interfere with urination and sexual function, they do not need surgery. surgery can be considered for cosmetic purposes. the surgery will require the bending of the penis and the presence of disrupting urinary function. it sometimes requires more than a stage. besides, the artificial urethra can leak (fistula), or scar tissue can appear along the bottom of the penis. as a result, urine leakage can occur, thus needs an additional operation to repair it (soebadi, 2015). objective this study aimed to determine whether patients with distal hypospadias need treated or untreated and what factors are based on a literature review. methods the method used is a case study. participants in this study is a 10-year-old male with distal hypospadias—location of the study in purwokerto city, banyumas district, central java. participants were interviewed and physically examined by a doctor and nurse. the results of interviews and physical examinations are recorded and analyzed based on a literature review to determine the decision, treatment, or untreated. results a 10-year-old child experienced hypospadia. a surgical nurse's physical examination revealed that the urethral opening was not at the tip of the penis but the neck of the glans, indicating distal hypospadias (figure 1). the appearance of the penis is hooded because only the upper half of the penis is covered by foreskin (prepuce). the patient has no complaints of pain or difficulty urinating, but he should lift his penis glans to urinate well. the parents are anxious about their children's future, whether their child will have healthy sexuality, and whether he can still have offspring(s). the patient advised visiting the pediatric urologist. the result of the examination shows that he has distal hypospadias. he was not advised to undergo hypospadias reconstruction surgery because the urethral opening is still close to the glans penis, and there are no symptoms of urinary dysfunction. besides, the operations will mean expensive costs and maybe requires two stages of surgery. the doctor argued that his sexual function would be useful, and he would still be able to have children without any surgery performed. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.1-7 3 discussion hypospadias is a congenital abnormality at birth, where the location of the urethral opening is below the penis (djakovic, nyarangi-dix, ozturk, & hohenfellner, 2008). based on the position of the meatus, hypospadias divided into distal and proximal (van der horst & de wall, 2017). hypospadias is very easy to detect because its symptoms are very typical. the symptoms are the opening of the urethra in locations other than the tip of the penis, the curve of the penis pointing downwards (chordee), appearance of the penis veil because the foreskin only includes the upper half of the penis, and the urination is not normal (kraft, shukla, & canning, 2010). hypospadias is a congenital disorder with multifactorial causes. the genetic factor, prenatally hormonal stimulation, placental, and environmental regarded to be hypospadias. as much as 7% of hypospadias patients have a genetic history (fredell et al., 2002). the study found that patients with hypospadias had mutations in the genes of wt1, sf1, bmp4, bmp7, hoxa4, hoxb6, fgf8, fgfr2, ar, hsd3b2, srd5a2, atf3, mamld1, mid1, and bnc2 (van der zanden et al., 2012). lack of androgen hormone production, increased estrogen during pregnancy, and placental insufficiency regarded to be a factor in hypospadias (hsieh, breyer, eisenberg, & baskin, 2008; sharpe, 2003; yinon et al., 2010). environmental variables such as exposure to pollution and chemicals can also increase the incidence of hypospadias (bouty, ayers, pask, heloury, & sinclair, 2015). purposeful consideration: cosmetic or reconstructive the only hypospadias treatment is reconstructive surgery (djakovic, nyarangi-dix, ozturk, & hohenfellner, 2008). there are various reconstructive surgery techniques for hypospadias patients, and they have a success rate (smith, 1953). although the surgery need for distal hypospadias is still controversial among the pediatric urologists--whether it is cosmetic or reconstructive surgery--they agreed that surgery has to taken if it interferes with the patient's urinary process (snodgrass & bush, 2018). in the case in question, the pediatric urologist does not recommend surgery because the urethral opening is still close to the glans penis. besides, the patient also does not complain of urinary difficulties or others. thus, the pediatrician thinks that surgery on distal hypospadias is more cosmetic nature than reconstructive. physiological considerations the hypospadias-affected penis will not develop normally. if the condition not treated, there will be more adverse symptoms. among them are an abnormal shape of the penis, arduous sexual intercourse, dysuria, strangury, and even urinary incontinence. in such a situation, surgery will be urgently required (keays et al., 2016; schlomer, breyer, copp, baskin, & disandro, 2014; snodgrass & bush, 2018). consideration of complications the results of surgery for hypospadias patients are often unsatisfactory, with reported rates of complications reaching 40% and even more (appeadu-mensah et al., 2015; mammo et al., 2018). for distal hypospadias, the highest complication reported reaching 33% (klijn, dik, & de jong, 2001; stein, 2012). postoperative hypospadias complications are divided into mild and severe complications. minor complications include bleeding, hematoma, edema, and severe complications, including wound infection, wound dehiscence, skin necrosis, flap necrosis, fistula, and penile torsion (agrawal & misra, 2013; bhat & mandal, journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.1-7 4 2008). some experts could consider this in deciding either to do a repair operation or not. cost considerations hypospadias surgery can be performed in a single stage or multiple stages, depending on the method applied, with or without urethral reconstruction (bracka, 2008; stein, 2012; subramaniam, spinoit, & hoebeke, 2011). one-stage surgery is a standard practice in the management of distal hypospadias (badawy & fahmy, 2013), but a study reports that its success rate is only 55.9% (mammo et al., 2018). the surgery cost is around the us $ 14,000 (svensson, reychman, troëng, & åberg, 1997). in indonesia, the range of its costs is between rp. 30,000,000-80,000,000 (us $ 2,142-5,714), depending on the hospital rate. consideration of sexual function and infertility a study conducted in adults with distal hypospadias who did not take surgery. it found that they were not interested in corrective surgery. they stated that they remained satisfied with the appearance of their penis, retained normal sexual function, and did not have any infertility problems (dodds et al., 2008). another survey result proved contradictory results for those having surgery. a patient with hypospadias who have undergone a surgery claimed dissatisfaction with the penis appearance and size. it also found a decrease in libido after hypospadias repair (kimihiko et al., 2006). this is likely related to an unfortunate result of cosmetic surgery (springer, a., 2014). a weak erection and ejaculation are experienced by almost all post-repair hypospadias patients (singh, jayanthi, & gopalakrishnan, 2008). there were no infertility problems found in distal hypospadias, either treated or not (kumar et al., 2016). the issues only found in those with the proximal type, and they usually have lower fertility (ortqvist et al., 2017). conclusion patients with distal hypospadias may not be treated as long as it does not interfere with the patient's urinary function. they will have a healthy sex life and have children. the physiological aspect, postoperative complications, and cost factors are more relevant to decision treatment of distal hypospadias than the cosmetic issue. implication for nursing science the role of the nurse as an educator is crucial in this case. health education for patients and families is essential so that families and patients feel calm. conflicts of interest the author declares no conflict of interest. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 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(2012). aetiology of hypospadias: a systematic review of genes and environment. human reproduction update, 18(3), 260–283. https://doi.org/10.1093/humupd/dms002 yinon, y., kingdom, j. c. p., proctor, l. k., kelly, e. n., salle, j. l. p., wherrett, d., … chitayat, d. (2010). hypospadias in males with intrauterine growth restriction due to placental insufficiency: the placental role in the embryogenesis of male external genitalia. american journal of medical genetics. part a, 152a(1), 75–83. https://doi.org/10.1002/ajmg.a.33140 yu, x., nassar, n., mastroiacovo, p., canfield, m., groisman, b., bermejo-sánchez, e., … agopian, a. j. (2019). hypospadias prevalence and trends in international birth defect surveillance systems, 1980&#x2013;2010. european urology, 76(4), 482–490. https://doi.org/10.1016/j.eururo.2019.06.027 figure captions figure 1. distal hypospadias appear https://pubmed.ncbi.nlm.nih.gov/22371315/ https://pubmed.ncbi.nlm.nih.gov/22371315/ https://pubmed.ncbi.nlm.nih.gov/20014131/ https://pubmed.ncbi.nlm.nih.gov/31300237/ journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 24 32 24 penerapan wudhu sebagai hydro therapy terhadap tingkat stress pada lansia upt pslu blitar di tulungagung dhita kurnia sari, muhamad wahyu mahardyka stikes surya mitra husada kediri deeniasari88@gmail.com abstrack aging is a gradual process of gradually disappearing the network's ability to repair itself. one of the health problems experienced by the elderly is stress. hydro therapy can be done to reduce stress levels in the elderly is by ablution. the purpose of this study was to determine the effect of ablution application as hydro therapy to stress level in elderly upt pslu blitar in tulungagung.this research uses pre research design design with one group pretest-posttest design research method. the population is the elderly who islamic in upt pslu blitar in tulungagung with a sample of 44 respondents taken with purposive sampling technique. the independent variable in this study is the provision of ablution therapy while the dependent variable is the stress level. while to know the relationship between variables in use wilcoxon test. the results showed, before given the treatment of ablution almost half of all respondents experiencing severe stress that is equal to 15 respondents (34%). after being given ablution treatment almost half of all respondents in normal stress that is equal to 17 respondents (39%). test wilcoxon with p value 0.05 = 0.000 <0.05 then h0 rejected which means there is influence between the implementation of ablution as hydro therapy to stress level in elderly upt pslu blitar in tulungagung.properly performed and regular ablution can reduce stress levels in the elderly. hydro therapy with ablution begins with positive words of intention and prayer where it can stimulate the brain to be more relaxed so as to reduce stress in the elderly. keywords: ablution, hydro therapy, stress level, elderly received august 21, 2017; revised september 07, 2017; accepted october 01, 2017 how to cite: sari, d.k & mahardika, m.w. (2017). penerapan wudhu sebagai hydro therapy terhadap tingkat stres pada lansia upt pslu blitar di tulungagung. journal of nursing practice. 1(1). 24-32. the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 24 32 25 pendahuluan kesehatan jiwa merupakan salah satu bagian dari unsur kesehatan masyarakat dan merupakan bagian yang tidak terpisahkan dalam rangka mewujudkan tujuan pembangunan kesehatan. gangguan jiwa yang paling banyak di derita oleh masyarakat saat ini adalah stres. di zaman modern ini stres merupakan salah satu gangguan yang sering diderita oleh semua kelompok masyarakat. stres dapat melanda siapa saja dan dimana saja dalam bentuk tertentu, tidak ada seorangpun yang dapat menghindari dari stres baik itu bayi, kaum remaja, kaum muda, dan orang dewasa, terlebih lagi kelompok lansia (sriati, 2008). proses menua akan terjadi perubahan-perubahan baik anatomis, biologis, fisiologis maupun psikologis. gejala-gejala kemunduran fisik antara lain kulit mulai mengendur, timbul keriput, pendengaran dan penglihatan berkurang, mudah lelah, gerakan mulai lamban dan kurang lincah. masalah tersebut akan berpotensi pada masalah kesehatan baik secara umum maupun kesehatan jiwa. penurunan kondisi fisik ini yang mempengaruhi kondisi mental dan psikologis pada lanjut usia. adanya perubahan-perubahan yang dialami lansia, seperti perubahan pada fisik, psikologis, spiritual, dan psikososial menyebabkan lansia mudah mengalami stres (azizah, 2011). who memperkirakan tahun 2025 jumlah lansia di seluruh dunia akan mencapai 1,2 miliar orang yang akan terus bertambah hingga 2 miliar orang di tahun 2050. data who juga memperkirakan 75% populasi lansia di dunia pada tahun 2025 berada di negara berkembang. jumlah lansia di indonesia mencapai 20,24 juta jiwa, setara dengan 8,03 persen dari seluruh penduduk indonesia pada tahun 2014. di indonesia jumlah rumah tangga lansia sebanyak 16,08 juta atau 24,50 % dari seluruh rumah tangga di indonesia. jumlah lansia perempuan lebih besar daripada laki-laki yaitu 10,77 juta lansia perempuan dibandingkan 9,47 juta lansia laki-laki (susenas, 2013). berdasarkan hasil studi pendahuluan yang dilakukan peneliti pada tanggal 16 juni 2016 di upt pslu blitar di tulungagung, didapatkan data bahwa terdapat 80 lanjut usia, 49 perempuan dan 31 laki-laki. dari 80 penghuni 72 diantaranya beragama islam. menurut pengelola panti belum ada pencatatan khusus tentang data tingkat stres yang terjadi padalansia di upt pslu tersebut.untuk itu peneliti melakukan studi pendahuluan awal dengan mengukur tingkat stres pada 10 orang lansia yang beragama islam di upt pslu tersebutdenganmenggunakankuesionertingkat stres dass 42. dari hasilpengukuran tersebut peneliti mendapatkan data terdapat 2 lansia mengalami stres berat, 6 lansia mengalami stres sedang dan 2 lansia mengalami stres ringan. dari keteranganlansiadi upt pslu tersebutmerekamengalamistres di sebabkankarenaberbagai masalahyang mengganggu fikirannya seperti masalah padakeluarga, masalahekonomisertatidaknyamandenganlingkungantempat tinggalnya. beberapa lansia di upt pslu tersebut juga belumteraturdalammelaksanakanibadah wudhu, khususnya dalam mengerjakan wudhu untuk melaksanakan sholad. wudhu adalah kegiatan menggunakan air yang suci dan bersih dengan membasuh, mengusap, menyela-nyela pada organ-organ tubuh yang terletak pada journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 24 32 26 wajah, tangan, kepala, telinga dan kaki. terapi wudhu dapat di kategorikan sebagai terapi air atau hydro therapy karena menggunakan media air sebagai syariatnya. dalam dunia kedokteran terapi air sudah lama dikenal. seorang dokter dari amerika telah menciptakan teori tentang hukum baruch, teori ini menjelaskan bahwa air memiliki daya penenang jika suhu air sama dengan suhu kulit, sedang bila suhu air lebih tinggi atau rendah maka dia akan memberikan efek stimulasi (haryanto, 2006).tujuan penelitianiniadalah untuk mengetahui pengaruh penerapan wudhu sebagai hydro therapy terhadap tingkat stres pada lansia upt pslu blitar di tulungagung. metode penelitian penelitian ini menggunakan desain penelitian pre exsperimental design dengan metode rancangan penelitian one group pretest-posttest design. populasinya adalah lansia yang beragama islam di upt pslu blitar di tulungagung dengan sampel sebanyak 44 responden di ambil dengan tehnik purposive sampling. variabel independen dalam penelitian ini adalah pemberian terapi wudhu sedangkan variabel dependennya adalah tingkat stres. sedangkan untuk mengetahui hubungan antar variabel di gunakan uji wilcoxon hasil penelitian karakteristik subyek tabel 1. karakteristik responden dalam penelitian ini meliputi jenis kelamin, usia, pendidikan, tingkatsresssebelumdansesudahdiberikanperlakuanwudhu. no karakteristik σn σ% 1 jenis kelamin laki-laki perempuan 16 28 36,4 63,6 2 usia (th) 55-65 66-75 76-85 15 23 6 34,1 52,3 13,7 3 pendidikan tidaksekolah sd smp sma 21 19 2 2 47,7 43,3 4,5 4,5 4 tingkat stress (pre) ringan sedang berat sangatberat 6 12 15 11 14 27 34 25 5 tingkat stress (post) normal ringan sedang berat 17 14 10 2 39 32 23 4 journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 24 32 27 sangatberat 1 2 total 44 100 sumber: hasil analisa data, tahun 2017 berdasarkan tabel 1 diatas dari total44 responden yang berusia antara 66-75 tahun yaitu berjumlah 23 responden (52,3%), berjenis kelamin perempuan yaitu berjumlah 28 responden (63,6%), memiliki tingkat pendidikan tidak sekolah yaitu 21 responden (47,7%), sebelum diberikan perlakuan wudhu mengalami stres berat yakni sebesar 15 responden (34%)dansetelah diberikan perlakuan wudhu hampir setengah dari seluruh responden dalam stres normal yaitu sebanyak 17 responden (39%). tabel 2. hasil uji statistikpenerapan wudhu sebagai hydro therapy terhadap tingkat stres pada lansia upt pslu blitar di tulungagung tanggal 17 23 juni 2017 n mean rank sum of ranks post test – pre test negative ranks 41 a 21.00 861.00 positive ranks 0 b .00 .00 ties 3 c total 44 a. post test < pretest b. post test > pretest c. post test = pretest berdasarkan tabel 2 analisa data menunjukkan bahwa sampel dengan nilai kelompok post test tidak ada yang lebih tinggi dari nilai kelompok pre test. dan terdapat 3 responden dengan nilai yang sama antara kelompok pre test dan post test. table 3.hasil uji statistikpenerapan wudhu sebagai hydro therapy terhadap tingkat stres pada lansia upt pslu blitar di tulungagung tanggal 17 23 juni 2017. tes statistics b postest – pretest z -5.583 a asymp. sig. (2-tailed) .000 a. based on positive ranks b. wilcoxon signed ranks test. berdasarkan tabel 3 uji statistik wilcoxon menggunakan program spss dengan α=0,05, didapatkan nilai p value=0,000 sehingga 0,000<0,05. dapat disimpulkan bahwa h0 ditolak yang berarti ada pengaruh antara penerapan wudhu journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 24 32 28 sebagai hydro therapy terhadap tingkat stres pada lansia upt pslu blitar di tulungagung. pembahasan tingkat stres pada lansia sebelum di berikan terapi wudhu pada lansia upt pslu blitar di tulungagung. hasil penelitian penerapan wudhu sebagai hydro therapy terhadap tingkat stres pada lansia upt pslu blitar di tulungagung sebelum dilakukan perlakuan wudhu kepada 44 responden berdasarkan tabel 4.1 di ketahui hampir setengah dari seluruh responden sebelum di berikan perlakuan wudhu mengalami stres berat yakni sebesar 15 responden (34%). azizah (2011) mengatakan faktor yang mempengaruhi stres pada lansia ada dua, yaitu faktor internal dan eksternal. faktor internal adalah sumber stres yang berasal dari diri lansia itu sendiri, seperti penyakit dan konflik. sedangkan faktor eksternal adalah sumber stres yang berasal dari luar diri lansia itu sendiri seperti keluarga dan lingkungan. stres pada lansia juga dapat menimbulkan dampak negatif misalnya pusing, tekanan darah tinggi, mudah marah, sedih, sulit berkonsentrasi, nafsu makan berubah dan tidak bisa tidur. dampak ini dapat merugikan sekali bagi lanjut usia, terutama untuk kesehatan psikis dan kehidupan dalam bermasyarakat. lansia yang telah memasuki usia 60 tahun ke atas harus menyesuaikan dengan berbagai perubahan baik yang bersifat fisik, mental maupun sosial. adanya perubahan-perubahan yang dialami lansia seperti perubahan pada fisik, psikologis, spiritual, dan psikososial menyebabkan menyebabkan lansia tersebut mudah mengalami stres. nungki kustantya (2013) pada penelitiannya mengungkapkan semakin kurang tingkat pengetahuan atau pendidikan lansia tentang perilaku hidup bersih dan sehat maka semakin tinggi resiko terkena penyakit. maka meningkatkan pengetahuan dapat mempengaruhi seseorang termasuk juga perilaku seseorang akan pola hidup terutama dalam memotivasi untuk sikap berperan serta dalam meningkatkan status kesehatan. dengan mengetahui pola hidup yang sehat maka lansia tidak akan mudah terkena stres karena mereka mengetahui bagaimana cara mengotrol stres yang efektif. tingkat stres pada lansia setelah di berikan terapi wudhu pada lansia upt pslu blitar di tulungagung. hasil penelitian penerapan wudhu sebagai hydro therapy terhadap tingkat stres pada lansia upt pslu blitar di tulungagung setelah dilakukan perlakuan wudhu kepada 44 responden berdasarkan tabel 4.2 di ketahui bahwa hampir setengah dari seluruh responden dalam stres normal yaitu sebanyak 17 responden (39%). wudhu adalah kegiatan menggunakan air yang suci dan bersih dengan membasuh, mengusap, menyela-nyela pada organ-organ tubuh yang terletak pada wajah, tangan, kepala, telinga dan kaki. sedangkan menurut istilahwudhu berarti membasuh,mengalirkan dan membersihkan dengan menggunakan air pada setiap journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 24 32 29 bagian dari anggota-anggota wudhu untuk menghilangkan hadast kecil(akrom, 2010). terapi wudhu sendiri dapat di kategorikan sebagai terapi air atau hydro therapy karena menggunakan media air sebagai syariatnya.hydro therapy dengan berwudhu ini memiliki kelebihan daripada hydro therapy yang biasa dilakukan oleh seseorang. hal ini dikarenakan hydro therapy dengan berwudhu disertai dengan kata-kata positif niat dan do’a, dimana kata-kata positif tersebut dapat bermanfaat bagi manusia (emoto, 2007). pada penelitian sebelumnya yang di lakukan oleh yudiardi haliman (2010) di jelaskan bahwa terapi wudhu dapat menurunkan tingkat kecemasan pada lansia. kecemasan merupakan salah satu tanda awal terjadinya stres pada seseorang. ketika seseorang itu mengalami kecemasan yang berlebihan maka akan mengakibatkan stres hingga depresi. sesuai dengan beberapa teori di atas maka melakukan wudhu secara teratur sangatlah di anjurkan bagi lansia. dari hasil penelitian di upt pslu blitar di tulungagung terbukti melakukan wudhu dengan benar dan teratur dapat menurunkan tingkat stres pada lansia. hal tersebut sesuai dengan penelitian sebelumnya tentang manfaat melakukan wudhu. untuk itu kedepannya di harapkan bagi lansia untuk lebih teratur melakukan wudhu agar fikiran menjadi tenang dan rileks agar tidak mudah terkena stres. pengaruh penerapanwudhusebagaihydrotherapyterhadaptingkatstrespadalansia upt pslu blitar di tulungagung. sebelum di berikan perlakuan wudhu 44 responden atau 100% responden mengalami stres dengan kriteria ringan, sedang, berat dan sangat berat. sedangkan sesudah di berikan perlakuan wudhu sebanyak 41 responden atau 93 % responden mengalami penurunan tingkat stres. hasil uji statistik pada tabel 4.11 menunjukkan bahwa p value<α atau 0,000<0,05, sehingga dapat disimpulkan bahwa terdapat perubahan antara tingkat stres sebelum dan sesudah diberikan perlakuan wudhu. pemberian terapiwudhu pada lansia dapat mempengaruhi tingkat stres pada lansia tersebut. hal tersebut dapat di lihat pada tabel 4.10dari 44 responden setelah di berikan perlakuan wudhu menunjukkan terjadinya penurunan tingkat stres kepada 41 responden. hal tersebut disebakan karena lansia tersebut mau mengikuti arahan yang di sampaikan oleh peneliti untuk melakukan wudhu 8 kali sehari dalam waktu 1 minggu secara teratur. sementara 3 responden lain tidak mengalami penurunan maupun peningkatan tingkat stres. hal tersebut di sebabkan karena 3 responden tersebut memiliki masalah berat pada keluarga dan lingkungannya hingga menyebabkan kurang fokus terhadap arahan dari penliti. salah satu responden tersebut mengatakan bahwa dia di telantarkan oleh keluarganya hingga menyebabkan dia tinggal di panti tersebut. keluarga dari responden tersebut juga tidak pernah menjenguk responden tersebut. di sisi lain responden tersebut tidak nyaman dengan suasana lingkungan tempat tinggalnya. hal tersebut yang menjadi journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 24 32 30 alasan lansia mengapa ketika peneliti melakukan penelitian tingkat stres pada lansia tersebut tidak mengalami penurunan. wudhu pada hakikatnya bukan saja sebagai sarana pembersihan diri tapi juga memberikan terapi yang luar biasa bagi ketenangan jiwa. percikan air wudhu pada beberapa anggota tubuh menghadirkan rasa damai sehingga pikiran dan tubuh menjadi rileks (akrom, 2010). berdasarkan penelitian yang dilakukan oleh prof leopold werner von ehrenfels, dia mengatakan bahwa pusat-pusat syaraf yang paling peka dari tubuh manusia ternyata berada di sebelah dahi, tangan dan kaki. pusat-pusat syaraf tersebut sangat sensitif terhadap air segar. jika bagian-bagian tersebut terbasuh air, maka akan tercipta kesegaran yang mencapai pusat saraf. ketika seseorang melakukan wudhu pasti akan membasuh ketiga bagian tubuh tersebut. hal ini akan menyebabkan terjaganya kesehatan dan kebugaran tubuh hingga seseorang tersebut tidak mudah mengalami stres(syarif hidayatullah, 2014). masaru emoto (2007) mengatakan bahwa kata-kata adalah getaran, dan ketika tubuh kita bersama semua air yang terkandung di dalamnya terpapar pada kata-kata yang baik, kita akan sehat dan sejahtera. air merupakan pengangkut utama yang mampu menangkap dan mengantarkan segala sesuatu dan segalanya, termasuk air yang diperdengarkan oleh kata-kata. hal ini dibuktikan dengan hasil penelitiannya yang menunjukkan bahwa air yang dipaparkan kata-kata positif akan menghasilkan kristal yang berbentuk heksagonal yang cantik. apabila kata-kata positif saja menghasilkan kristal yang cantik, tentulah niat dan do’a yang baik akan menghasilkan kristal yang lebih sempurna. oleh karena itu, ketika air yang kita gunakan untuk berwudhu mendengarkan kata-kata positif (niat dan do’a) dari kita, maka air tersebut mengirimkan pesan ke dalam tubuh kita agar selalu dalam keadaan sehat. air yang mengandung getaran ini mendorong ke luar getaran negatif yang berada dalam tubuh. akibatnya metabolisme dalam tubuh menjadi sehat seta menjadikan fikiran terhindar dari stres. ketika seseorang mengalami stres, hormon kortisol dalam tubuh akan meningkat. dengan melakukan wudhu yang baik dan benar akan menstimulasi hormon endorfen dalam tubuh. hormon endorfen merupakan hormon yang membuat manusia menjadi rileks dan bahagia. ketika fikiran dan tubuh kita terasa rileks maka jumlah hormon endorfin dalam tubuh kita akan meningkat. di sisi lain hormon kortisol atau hormon yang menyebabkan stres dalam tubuh akan menurun. untuk itu sangat di anjurkan bagi lansia untuk melakukan wudhu secara teratur. dari uraian teori di atas dapat di ketahui bahwa sebenarnya lansia mampu untuk mengurangi tingkat stresnya, yaitu dengan melakukan wudhu secara benar dan teratur. dengan teratur melakukan wudhu kedepannya di harapkan lansia mampu untuk mengontrol tingkat stresnya secara mandiri. kesimpulan dan saran kesimpulan 1. berdasarkan hasil penelitian di dapatkan bahwa sebagian besar responden sebelum diberikan perlakuan wudhu hampir setengah dari seluruh respondenmengalami stres berat yakni sebesar 15 responden (34%). journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 24 32 31 2. setelah diberikan perlakuan wudhu di dapatkan rata-rata tingkat stres pada responden mengalami penurunan,diketahui hampir setengah dari seluruh responden dalam stres normal yaitu sebanyak 17 responden (39%). 3. berdasarkan tabel uji statistik wilcoxon menggunakan program spss dengan α=0,05, didapatkan nilai p value=0,000 sehingga 0,000<0,05. dapat disimpulkan bahwa h0 ditolak yang berarti ada pengaruh antara penerapan wudhu sebagai hydro therapy terhadap tingkat stres pada lansia upt pslu blitar di tulungagung. daftar pustaka akrom, muhammad.(2010). terapi wudhu; sempurna sholat, bersihkan penyakit, yogyakarta: mutiara media. amin ruwaihah. (2008). al-tadaawi bi al-maa (pengobatan dengan air) terj. abu maftuh gherry. surabaya: duta media. atun.(2010).lansia sehat & bugar. jakarta: kreasi wacana. azizah, lilik ma’rifatul. (2011). keperawatan lanjut usia, edisi i. yogyakarta : graha ilmu. chaitow, leon (2008). hydrotherapy,water therapy, for health dan beautiful (terapi air untuk kesehatan dan kecantikan). jakarta: prestasi pustaka darmojo, boedhi, hadi martono.(2006). buku ajar geriatri (ilmu kesehatan usia lanjut) edisi ke 3. jakarta: fkui. dian adi saputro. (2015). pengaruh terapi wudhu sebelum tidur terhadap tingkat insomnia pada lanjut usia di pstw unit budhi luhur yogyakarta. skripsi mahasiswa sarjana keperawatan pada program pendidikan ners di sekolah tinggi ilmu kesehatan aisyiyah yogyakarta. effendi, m. (2009). keperawatan kesehatan komunitas. jakarta:salemba medika. emoto, masaru. (2007). the miracle of water (mu’jizat air), terj. susi purwoko, jakarta: pt gramedia pustaka utama. haryanto, s. (2006). psikologi shalat. yogyakarta: pustaka pelajar. hasanuddin, oan.(2007). mukjizat berwudhu. jakarta: qultum media. hawari, dadang. (2011). manajemen stres cemas dan depresi. jakarta: fk universitas indonesia. hidayatullah, syarif (2014), dahsyatnya ibadah ibadah siang hari. jogjakarta: diva press, ibrahim al-bajuri. (2007). al bajuri ‘ala ibn qosim. jakarta: dar al-kutub al-islamiyah. ismail, h.(2009).memahami krisis lanjut usia, jakarta: gunung mulia. kardjono, moehari.(2009). kedahsyatan wudhu penghapus dosa. yogyakarta: best publisher. kholid, m. (2012). keperawatan geriatrik. yogyakarta: pustaka belajar. kholilu rohman. (2008). pengaruh wudhu dalam mereduksi marah. skripsi mahasiswa sarjana psikologi di universitas islam negeri syarif hidayatullah jakarta. journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 24 32 32 lazarus, richard s. (2007). stress, appraisal and coping. usa: springer verlag. maryam, dkk.(2008).mengenal usia lanjut dan perawatnnya. jakarta: salemba medika. muhyidin, muhammad (2007). misteri energi wudhu: keajaiban fadhilah energi wudhu terhadap kekuatan fisik, emosi dan hati manusia. jogjakarta: diva press mujib, a. (2007). kepribadian dalam psikologi islam. jakarta: rajawali pers. norkasiani, s.(2009). kesehatan usia lanjut dengan pendekatan asuhankeperawatan, jakarta: salemba merdeka. nugroho ,w. (2012).keperawatan gerontik& geriatrik. jakarta:egc. potter, patricia a, anne grifin perry.(2005). buku ajar fundamental keperawatan : konsep, proses dan praktek, edisi 4. jakarta : egc. rasmun. (2009). stres, koping dan adaptasi. jakarta: sagung seto. santrock, jhon w. (2003). life-span development (perkembangan masa hidup) jilid 2 edisi 5. trj, achmad chusairi dan juda damanik. jakarta: erlangga sholeh. (2009). terapi shalad tahajud. jakarta: noura books sriati. (2008). tinjauan tentang stres. jatinangor: unpad syafi’ie el-bantanie, muhammad.(2010). dahsyatnya terapi wudhu.jakarta: pt alex media komputindo. tamber, s. & noorkasimi. (2009). kesehatan usia lanjut dengan pendekatan asuhan keperawatan. jakarta: salemba medika. wijaya, elen. (2009). penggunaan obat psikotropika pada usialanjut. jakarta : graha ilmu yafie, alie, dkk. (2010). ensiklopedi al-qur’an jilid i: bersama allah.jakarta : kharisma ilmu. yuniardi haliman. (2010). pengaruh terapi wudhu terhadap penurunan tingkat kecemasan pada lanjut usia di panti sosial tresna werdha puspakarma mataram. skripsi mahasiswa sarjana keperawatan di sekolah tinggi ilmu kesehatan mataram. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.155-161 155 tandem walking exercise for the risk of falling and the daily and activities’ independency toward elderly preopleat upt pstw nirwana puri samarinda hesti prawita widiastuti*, leny pamungkas, arsyawina, hilda nursing department, poltekkes kemenkes kaltim, indonesia corresponding author: hestiprawita.poltekkeskaltim@gmail.com abstract background: stability is the ability of maintaining static and dynamics equilibrium, which influenced the falling incident and the capability in doing everyday activities of elderlies purpose: the purpose of this study is to analyze the effect of tandem walking exercise for the daily activities’ independency and the risk of falling towards elderly people. methods: this research is quasi experiment with pre and post-test nonequivalent control group design. the samples are 22 people that distributed into control and treatment group who were given tandem walking exercise three times a week for two weeks. assessment of the independence of daily activities through observation, interviews and using barthel index instruments while falling risk is assessed using time up and go test (tugt). results: the result of hypothesis tests with wilcoxon obtained that there is an impact from tandem walking exercise for the daily activities’ independency (p value = 0,009) and the risk of falling (p value = 0,003). the deviation analysis on two groups acquired that the group 1 with interventions of tandem walking exercise is having more impact on the improvement of daily activities’ independency with mann-whitney test (p value = 0,044) and the reduction on risk of falling with independent t-test (p value = 0,000) compared to control group. conclusion: tandem walking exercise could improve daily activities’ independency and lower the risk of falling towards elderly people. keywords: tandem walking, independency, elderly people, risk of falling. received august 12, 2021; revised august 21, 2021; accepted september 17, 2021 doi: https://doi.org/10.30994/jnp.v5i1.166 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. http://thejnp.org/ mailto:hestiprawita.poltekkeskaltim@gmail.com https://doi.org/10.30994/jnp.v5i1.166 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.155-161 156 background along with the increase in the welfare and health of the population, life expectancy (uhh) has also increased. life expectancy in indonesia in 2015 reached 70.8 years, an increase from 70.07 years in 2013. this figure shows that life expectancy in indonesia is getting higher from year to year. the increase in life expectancy is directly proportional to the increase in the elderly population. the elderly population in indonesia reaches 20.24 million people, equivalent to 8.03% of the entire population of indonesia (badan pusat statistik, 2014), while data kementerian kesehatan ri (2016), the percentage of the elderly population in indonesia reaches 8.5% of the total population of indonesia. total population in indonesia. problems that often occur due to an increase in the number of the elderly population such as physical, psychological, and social decline (padila, 2013). falls are one of the physical problems that often occur in the elderly. falls can result in various types of injuries, physical and psychological damage. the most worrying consequences of falls are fractures that cause ± 20-30% of deaths, head trauma, fear of repeated falls and the most common is loss of independence due to decreased movement and functional ability (stanley, m., & beare, 2007). the results of a preliminary study in april 2017 found that the number of elderly people was 88 people, with a level of independent dependence as much as 54.25%, mild dependence as much as 38.29%, moderate dependence as much as 1.06%, severe dependence as much as 5.31%, and total dependence. as much as 1.06%. while the results of a preliminary study in october 2017, out of a total of 102 elderly people, 9 elderly people have fallen in the past year. this figure has increased compared to the previous year, which was 6 incidents of falls. this shows the high incidence of falls in the elderly. good, correct, measurable, and regular physical exercise (bbtt) as well as exercises that are in accordance with the level of health, physical activity, and fitness of each individual can reduce the risk of bone disorders that cause the risk of falls in the elderly (tobing, 2011). one of the best physical exercises is balance training. balance training is important in the elderly because this exercise really helps to maintain a stable body so as to prevent falls that often occur in the elderly, optimize their abilities so as to avoid the impacts that occur due to their inability (nugrahani, 2014). the tandem stance is a test as well as an exercise performed by walking in a straight line with the heel of the foot touching the toes of the other for 3-6 meters. this exercise can improve lateral postural balance which plays a role in reducing the risk of falling in the elderly and is a type of balance exercise that involves proprioception of body stability (baston, 2009). the formulation of the problem in this study is "is there an effect of tandem walking exercise on the risk of falling and the independence of daily activities in the elderly at uptd pstw nirwana puri samarinda?". objective the purpose of this study was to determine the effect of tandem walking exercise on the risk of falls and the independence of daily activities in the elderly at uptd pstw nirwana puri samarinda. methods this research is quasi experiment with pre and post-test nonequivalent control group design. the population at the time of the study amounted to 102 elderly in uptd nirwana puri samarinda. a sample of 22 people was selected based on consecutive sampling http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.155-161 157 technique and divided into 2 groups, 11 people in the control group took part in elderly gymnastics which was routinely held at the orphanage and 11 people in the treatment group were given tandem walking exercises as far as 3 meters in 3 sets with a frequency of 3 times. intervention every week for 2 weeks. data collection was carried out on april 23 – 05 may 2018 at uptd pstw nirwana puri samarinda. the data collection stage is through direct measurement of the independence of daily activities and the risk of falling pre-test and post-test of tandem walking exercises. assessment of the independence of daily activities through observation and interviews using the barthel index instrument while the risk of falling is assessed using the time up and go test (tugt). the data that has been collected was analyzed by comparing the value of independence in daily activities and the risk of falling before and after giving tandem walking exercises using the paired t-test statistical test and the wilcoxon test on data that did not meet the assumptions (not normally distributed). furthermore, the analysis was carried out using the independent t-test test on normally distributed data or the mann whitney test on data that were not normally distributed to test the difference in the mean of the two measurement results in the two groups. results respondents who became the sample amounted to 22 people. there were no respondents who dropped out in this study. tables 1 show the frequency distribution of the respondents' characteristics. table 1. frequency distribution of respondents by gender and age variable group 1 group 2 gender: male female 4 (36,4%) 7 (63,6%) 4 (36,4%) 7 (63,6%) age (years): 60 – 64 65 – 69 70 74 1 (9,1%) 3 (27,3%) 7 (63,6%) 0 2 (18,2%) 9 (81,8%) based on table 1, the average respondent in this study was > 70 74 years old. this is in accordance with the departemen kesehatan ri, (2009) which says that over 70 years of age is a high risk age group. ages over 70 years experience decreased body system functions, including balance, compared to elderly people aged less than 70 years. the decline in the function of these body systems includes the neurological, sensory, cardiovascular, and musculoskeletal systems. the sample in this study amounted to 22 people who were divided into two groups with a frequency of four males and seven females in each group. this shows that there are more women than men. this is supported by research by maryam, r. s., sahar, j., & nasution, (2009) which states that balance disorders are more common in elderly women than men. hormonally, elderly women experience menopause where there is a decrease in the hormone estrogen which can cause bones to lose calcium so that it affects balance (mauk, 2010). http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.155-161 158 table 2. the risk of falling and the independence of daily activities in group 1 responden the risk of falling the independence of daily activities pre post difference pre post difference 1 13,8 9,21 4,62 19 20 1 2 28,1 17,6 10,48 19 19 0 3 18,0 14,7 3,23 19 20 1 4 16,4 10,2 6,21 19 20 1 5 15,0 10,4 4,55 19 20 1 6 32,4 27,3 5,04 16 18 2 7 16,3 10,7 5,62 18 20 2 8 19,7 12,7 7,00 20 20 0 9 14,1 10,6 3,45 20 20 0 10 23,6 18,1 5,58 17 19 2 11 19,5 14,7 4,78 19 20 1 mean 19,7 14,2 5,51 18,6 19,6 1,00 sd 6,01 5,31 1,98 1,21 0,67 0,78 table 2 shows the difference in the mean and standard deviation between the pretest and post-test for independence of daily activities, namely 1.00±0.78, while the difference between the mean and standard deviation of the risk of falling is 5.51±1.98. it can be concluded that there was a change in the independence of daily activities and the risk of falling between pre-test and post-test in group 1. table 2. the risk of falling and the independence of daily activities in group 2 responden the risk of falling the independence of daily activities pre post difference pre post difference 1 20,3 19,8 0,54 19 20 1 2 18,8 15,6 3,22 19 19 0 3 21,7 17,6 4,15 18 19 1 4 18,5 16,9 1,64 19 19 0 5 23,6 22,4 1,17 18 18 0 6 23,7 23,3 0,46 18 18 0 7 15,4 13,7 1,69 19 19 0 8 15,2 13,1 2,08 19 20 1 9 21,3 20,4 0,87 18 18 0 10 16,2 15,8 0,41 19 19 0 11 16,9 14,1 2,83 18 19 1 mean 19,2 17,5 1,73 18,5 18,9 0,36 sd 3,11 3,51 1,23 0,52 0,70 0,51 table 3 shows the difference in the mean and standard deviation between the pretest and post-test for independence in daily activities, which is 0.36±0.51, while the difference between the mean and standard deviation of the risk of falling is 1.73±1.23. based on these data, it can be concluded that there is a change in the independence of daily activities and the risk of falling between pre-test and post-test in group 2. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.155-161 159 table 4. hypothesis significance test two paired samples variable value pre test post test p group 1 risk of fall median (minmaxs) 18,01 (13,8332,43) 12,78 (9,2127,39) 0,003 the independence of daily activities median (minmaxs) 19 (16-20) 20 (18-20) 0,009 group 2 risk of fall mean± sd 19,29± 3,11 17,56± 3,51 0,001 the independence of daily activities median (minmaxs) 19 (18-19) 19 (18-20) 0,046 in table 4 the results of hypothesis testing from the pre-test and post-test values using the paired t-test and the wilcoxon test show that in both groups there is a change in the independence of daily activities and the risk of falling, both in group 1 with tandem walking exercise intervention. as well as in group 2 who took part in routine elderly gymnastics held at the orphanage. table 5. differences in the mean difference between risk of fall and daily activity independence and risk of falls in group 1 and group 2 variable group value difference p risk of fall 1 mean± sd 5,51±1,98 0,000 2 mean±sd 1,73±1,23 the independence of daily activities 1 2 median (min-maxs) median (min –maxs) 1 (0-2) 0 (0-1) 0,044 table 5. the test of the difference in the average difference in the independence of daily activities in groups 1 and 2 was carried out with the mann-whitney test showing the value of the median difference (minimum-maximum) of 1 (0-2) in group 1 and in group 2 of 0 (0-2). 1), with p value = 0.044 < 0.05. while the test for the difference in the mean difference in risk of falling in groups 1 and 2 was carried out with the independent t-test test, the difference between the mean and standard deviation values was 5.51 ± 1.98 in group 1 and in group 2 of 1.73 ± 1.23, with p value = 0.000 < 0.05. based on the results of these data, it was concluded that statistically there was a significant difference between the average difference in the independence of daily activities and the risk of falling in the two groups. so that group 1 with tandem walking exercise intervention had a greater effect on increasing independence in daily activities and decreasing the risk of falling compared to group 2 or the control group. discussion the tandem walking exercise is a test as well as an exercise performed by walking in a straight line with the heel of the foot touching the toes of the other for 3-6 meters (baston, 2009). in a previous study conducted by nugrahani (2014) it was revealed that giving tandem walking exercises was able to improve balance, besides tandem walking is one of the exercises that aims to train posture or body position, control balance, muscle coordination and body movements. research that focuses on balance with tandem walking http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.155-161 160 exercises has also been conducted by talkowski, et al. (2008) with the title impact of health perception, balance perception, fall history, balance performance, and gait speed on walking activity in older adults. this study was conducted on elderly people over 65 years old and concluded that elderly people who have good proprioception and a history of falling slightly have a good balance in walking speed. balance also affects the risk of falling in the elderly because of physiological changes in the form of increasing the threshold of vestibular stimulation, worsening perception, visual degeneration, reduced muscle mass and muscle strength, reduced joint range of motion, changes in the center of gravity in the elderly, slowed postural responses, is the main component of controlling balance (irfan, 2010). the researcher assumes that the change in the independence of daily activities and the risk of falling in group 1 and group 2 is caused by the respondent's condition in a good condition at the time of the study so that the respondent can participate in the intervention provided, namely tandem walking exercises and regular elderly gymnastics at the orphanage. in addition, respondents also prevent extrinsic factors from falling during activities, for example walking by holding on to a handrail or using a walking aid, arranging furniture so as not to block the road, or asking other people to assist when walking. table 5 was concluded that statistically there was a significant difference between the average difference in the independence of daily activities and the risk of falling in the two groups. this is because elderly exercise alone is not enough to improve balance in the elderly, other combinations of exercises are also needed to further optimize the balance of the elderly, for example tandem walking, thai gymnastics, swiss ball, and others. these results are in line with the research conducted by munawwarah, m., & nindya, (2015) which found that tandem walking had a significant effect on improving the balance of the elderly. tandem walking also affects the m/l (medial/lateral) walking relationship, controlling the ankle, investor/ everstor mechanism, dominant muscles load/unload from hip abduction and adduction, whereas in ap conditions, tandem walking will increase hip extensor and flexors so that they can train sensory and motor skills to maintain balance in a neuro-control perspective (winter, 2009). researchers assume that elderly balance exercises that only contain elderly exercise have several shortcomings, namely the use of the body's sensory response to the balance of the elderly is not optimal, so it takes a combination of other exercises that can support the balance of the elderly not only from motor responses but also sensory and neurological responses. the addition of tandem walking exercises can improve balance better than just doing elderly exercise alone. conclusion based on the results of the study, it can be concluded that the tandem walking can decrease the risk of fall and increase the daily activities independence towards elderly people. it is recommended that health workers, both nurses, and doctors, use tandem walking in elderly people. further research is needed to to compare tandem walking exercise with other balance exercises in terms of improving daily activities’ independency and reducing the risk of falling towards elderly people. acknowledgments we thank the health polytechnic of the ministry of health of east kalimantan, uptd pstw nirwana puri samarinda, all respondents who participated in this study. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.155-161 161 references badan pusat statistik. 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(2015). pemberian latihan pada lansia dapat meningkatkan keseimbangan dan mengurangi resiko jatuh lansia. jurnal fisioterapi. nugrahani, p. (2014). latihan jalan tandem lebih baik daripada latihan dengan menggunakan swiss ball terhadap peningkatan keseimbangan untuk mengurangi resiko jatuh pada lanjut usia (lansia). jurnal fisioterapi, 14(2), 87–96. padila. (2013). buku ajar keperawatan gerontik (1st ed). nuha medika. stanley, m., & beare, p. g. (2007). buku ajar keperawatan gerontik (2nd ed). egc. talkowski, j. b., s. brance, j., studenski, s., & b. newman, a. (2008). impact of health perception, balance perception, fall history, balance performance, and gait speed on walking activity in older adultst. physiotherapy journal, 88(12), 1474–1481. https://doi.org/10.2522/ptj.20080036 tobing, h. g. (2011). prinsip ilmu bedah saraf. sagung seto. winter, d. a. (2009). biomechanical motor control human movements (pp. 359–467). http://thejnp.org/ journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 9 16 9 tingkat pengetahuan ibu dengan kepatuhan ibu dalam penerapan terapi diet gfcf (gluten free casein free) pada anak penyandang autisme di yayasan mutiara kasih trenggalek eva agustina yalestyarini1, choirimma permatasari 2 ¹ ² program studi pendidikan ners stikes surya mitra husada kediri corresponding author: va-nyiel@yahoo.com abstract knowledge is closely related to human success in obeying an objective. knowledge and compliance about gfcf (gluten free casein free) diet is important for the parents with children autism. gfcf diet therapy (gluten free casein free) aim is to reduce the symptoms of autism and child hyperactivity.the objective of this study is to determine whether there is a relationship between maternal knowledge level with maternal obedience in the application of gfcf (gluten free casein free) diet at mutiara kasih foundation trenggalek.the research design of this study is observational analytical with cross sectional approach and questionnaire instrument. the population is all mothers who have autism children in the mutiara kasih foundation trenggalek as many as 32 people. the sample of research was 32 by using total sampling technique, while to know the relation between variables uses chi-square test by the significant level 0,05.the results showed that most (40,6%) of respondents knowledge in less category and most (58,8%) respondent's compliance in non compliance category. the result of statistical test shows that p value = 0,059> 0,05. there is no significant relationship between maternal knowledge with maternal compliance in the application of gfcf (gluten free casein free) diet in autistic children.maternal compliance in the application of gfcf (gluten free casein free) diet has no relationship with knowledge. this happened because of several factors, such as the parent's life style, the attitudes of the child, and the lack of knowledge of the mother about the choice of food, so that many mothers are not obedient into therapy. application of gfcf therapy will provide maximum results if done with good knowledge, obedience, and get good supervision from parents and health teams. keywords: autism, knowledge, gluten and casein, adherence received august 21, 2017; revised september 07, 2017; accepted october 01, 2017 how to cite: yalestyarini, e.a & permatasari, c. (2017). tingkat pengetahuan ibu dengan kepatuhan ibu dalam penerapan terapi diet gfcf (gluten free casein free) pada anak penyandang autisme di yayasan mutiara kasih trenggalek. journal of nursing practice. 1(1). 9-16. the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 9 16 10 pendahuluan menurut harlimsyah (2007) perkembangan anak adalah segala perubahan yang terjadi pada diri anak dilihat dari berbagai aspek antara lain aspek fisik (motorik), emosi, kognitif, dan psikososial (bagaimana anak berinteraksi dengan lingkungan). pada beberapa kondisi terdapat anak-anak yang mengalami masalah perkembangan. salah satu kelainan yang diderita anak yang menjadi sorotan saat ini adalah autis. autisme merupakan gangguan perkembangan pervasif pada anak yang ditandai adanya gangguan dalam bidang kognitif, bahasa, perilaku, komunikasi dan interaksi sosial (wong, 2009). dengan adanya metode diagnosis yang makin berkembang hampir berbagai jenis terapi telah dilakukan untuk mengembangkan kemampuan anak autisme sehingga gejala autisme dapat dihilangkan dan dapat hidup mendekati normal. jika anak autisme tidak atau terlambat mendapat intervensi hingga dewasa, maka gejala autisme bisa menjadi semakin parah, bahkan tidak tertanggulangi. melalui beberapa terapi anak autisme akan mengalami kemajuan seperti anak normal lainnya (amilia, 2013). salah satu jenis terapi untuk anak autisme adalah terapi diet gfcf (gluten free casein free). diet gluten free casein free (gfcf) yang berarti menghindari makanan dan minuman yang mengandung gluten dan kasein. gluten dan kasein merupakan jenis protein yang sulit dicerna. gluten adalah protein yang terkandung dalam gandum/tepung/roti, sedangkan kasein adalah protein yang ditemukan di semua susu hewan dan produk-produk olahannya. gluten dan kasein dapat mempengaruhi fungsi susunan syaraf pusat, menimbulkan keluhan diare dan meningkatkan hiperaktivitas, yang tidak hanya berupa gerakan tetapi juga emosinya seperti marah-marah, mengamuk atau mengalami gangguan tidur pada anak (suryana, 2010). akan tetapi, pada umumnya banyak orangtua yang tidak mengetahui akan terapi ini, dan ada sebagian yang mengetahui tentang terapi gfcf tetapi tidak diterapkan dan tidak patuh dengan terapinya karena ketidak tahuan orangtua tentang tahapan diet (dwi murni, 2011). data wawancara pendahuluan yang telah peneliti lakukan didapatkan hasil bahwa 6 dari 15 ibu mengetahui tentang diet gluten free casein free (gfcf) dari dokter yang bekerjasama dengan yayasan akan tetapi belum mematuhi terapi dietnya dengan baik dikarenakan sulitnya dalam pemilihan makanan dan menghindarkan makanan yang mengandung gluten dan kasein dari anak. sementara 9 dari 15 ibu tersebut belum mengetahui tentang terapi diet gluten free casein free dikarenakan belum memeriksakan anaknya ke dokter yang bekerjasama dengan yayasan. intervensi diet gfcf dimaksudkan untuk menghilangkan atau mengurangi gejala autisme, meningkatkan kualitas hidup, serta memberikan status nutrisi yang baik. intoleransi dan alergi makanan merupakan salah satu faktor pencetus yang perlu diperhatikan terhadap anak autis. diet gfcf adalah terapi yang dilaksanakan dari dalam tubuh dan apabila dilaksanakan dengan terapi lain, seperti terapi perilaku, terapi wicara, dan terapi okupasi yang bersifat fisik akan lebih baik. setelah mengikuti dan menjalani diet gfcf banyak anak autisme mengalami perkembangan pesat dalam kemampuan bersosialisasi dan mengejar ketinggalan dari anak-anak lain (danuatmaja, 2008). menurut washnieski (2009), ada beberapa rintangan/hambatan dalam upaya menerapkan diet gfcf diantaranya adanya perlawanan dari anak, pembatasan diet yang membuat anak sulit untuk makan, masalah lingkungan sekolah, orang tua tidak tahu bagaimana menyiapkan makanan yang bebas kasein dan gluten, tidak tahu dimana harus menemukan sumber yang dapat membantu untuk mengimplementasikan diet.tujuan penelitianini adalah untuk mengetahui adakah hubungan antara tingkat pengetahuan ibu dengan kepatuhan ibu dalam penerapan terapi diet gfcf (gluten free casein free) pada anak penyandang autis di yayasan mutiara kasih trenggalek. journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 9 16 11 metode penelitian desain penelitian ini adalah analitik observasional dengan pendekatan cross sectional dan instrumen lembar kuesioner. populasi adalah semua ibu yang memiliki anak penderita autis di yayasan mutiara kasih trenggalek sebanyak 32 orang. besar sampel sebanyak 32 dengan menggunakan teknik total sampling, sedangkan untuk mengetahui hubungan antar variabel digunakan uji chi-square dengan taraf signifikan 0,05. hasil penelitian karakteristik subyek tabel 1. karakteristik responden dalam penelitian ini meliputi pendidikan terakhir, pekerjaan, sumber informasi, usia anak responden, tingkat pengetahuan dan kepatuhan. no karakteristik σn σ% 1 pendidikan sd smp diploma 4 24 4 13 75 12 2 pekerjaan tidak bekerja petani swasta wiraswasta pns 11 1 10 8 2 35 31 25 6 3 sumber informasi dokter non dokter 24 8 75 25 4 usia anak 3-4 5-6 >7 1 11 20 3 34 63 5 pengetahuan baik cukup kurang 12 7 13 37,5 21,9 40,6 6 kepatuhan patuh tidak patuh 12 20 35,3 58,8 7 total 32 100 sumber: hasil analisa data, tahun 2017 berdasarkan tabel 1 diatas dari total32 responden sebagian besarberpendidikan terakhir sma yakni sebanyak 24 (75%), sebagian besartidak bekerjayaitusebanyak 35% atau 11responden, 24 (75%) mendapatkan informasi tentang terapi diet gfcf (gluten free casein free) dari dokter, usia anak responden sebagian besar berusia lebih dari 7 tahun yakni sebanyak 20 responden (63%), tingkat pengetahuan ibu tentang terapi diet gfcf (gluten free casein free) sebagian besar dalam kategori kurangyakni sebanyak 13 (40,6%) dan tingkat kepatuhan ibu dalam penerapan terapi diet gfcf (gluten free casein free) dalam kategori tidak patuh yakni sebanyak 20 responden ( 58,8%). tabel 2. hasil uji statistis chi-square tests value df asymp. sig. (2-sided) pearson chi-square 5.665a 2 .059 likelihood ratio 5.828 2 .054 journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 9 16 12 linear-by-linear association 1.141 1 .286 n of valid cases 32 a. 4 cells (66.7%) have expected count less than 5. the minimum expected count is 2.63. symmetric measures value approx. sig. nominal by nominal phi .421 .059 cramer's v .421 .059 contingency coefficient .388 .059 n of valid cases 32 dari data tingkat pengetahuan dengan tingkat kepatuhan yang diperoleh, kemudian dilakukan uji stastistik menggunakan uji chi square dengan nilai α = 0,05 dengan bantuan spss 16 for windows. dari hasil perhitungan didapatkan nilai signifikan 0,059. karena α > 0,05 maka dapat disimpulkan ho diterima, berarti secara statistik 95% kita percaya bahwa tidak ada hubungan pengetahuan dengan kepatuhan ibu dalam penerapan terapi diet gfcf (gluten free casein free) di yayasan mutiara kasih trenggalek. . pembahasan tingkat pengetahuan ibu dalam penerapan terapi diet gfcf (gluten free casein free) di yayasan mutiara kasih trenggalek hasil penelitian tentang tingkat pengetahuan ibu dalam penerapan terapi diet gfcf (gluten free casein free) di yayasan mutiara kasih trenggalek menunjukkan bahwa sebagian responden dalam kategori kurang yaitu sebanyak 13 (40,6%) sedangkan dari total 32 responden. menurut notoatmodjo (2007) pengetahuan adalah hasil dari tahu dan ini setelah orang melakukan penginderaan terhadap obyek tertentu. penginderaan terjadi melalui panca indera manusia, yakni indera penglihatan, pendengaran, penciuman, rasa dan raba. sebagian besar pengetahuan manusia diperoleh melalui mata dan telinga. tingkat pendidikan terutama ibu, dapat mempengaruhi konsumsi keluarga. tingkat pendidikan ibu yang tinggi akan mempermudah penerimaan informasi tentang gizi dan kesehatan anak serta mengimplementasikannya dalam perilaku dan gaya hidup sehari-hari, khususnya dalam hal kesehatan dan gizi (wknpg dalam dwi murni 2011). kurangnya pengetahuan responden tentang cara penerapan terapi diet dan pemilihan makanan disebabkan oleh jarangnya interaksi antara ibu dengan pendidik atau tenaga kesehatan lain karena minimal 2 bulan sekali mereka harus mengajak anaknya untuk kontrol ke dokter yang telah bekerjasama dengan pihak yayasan. mereka hanya sekali mendapatkan pengetahuan tentang terapi diet gfcf (gluten free casein free) pada saat kunjungan pertama ke dokter tanpa evaluasi kembali atau mendapatkan pengawasan dari dokter dan terapis lain. hal ini dikuatkan dengan hasil kuesioner pengetahuan dimana pada soal yang menuliskan bahwa susu sapi adalah minuman yang sangat penting bagi anak, 20 responden dari 32 reponden menjawab benar padahal terapi diet gfcf adalah terapi diet yang menghindari tepung (gluten free) dan susu sapi (free casein). dari ibu sendiri juga kurang aktif untuk meningkatkan informasi tentang diet gfcf (gluten free casein free). hal ini didukung dengan hasil kuesioner dimana responden sebagian mendapatkan informasi dari dokter yayasan tanpa mendapatkan journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 9 16 13 sumber informasi dari sumber lain seperti buku, media elektronik dan tenaga kesehatan yang lain. kondisi ini sesuai dengan ungkapan notoatmodjo (2007) pendidikan merupakan salah satu faktor yang mempengaruhi pengetahuan. pada umumnya semakin tinggi tingkat pendidikan seseorang, semakin baik pua pengetahuannya. selain itu, didapatkan hasil yang beda tipis dengan jumlah pengetahuan responden dalam kategori kurang, sebagian besar responden juga dalam kategori pengetahuan yang baik yaitu sebanyak 12 responden. hasil ini terjadi karena responden yang mayoritas berpendidikan terakhir sma dirasa cukup untuk menerima informasi-informasi dari dokter dan dari pendidik. sehingga sebenarnya responden tahu tentang terapi bebas gluten dan kasein akan tetapi mereka tetap memberikan susu dan makanan yyang mengandung gluten dan kasein karena anak yang sulit untuk dicegah dan dihindarkan dari susu atau makanan tersebut. tingkat kepatuhan ibu dalam penerapan terapi diet gfcf (gluten free casein free) di yayasan mutiara kasih trenggalek hasil penelitian tingkat kepatuhan ibu dalam penerapan terapi diet gfcf (gluten free casein free) di yayasan mutiara kasih trenggalek menunjukkan bahwa sebagian besar responden dalam kategori tidak patuh yaitu sebanyak 20 (58,8%) responden dari total 32 responden. kepatuhan adalah tingkat seseorang dalam melaksanakan suatu aturan dan perilaku yang disarankan (smet, 1994) dalam (notoadmodjo, 2007). kepatuhan dibedakan menjadi dua yaitu kepatuhan penuh (total compliance) dimana pada kondisi ini orang tua/ibu menerapkan dan mematuhi secara sungguh-sungguh terhadap diet kepada anaknya, dan penderita yang tidak patuh (non compliance) dimana pada keadaan ini orangtua atau ibu tidak melakukan diet. dari hasil yang diperoleh diatas, didapatkan bahwa kebanyakan responden tidak patuh terhadap terapi diet gfcf (fluten free casein free) pada anak penyandang autis. hal ini dapat dilihat dari hasil kuesioner dimana susu sapi masih sering dikonsumsi oleh anak penyandang autis yaitu sebanyak 11 anak dengan frekuensi konsumsi 1-2 x sehari, roti sebanyak 7 anak dengan frekuensi konsumsi 1-2x sehari, dan ayam bumbu tepung sebanyak 10 anak dengan frekuensi konsumsi 3 x seminggu. hal ini terjadi karena beberapa faktor antara lain, kurangnya pengetahuan ibu tentang terapi diet gfcf (gluten free casein free), sulitnya dalam pemilhan jenis makanan yang harus dihindari karena makanan di lingkungan sekitar responden mayoritas berbahan dasar tepung terigu, susu sapi, dan bahan kimia tambahan lain sehingga anak kesulitan untuk menghindari makanan tersebut dan ibu tidak bisa menjauhkan makanan tersebut dari anaknya. hal ini sesuai dengan ungkapan niven (2008) bahwa terdapat beberapa faktor yang mempengaruhi ketidakpatuhan antara lain karena kompleksitas prosedur pengobatan/terapi, derajat perubahan gaya hidup yang dibutuhkan, lamanya waktu pengobatan atau terapi, apakah prosedur tersebut berpotensi menyelamatkan hidup atau meningkatkan kualitas kesehatan, dan bagaimana persepsi keluarga terhadap anaknya atau klien. sehingga dapat disimpulkan bahwa dalam penerapan terapi ini pada penerapan pertama kali boleh minum susu dan jenis protein yang lain akan tetapi porsi dan frekuensi dikurangi dan bisa dicampur dengan bahan yang dianjurkan dan untuk anak yang sudah menerapkan diet lama diharapkan orangtua dapat mengawasi dan berhasil menghindari makanan yang mengandung gluten dan kasein. dari hal ini maka responden dapat diberikan informasi ulang dengan melakukan health education secara mengelompok untuk memberi penjelasan yang lebih spesifik tentang penerapan terapi diet yang benar dengan melakukan kerjasama dengan pihak ahli gizi dan tim kesehatan lain. journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 9 16 14 hubungan tingkat pengetahuan dengan kepatuhan ibu dalam penerapan terapi diet gfcf (gluten free casein free) di yayasan mutiara kasih trenggalek sesuai hasil penelitian yang terlihat dalam tabulasi data dapat diketahui bahwa mayoritas responden memiliki pengetahuan dalam kategori kurang, yaitu sebanyak 13 orang, 8 menunjukkan ketidakpatuhan dalam penerapan terapi diet gfcf (gluten free casein free) dan 5 menunjukkan kepatuhan dalam penerapan terapi diet gfcf (gluten free casein free). responden yang memiliki pengetahuan dalam kategori baik beda tipis dengan jumlah responden dalam kategori kurang yaitu sebanyak 12 orang, 10 orang menunjukkan hasil ketidakpatuhan dan 2 orang menunjukkan hasil kepatuhan. berdasarkan ui statistik chi square dengan tingkat alpha sebesar 0,05 didapatkan sig sebesar 0.059. dengan demikian maka didapatkan sig > α (0,059 > 0,05). sehingga ho diterima dan h1 ditolak. tidak ada hubuungan antara pengetahuan dengan kepatuhan terapi diet gfcf (gluten free casein free) pada anak penyandan autisme di yayasan mutiara kasih trenggalek. berdasarkan analisa data dapat diketahui bahwa mayoritas responden dengan pengetahuan kurang menunjukkan adanya ketidakpatuhan, sebab dengan pengetahuan yang kurang mereka belum dapat mengetahui tentang apa dan bagaimana penerapan terapi diet gfcf (gluten free casein free) serta dampak negatif jika terapi diet gfcf (gluten free casein free) tidak dilakukan. sesuai teori lawrence green yang dikutip oleh notoadmodjo (2010) pengetahuan merupakan salah satu faktor yang sangat berpengaruh dalam menentukan perilaku seseorang. jadi responden yang memiliki pengetahuan dalam kategori kurang akan mempersulit responden dalam melakukan kepatuhan terhadap terapi diet gfcf (gluten free casein free). padahal kita tahu bahwa pengetahuan ibu memiliki peranan dalam melakukan penerapan terapi diet gfcf (gluten free casein free) sesuai dengan ungkapan suhardjo (2008) bahwa pengetahuan gizi yang baik dapat menghindarkan seseorang dari konsumsi pangan yang salah dan buruk. ibu memiliki peranan utama dalam menyediakan dan mengolah makanan bagi keluarga. pemberian makanan yang tepat sangat diperlukan bagi anak autis, sehingga pengetahuan ibu tentang makanan bagi anak autis menjadi hal yang penting untuk diperhatikan. dari data didapatkan sebagian besar responden tidak patuh dengan terapi. hal ini terjadi karena banyak faktor antara lain pendidikan, pemberian informasi dan faktor lingkungan serta kebiasaan orang tua dalam pemilihan menu makanan sehari-hari. menurut brunner dan suddart (2008) latar belakang pendidikan maupun kontak dengan professional kesehatan sangat mendukung kepatuhan seseorang terhadap program terapi. menurut dwi murni (2011) tinggi rendahnya pengetahuan ibu akan mempengaruhi pola makan anak autis. tingkat pengetahuan ibu yang baik diharapkan dapat menghindarkan dari konsumsi pangan yang salah dan buruk. diet sangat ketat bebas gluten dan kasein dapat menurunkan kadar peptida opioid serta dapat mempengaruhi gejala autis pada beberapa anak. akan tetapi, pilihan makanan yang terbatas yang pada akhirnya berpotensi menjadikan anak mudah terserang penyakit atau mengalami gizi kurang. oleh karena itu, diharapkan dengan tingkat pengetahuan ibu yang baik maka penerapan diet gfcf dapat dijalankan dengan baik dan kecukupan zat gizi anak tetap terpenuhi.pendidikan yang cukup serta pemberian informasi yang benar dan terus-menerus serta dukungan keluarga, tim kesehatan, dan lingkungan sekitar sangat menunjang kepatuhan ibu dalam menerapkan terapi diet gfcf (gluten free casein free) pada anak penyandang autisme. simpulan dan saran simpulan journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 9 16 15 1. sebagian besar pengetahuan ibu tentang terapi diet gfcf (gluten free casein free) pada anak penyandang autisme di yayasan mutiara kasih trenggalek adalah kurang sebanyak 13 (40,6%) responden. 2. sebagian besar kepatuhan ibu dalam penerapan terapi diet gfcf (gluten free casein free) pada anak penyandang autisme di yayasan mutiara kasih trenggalek adalah tidak patuh sebanyak 20 (62,5%) responden. 3. berdasarkan uji statistik chi-square didapatkan α = 0.059 yang artinya tidak ada hubungan antara pengetahuan dengan kepatuhan ibu dalam penerapan terapi diet gfcf (gluten free casein free) pada anak penyandang autisme di yayasan mutiara kasih trenggalek. saran 1. bagi responden hendaknya orangtua lebih aktif dalam mencari informasi untuk meningkatkan kepatuhan dalam penerapan terapi diet gfcf (gluten free casein free) secara bertahap 2. bagi peneliti lain dapat mengembangkan dan melakukan penelitian selanjutnya tentang anak autis dan terapinya. 3. bagi lahan penelitian a. dari hasil skripsi ini dapat memacu tenaga pendidik dan tenaga kesehatan untuk memberikan informasi secara terus-menerus, mendukung dan mengawasi ibu/orangtua dalam melakukan terapi diet gfcf (gluten free casein free). b. lahan penelitian dapat bekerjasama dengan ahli gizi untuk memberikan pengetahuan dan 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(2007). autisme. kongres/konferensi nasional autisme indonesia, 3-4 mei 2003. jakarta wargasetia tl. 2003. aspek genetika pada autisme. di dalam : r. sutadi la, bawazir, dan n tanjung, editor. penatalaksanaan holistik autisme.jakarta: pusat informasi dan penerbitan bagian ilmu penyakit dalam, fakultas kedokteran, universitas indonesia. washnieski, g., (2009). gluten-free and casein-free diets as a form of alternative treatment for autism spectrum disorders. stout : university of wisconsin-stout. winarno dan agustinah, widya. 2008. pangan dan autism. makalah. (http://autim-danperan-pangan.prof-winarno-20-09-08.pdf, diakses tanggal 20 september 2016). wong, d.l. (2009). whaley and wong’s essentials of pediatric nursing 4th ed. usa : mosby. yuliana, emilia e. (2006). penanganan anak autis melalui terapi gizi dan pendidikan. jurnal pendidikan dan kebudayaan 61 : 429-447. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 33 40 33 effect performance of posyandu toddlers cadre against satisfaction level mother of toddlers at posyandu melati 9 health center liliba kota kupang joice d taek, kristoforus tnomel, sefrianus oeleu puskesmas liliba, kupang, nusa tenggara timur, indonesia corresponding author : joicedt17@gmail.com abstract background: one of the problems that is often faced today is the disability of under-five mothers in obtaining health services for children under five years old because of the lack of performance of posyandu health workers. purpose : the purpose of this research is to know the effect performance of posyandu toddler cadres against satisfaction level of toddler mother at posyandu melati 9 health center liliba kota kupang methods : the design of this study used an observational quantitative approach with cross sectional approach. respondents were taken with simple random sampling technique. population studied all mothers under five at posyandu melati 9 puskesmas liliba kota kupang with sample 39 mother. independent variables studied is the performance of posyandu toddler and dependent variable is the level of satisfaction of under-five mother. the results were analyzed by using ordinal regression statistic test. result : the results showed that kader performance is known that almost half of the respondents in the good category is as many as 14 (36%) of respondents. satisfaction rate of underfive mothers is known that most respondents in the category very satisfied is as much as 20 (51%) respondents. the result of data analysis shows that the significance level of 0,000 <α = 0.05 so that h0 is rejected and h1 is accepted thus there is effect performance of posyandu toddler cadres against satisfaction level of toddler mother at posyandu melati 9 health center liliba kota kupang. conclusion : based on the result of the research, it is known that the satisfaction of mother of balita to posyandu service where cadre always do monitoring and evaluation to posyandu. besides, it is also supported by cadre training and comparative study of posyandu cadres to other posyandu as a learning media so that they can follow the improvement effort that has been done. keywords : performance of posyandu toddler cadres, satisfaction, toddler mother received: february 03, 2018; revised february 24, 2018; accepted march 10, 2018 how to cite: taek, d.j., tnomel, k., & oeleu, s., (2018). effect performance of posyandu toddlers cadre against satisfaction level mother of toddlers at posyandu melati 9 health center liliba kota kupang. journal of nursing practice. 1(2). 33-40 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 33 40 34 background satisfaction is a function of the difference between perceived performance and expectations. the new patient will be satisfied if the healthcare performance is equal to or exceeding expectations and vice versa, patient dissatisfaction or feelings of disappointment will arise if the health care performance is not as expected. customer satisfaction is determined by customer perceptions of product or service performance in meeting customer expectations. customers are satisfied if their expectations are met or will be very satisfied if customer expectations are exceeded (nugroho, 2010). the central sulawesi health office found that most cadres (83.2%) said that facilities such as kms / kia, record books, weighing instruments, immunization materials and polio drops, medicines (vitamins a and fe) were available at posyandu. while the number of active cadres in posyandu between 2-3 people (77.3%), on the contrary the user reached (97.9%), but the cadre awareness level provided service at posyandu every month reached (65.9%). this means there is a positive and significant relationship between the motivation of cadres and users on the opening day of posyandu (central sulawesi health office, 2016). based on the result of sugi purwanti (2015) study, it is known that according to the community, the performance of posyandu officers is 29 (43,94%) and at least 18 officers (27,27%). while the picture of satisfaction level of mother of balita at posyandu majority of satisfaction level of mother in category satisfied enough 30 people (45,46%) and 18 people (27,27%) into less satisfied category. there are some things that according to the mother of toddler still less according to their desire about good posyandu service like skill officer40,91% dissatisfied, communication 24,24% not satisfied, handling of complaint 34,85% dissatisfied, giving comfort 36,36% not satisfied. according to the health profile of nusa tenggara timur in 2017, in 2016 the number of posyandu has decreased by 530 posyandu compared to 2014 from 46,275 to 45,745. similarly, the number of active cadres which in 2016 decreased 46,652 cadres compared to 2014 from 194,552 cadres to 147,900 cadres. based on kupang puskesmas report 2014, the coverage of d / s is 69.03% and in 2015 is 67.08% and all have not reached 80% target. on the other hand, knowledge about the existence of posyandu is 65.2%, the highest in west java (78.2%) and the lowest in bengkulu (26.0%) (trihono, 2013). data on the number of active cadres in posyandu melati 9 puskesmas liliba kupang city is as many as 10 cadres while the coverage of the number of infant mothers is as many as 48 mothers under five. preliminary study conducted by researchers at posyandu melati 9 puskesmas liliba kota kupang on december 5, 2016 to 10 mother toddlers where it is known that 5 mother toddler said posyandu cadres are often not present when posyandu schedule with reason out of town or even do not remember posyandu schedule. besides, the delay of the cadres visited posyandu to be one bad example where this is supported by observation result conducted by the researcher.3 mother said that communication between cadres with mother of toddler often misunderstanding because of unavailability of vaccine for children even injectable contraceptive drugs that are not available every month. so when the posyandu of injecting drug contraception should be paid by the mother of a toddler. while 2 mothers of children under five said that the skills and knowledge of the cadres have been good because it is supported by long work as a cadre officer in the community and also various training and guidance provided by health workers (study results introduction in posyandu melati 9 puskesmas liliba kota kupang, 2016). performance of public services one of the demands to be fulfilled is the satisfaction of customers served. including posyandu as community based health effort (ukbm) which journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 33 40 35 incidentally from, by and for society, also should be able to give satisfaction of its target. satisfaction according to oliver as quoted sari (2008) is the level of one's feelings (customers) after comparing the performance or perceived results (service received and perceived) with the expected. technically posyandu cadres must show their best performance so that the people served are satisfied. the success of posyandu is highly determined by the performance of the cadres, because the cadres are the posyandu activator and the life of the posyandu's death depends on whether or not the cadre is active. not infrequently due to the lack of attention from the village head, the head of tp pkk, and the puskesmas officers towards the cadres and posyandu make posyandu become increasingly withered (depkes, 2014). therefore, considering the above problems, to improve the satisfaction of the mother of the children to posyandu services, it is necessary to monitor and evaluate the posyandu. assessment of posyandu strata conducted so far needs to be carried out continuously. training of posyandu cadres in a certain period of time should also be done. comparative studies of posyandu cadres to other posyandu should also be done as adult learning media so that they can follow the improvement efforts that have been done. it is also necessary to conduct a study on community satisfaction on posyandu services. besides, awards are also given to increase the motivation of the cadres should always be there. a cadre who has high motivation and good ability in carrying out his duties will produce good performance. provision of incentives and rewards are considered to increase the motivation of cadre performance because the motivation of cadres in the implementation of posyandu is a dominant factor that is very influential on the utilization rate of balita balita. based on the above phenomenon, the researcher is interested to carry out the research entitled "the influence of performance of posyandu cadre of toddlers against satisfaction level of toddler mother at posyandu melati 9 puskesmas liliba kota kupang". objective to know the knowledge and role of nurses in the implementation of emergency patient handling with cardiovascular system disorder. methods the design of this study used an observational quantitative approach with cross sectional approach. respondents were taken with simple random sampling technique. population studied all mothers under five at posyandu melati 9 puskesmas liliba kota kupang with sample 39 mother. independent variables studied is the performance of posyandu toddler and dependent variable is the level of satisfaction of under-five mother. the results were analyzed by using ordinal regression statistic test. data analysis technique used to test the influence of performance of posyandu toddlers cadre on satisfaction level of toddler mother at posyandu melati 9 kota kupang by using ordinal regression statistic test to know the influence of independent variable to dependent variable with trust level α = 0,05. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 33 40 36 results table 1. performance of posyandu toddler cadre at posyandu melati 9 puskesmas liliba kota kupang no performance frekuensi (%) 1. lack 14 36% 2. enough 11 28% 3. good 14 36% total 39 100% based on table 1 performance of posyandu posyandu balita in posyandu melati 9 puskesmas liliba kota kupang it is known that almost half of the respondents in the good category are as many as 14 (36%) of respondents. table 2. level of satisfaction of under fives at posyandu melati 9 puskesmas liliba kota kupang no satisfaction frekuensi (%) 1 very dissatisfied 5 13% 2 dissatisfied 9 23% 3 satisfied 5 13% 4 very satisfied 20 51% total 39 100% based on table 2 level of satisfaction of mother toddler at posyandu melati 9 puskesmas liliba kupang city known that most of respondent in category very satisfied to performance of posyandu cadre is as much as 20 (51%) respondents. the result of data analysis showed that kader performance with significance level 0,000 <α = 0.05 so that h0 rejected and h1 accepted thus there is influence performance cadre posyandu toddler in posyandu melati 9 puskesmas liliba kota kupang. while the level of satisfaction of mother of toddler with significance level 0,000 <α = 0,05 so that h0 rejected and h1 accepted thus there is influence of satisfaction level of mother toddler at posyandu melati 9 puskesmas liliba kota kupang discussion performance of posyandu toddler cadre at posyandu melati 9 puskesmas liliba kota kupang based on the results of the research, it is known that the performance of posyandu toddler cadid di posyandu melati 9 puskesmas liliba kota kupang is known that almost half of the respondents in the good category are 14 (36%) respondents. this is supported by the presence of cadres during the posyandu schedule, information and knowledge of cadres to the service, the availability of complete facilities and infrastructure at posyandu, cadre skills in providing services, interaction and good communication between cadres and mothers. performance of cadres in the category of enough is as much as 11 (28%) of respondents where marked with skilled cadres in providing services to the mother of the toddler as well as weighing balita appropriate to the age of toddlers and vaccines given to toddlers while the category less is as many as 14 (36%) respondents where it was marked by several cadres who arrived late when the posyandu schedule. this is supported by the cadre's statement that the busyness of the household is like taking care of the children to go to school which causes the delay of visiting cousins of the pesosandu. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 33 40 37 performance of public services one of the demands to be fulfilled is the satisfaction of customers served. including posyandu as community based health effort (ukbm) which is in fact from, by and for society, it is also appropriate to give satisfaction of its target (sari, 2016). the success of posyandu is highly determined by the performance of the cadres, because the cadres are the posyandu activator and the life of the posyandu's death depends on whether or not the cadre is active. not infrequently due to the lack of attention from the village head, the head of tp pkk, and the puskesmas officers towards the cadres and posyandu make posyandu become increasingly withered (depkes, 2014). according to the researcher's opinion that the cadre's performance in providing optimal service is supported by the presence of cadres during the posyandu schedule, information and knowledge of cadres towards the service, the availability of complete facilities and infrastructure in posyandu, cadre skills in providing services, interaction and good communication between the cadres with a toddler mother. based on the results of cross-tabulation between age and performance of posyandu toddlers cadre at posyandu melati 9 puskesmas liliba kota kupang it is known that almost half of the respondents with age 25 30 years in good category is as much as 9 (43%) respondents. this is supported by the increasingly mature cadres so that in providing services always supported by good performance with information and knowledge so that the service provided was in accordance with the wishes of the mother of the toddler. a person's age is closely related to the education and knowledge of cadres about the benefits or importance of posyandu toddlers where the more mature one's age then the level of maturity and strength of a person will be better in thinking and determining health attitudes and behaviors, especially in providing services for maternal satisfaction (depkes, 2014) . therefore, according to the opinion of the researcher that with the age of the cadres are more mature so that in providing services always supported by good performance with information and knowledge so that the service provided was in accordance with the wishes of the mother of the toddler. based on the result of cross tabulation between education and performance of posyandu balita cadre at posyandu melati 9 puskesmas liliba kota kupang it is known that almost half of respondents with high school education level in good category is 12 (41%) respondents. this is supported by the optimal cadre education about posyandu balita and also material obtained from health officer about the importance of 5 tables that applied by the service center so that the mother of toddler is able to apply it well at posyandu schedule. education is an experience with that experience, a person or group of people can understand something they did not understand before. the experience happens because there is interaction between a person or a group with the environment. the interaction leads to a process of change (learning) in humans and then the process of change that produces development (development) for the life of a person or group in the environment (notoatmodjo, 2010). in the opinion of researchers that education posyandu cadres are able to add insight into optimizing thinking activities conducted as well as posyandu toddler activities. with information and knowledge owned by the cadres so that in the implementation of the activity there is no error in the service. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 33 40 38 based on the result of cross tabulation between the work and performance of posyandu toddler cadre at posyandu melati 9 puskesmas liliba kupang city it is known that almost half of the respondents work as traders in the enough category are 7 (35%) respondents. this is supported by the attitude and behavior of mothers who always take the time to deliver their children when the posyandu schedule so that children always get health services posyandu regularly. work is a set of positions that have the same liability or duties. in a job analysis activity, one job can be occupied by one person, or multiple people scattered in various places. in a broad sense work is the main activity undertaken by humans. in a narrow sense, the term work is used for a task or work that earns money for a person. in everyday conversations the term is often considered synonymous with the profession (adi, 2014). in the opinion of the researcher that with attitude and behavior of mother always take time to deliver their child when posyandu schedule so that child always get health service posyandu with regular level of satisfaction of under fives at posyandu melati 9 puskesmas liliba kota kupang based on the results of the research, it is known that maternal satisfaction level in posyandu melati 9 puskesmas liliba kupang city is known that most respondents in the category of very satisfied is as much as 20 (51%) of respondents. this is supported by the satisfaction of the mother of toddler to cadre service such as interaction / communication between cadres with mother of balita, presence of cadre before activity started, availability of facilities and infrastructure of posyandu and others. satisfaction is a function of the difference between perceived performance and expectations. the new patient will be satisfied if the healthcare performance is equal to or exceeding expectations and vice versa, patient dissatisfaction or feelings of disappointment will arise if the health service performance is not as expected (tjiptono, 2010). customer satisfaction is determined by customer perceptions of product or service performance in meeting customer expectations. customers are satisfied if their expectations are met or will be very satisfied if customer expectations are exceeded (nugroho, 2010). according to the researcher's opinion that the satisfaction of the mother of toddler to the service of cadre which supported by the accuracy of cadre in giving service to children like giving the vaccine according to the age of the toddler beside that cadres always pay attention to the giving of the vaccine to the toddler if the toddler is sick. this becomes one of the actions that cause the consumer / mother toddler to feel happy about the skill of the cadre during the activity. the influence of performance of posyandu toddler cadres against satisfaction rate of under fives at posyandu melati 9 puskesmas liliba kota kupang the result of data analysis shows that the significance level of 0,000 <α = 0.05 so that h0 is rejected and h1 is accepted thus there is influence performance of posyandu toddler cadre against satisfaction level of toddler at posyandu melati 9 puskesmas liliba kota kupang. one of the problems that is often faced today is the lack of satisfaction of under-five mother in getting health service of children under five years old because of the lack of performance of posyandu health officer in this case the absence of cadre during posyandu schedule, lack of knowledge of cadre to service, lack of complete facilities and journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 33 40 39 infrastructure at posyandu, cadre delays visited posyandu, staff skills, communication and so on (avicena, 2015). satisfaction is a function of the difference between perceived performance and expectations. the new patient will be satisfied if the healthcare performance is equal to or exceeding expectations and vice versa, patient dissatisfaction or feelings of disappointment will arise if the health care performance is not as expected. customer satisfaction is determined by customer perceptions of product or service performance in meeting customer expectations. customers are satisfied if their expectations are met or will be very satisfied if customer expectations are exceeded (nugroho, 2010). performance of public services one of the demands to be fulfilled is the satisfaction of customers served. including posyandu as community based health effort (ukbm) which incidentally from, by and for society, also should be able to give satisfaction of its target. satisfaction according to oliver as quoted sari (2008) is the level of one's feelings (customers) after comparing the performance or perceived results (service received and perceived) with the expected. technically posyandu cadres must show their best performance so that the people served are satisfied. the success of posyandu is highly determined by the performance of the cadres, because the cadres are the posyandu activator and the life of the posyandu's death depends on whether or not the cadre is active. not infrequently due to the lack of attention from the village head, the head of tp pkk, and the puskesmas officers towards the cadres and posyandu make posyandu become increasingly withered (depkes, 2014). therefore, considering the above problems, to improve the satisfaction of the mother of the children to posyandu services, it is necessary to monitor and evaluate the posyandu. assessment of posyandu strata conducted so far needs to be carried out continuously. training of posyandu cadres in a certain period of time should also be done. comparative studies of posyandu cadres to other posyandu should also be done as adult learning media so that they can follow the improvement efforts that have been done. it is also necessary to conduct a study on community satisfaction on posyandu services conclusion performance of posyandu kader balita in posyandu melati 9 puskesmas liliba kota kupang it is known that almost half of the respondents in the good category are 14 (36%) of respondents. maternal satisfaction level at posyandu melati 9 puskesmas liliba kota kupang is known that most respondents in the category of very satisfied is as much as 20 (51%) of respondents. the results of data analysis showed that the level of significance 0.000 <α = 0.05 so that h0 rejected and h1 accepted thus there is influence performance cadres posyandu toddlers against satisfaction levels under fives at posyandu melati 9 puskesmas liliba kota kupang. references adi, isbandi rukminto. 2014. psikologi, pekerjaan sosial dan ilmu kesejahteraan sosial: dasar-dasar pemikiran.jakarta: pt raja grafindopersada. avicena, 2015. kepuasan ibu balita berkunjung ke posyandu. surabaya : dinkes jatim. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 33 40 40 depkes ri. 2014. profil kesehatan indonesia 2014 : menuju indonesia sehat 2015. jakarta : departemen kesehatan ri. hurlock, elizabeth. 2010. psikologi perkembangan suatu pendekatan sepanjang rentang kehidupan. jakarta:penerbit erlangga. ilyas, y. 2009. kinerja : teori penilaian dan penelitian. jakarta : fkm ui. kamus besar bahasa indonesia (kbbi) (2010). konsep pendidikan. jakarta : rineka cipta. notoatmodjo, soekidjo. 2010. pendidikan dan perilaku kesehatan. jakarta : rineka cipta. sari, 2016. kualitas dalam goetsh dan davis. kualitas pelayanan. gramedia indonesia : jakarta. sari. w, irine diana. 2010. manajemen pemasaran usaha kesehatan. cetakan keempat. yogyakata: nuha medika. setiadi, j nugroho. perilaku konsumen, jakarta : kencana prenada media group, 2010. tjiptono, fandy. 2010. strategi pemasaran, edisi 2, andi offset, yogyakarta journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.61-69 61 empathy in mental health nursing care in brazil samyra fernandes gambarelli1, christian marx carelli taets2, gunnar glauco de cunto carelli taets2* 1federal fluminense university, brazil 2federal university of rio de janeiro, brazil corresponding author: master@ufrj.br abstract background: empathy, from the greek empathetic means to enter into the feeling, a term initially used by aesthetic theorists, to designate the ability to perceive the subjective experience of the other. for empathy to occur as a therapeutic process, it is essential that a relationship of mutual respect be developed and that nurses provide individualized care, respecting the culture, beliefs and values of the person. purpose: this study aimed to determine to know and characterize the scientific production on empathy in mental health nursing care in brazil. methods: this is a metasynthesis performed in the first half of 2018 that involved five stages: formulation of the problem, data collection, evaluation of the collected data, analysis and interpretation of the data, and presentation of the results. results: of the 6 studies that were part of this metasynthesis, the method most used among the forms of treatment among the health professional/patient is the biomedical model, focusing on the disease and not on the human being in a broad and holistic way, consequently, being performed only one punctual care and not a care in order to meet all the biopsychosocial needs of the patient. conclusion: as a way to improve care and meet the patient's needs, empathy is one of the main tools of mental health care in brazil, because with it we can gain trust and establish bonds with the patient, thus gaining an effective relationship for both parties, thus being able to perform an affectionate, integrative and productive care. keywords: empathy, nursing, mental health. received july 14, 2020; revised july 30, 2020; accepted august 15, 2020 doi: https://doi.org/10.30994/jnp.v4i1.109 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:master@ufrj.br https://doi.org/10.30994/jnp.v4i1.109 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.61-69 62 background the brazilian psychiatric reform began in the late 1970s, as a social movement and scientific field. psychosocial care centers (caps) are the equipment that organizes the mental health network and aims to replace the numerous hospital beds of the asylum model. on a territorial and community basis, caps serve people with severe and persistent mental disorders (leal, 2007). in this new paradigm of care, it is essential that the professional is willing to contact the experience lived by the client, guiding his care for it. empathy, from the greek empathetic means to enter into feeling, a term initially used by aesthetic theorists, to designate the ability to perceive the subjective experience of the other (goleman, 1995). for empathy to occur as a therapeutic process, it is essential that a relationship of mutual respect be developed and that nurses provide individualized care, respecting the culture, beliefs and values of the person. the main therapeutic tool of nurses is the use of oneself in the interpersonal context. empathy is a skill that can be performed with the user verbally and non-verbality. its development is extremely important when we propose to help someone. therefore, it is necessary that the professional is willing to know the potentialities and limitations of both his or her and the user's own in order to provide the necessary therapeutic nursing care. fish & shelly (1986, p. 110) define empathy as the "ability to understand what a person is feeling and transmit understanding to him, while maintaining a certain objectivity to be able to provide the necessary help". also, according to these authors, two other elements can be evidenced in an interpersonal relationship. one of them, sympathy, that first contact, first look, first smile. the other, intellectualization, where data are observed and collected objectively, without getting involved. they state that only when feelings and facts are placed side by side and objectively analyzed will they discover the cause(s) of the client feeling how he/she feels; we can then provide the necessary help, that is, act with empathy. often the professional-user relationship is close and considered a one-way street, where the subject does not have active participation in his own treatment, being only the object of study that needs to follow guidelines without having the right to question what may be better for himself or seek solutions together with the professional, thus providing an open, continuous dialogue that will make both, co-responsible for the therapeutic process. the theme was chosen due to recognizing the need and importance of empathy as a light care technology, so that it contributes to interpersonal relationships, enabling the user to share feelings and desires. thus, the health professional is able to develop a look from the perspective of the user intervening effectively and effectively. in the field of mental health, according to peixoto (2016), empathy allows a better understanding of the user experience, favoring the professional-user relationship and care. however, various forms of psychopathology, cultural, religious and social differences present themselves to it as an obstacle. the failure of empathy can weaken the bond with the user, thus preventing the construction of a therapeutic relationship. objective this study aimed to determine to know and characterize the scientific production on empathy in mental health nursing care in brazil. methods this is a metasynthesis performed in the first half of 2018 that involved five stages: formulation of the problem, data collection, evaluation of the collected data, analysis and interpretation of the data, and presentation of the results. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.61-69 63 the formulation of the problem was characterized by the guiding question: how is the use of empathy in mental health nursing care characterized in scientific production? for data collection, the scientific electronic library online (scielo) and virtual health library (vhl) databases were used. through the descriptors: empathy, mental health, nursing care. in the vhl, 1321 articles were found. the following filters were applied: full text, year of publication 2012 to 2017 and language portuguese. six articles were found, where repeated articles were excluded, totaling 3 articles in the vhl database. through the descriptors: "empathy" and "nursing care" in scielo, 47 articles were found. we apply the following filters: language portuguese, year of publication 2013 to 2017. we found 15 articles, where repeated articles were excluded, totaling 14 articles in the scielo database. through the descriptors "nursing care" and "mental health" in scielo, 182 articles were found. we apply the following filters: language portuguese and year of publication 2013 to 2017. we found 37 articles, where repeated articles were excluded, totaling 35 articles. the search resulted in 3 articles in the vhl and 49 articles in scielo, being careful reading of the articles to verify the approximation with the proposed theme, 6 articles were selected for analysis and discussion. the methodological path followed by being visualized through figure 1 figure 1. methodological path traveled, 2017. sources of researchers.. results to organize the information of the articles, a synthesis of the main information of each study was performed in a table that contains the following topics: title, author, year, type of study and a brief summary of the study (chart 1). it was possible to observe the need for strategies and tools that contribute so that health professionals, especially nurses, can assist the service user with more empathy, that is, in the way they would like to be assisted or cared for. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.61-69 64 table 1: title author year type of study synthesis article 1 the affective touch in the nurse's vision days ab, et al. 2008 analyticaldescriptive with qualitative approach the objective of this study was to investigate the nurse's conception of affective touch as a tool for the promotion of care and to identify its meaning in nursing care and the moment where it is used as a care instrument. through data analysis, the use of affective touch was demonstrated strictly during invasive procedures, even considering it an effective instrument to establish empathy. article 2 nursing care and jean watson: a reflection on empathy savieto rm, lion er 2016 theoreticalreflective it relates empathy with the theory of human care in the current context of nursing. it proposes a discussion about empathy and its relationship with the theory of human care, by jean watson, in contemporary practice of nursing. it is imperative to combine technical and humanistic aspects in the provision of nursing care, in addition to rescuing the appreciation of the empathy approach in the education of health professionals, as well as in the continuity of studies after graduation. article 3 the permanent education of the nursing team for care in mental health services mcm tavares 2006 exploratorydescriptive it analyzes the need for permanent education of the nursing team to care for mental health services. it was found that the mental health nursing team demands broad-spectrum qualification. it is concluded that the permanent education of the mental health nursing team requires, in addition to educational programs based on the definition of specific competencies, critical journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.61-69 65 educational processes aimed at the development of interdisciplinary knowledge. article 4 the importance of empathy in health care and nursing terezam r, kingsqueiroz j, hoga lak. 2017 critical review it provides a reflection on nursing practice in today's world, full of difficulties. it highlights the need for health professionals to be empathetic to themselves, so as to be able to offer effective care permeated by the empathic attitude. where the search for this care must be constant. presenting tools/strategies necessary to realize this ideal. article 5 psychiatric nursing, aben and the scientific department of psychiatric nursing and mental health: advances and challenges esperidião e, et al. 2013 theoreticalreflective it proposes to contextualize psychiatric nursing and mental health in brazil, considering the main historical, political and social milestones that influence nursing care in this area. bringing the paradigm change in the care context as well as in the nursing education. the achievements desired for this specialty permeate a critical and politically organized scientific community, thus the scientific department of psychiatric nursing and mental health is established as a strategy to bring together and consolidate the work of specialists, aiming at the excellence of care. article 6 medicalization and mental health: alternative strategies zanella m, et al. 2016 expositoryargumentative the regulation of the behavior of patients with psychological distress is based on pharmacological prescription in an indiscriminating manner, disregarding psychological, historical and social aspects. the objective is to discuss the alternatives to the biomedical model, suggesting possible strategies in mental health and psychosocial care, offered in journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.61-69 66 the public network. it shows that all health professionals should feel able to produce care beyond pharmacological treatment, based on empathy and active listening. article 1 presents the nurse's point of view on affective touch as an instrument for promoting care. according to dias ab, et.al 2008 in the care provided by nursing, there are two types of touch: instrumental touch, characterized by objective care, through technical procedures and affective touch, where care is subjective, based on sensitivity, creativity, support and intuition to care for another being; because the client is lacking holistic care. also according to dias ab, et al. 2008, touch in the context of nonverbal manifestations allows nursing to demonstrate both its technical ability and its ability to be supportive and understanding. despite the movement towards humanization in care, nurses still feel embarrassment when caring for the holistic, integral being, remaining restricted to the technical care required. it was observed that empathy has been used during invasive procedures as a communication tool, but in a restrictive way, which hinders the nurse-patient relationship. article 2 addresses nursing care, based on jean watson's theory. nursing has sought possibilities to understand and care that go beyond the limits constructed through the biomedical model. in such a way that there is appreciation of personal, subjective and cultural conditions of those involved in the care process. (savieto rm, leo er 2006) empathy according to watson is the most appropriate instrument for establishing a good relationship with the client. the clinical caritas contains ten elements that consider being cared for as sacred, showing in each element the empathy to the client, not only technical competence, but active listening, respect, compassion, the valorization of human aspects, providing nurses with a way to expand their field of action, enabling a more complete attention to the needs of those who are being cared for. this article reinforces the importance of this reflection for care practice with the real needs of patients, which are certainly not fully contemplated by the biomedical approach, but by a holistic and empathetic approach. article 3 aims to analyze the need for permanent education of the nursing team for care in mental health services. the study points out that in the 1980s the transfer to the mental health sector was associated with punishment, there was a great deal of resistance on the part of health professionals, where very few professionals went willingly. and most nurses did not have specific qualifications to work in this field, a reality experienced nowadays. due to lack of qualification, some have doubts about how to deal with patients who have aggressive behavior, and above all, doubts about the meaning of their role as a professional. the lack of preparation to live/work with users in the crisis highlights the need and urgency of assistance to help mobilize the resources needed to intervene in the crisis. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.61-69 67 discussion throughout the study, it is evident the interest of nurses and staff in qualifying so that there is no compromise of humanized care and that the bond for care care care is not broken. the permanent education of mental health nurses requires in addition to educational programs, but shows the need to build integral systems of permanent education within the service itself. article 4 is a critical review based on the book "cultivating empathy", by author kathleen stephany, which shows the importance of empathy for care. during the criticism, it is evident the need for health professionals to be empathetic, to put themselves in the place of the other, understanding their pain and suffering. empathy in mental health care is placed in the client's relationship with the family, where nurses need to create strategies with the family where there is home harmonization, and it is necessary that the family member put himself in the user's place to better understand his/her situation and behavior; thus improving its relationship with the user himself, through efficient listening, understanding that there are two types of communication and that the nonverbal is present and needs to be respected and understood. these are important aspects for the adoption of empathic attitudes: self-knowledge, the ability to discern between emotions that are proper and those of others, the absence of prior judgment, and the ability to remain attentive to the effects of words themselves and reactions on others. (terezam r, reis-queiroz j, hoga lak, 2017) in article 5 it is possible to see the advances of psychiatric nursing and mental health in brazil from the psychiatric reform, evidencing the paradigm shift and what benefits were achieved for the nursing field and for subjects in psychological distress with such transformation. according to the historical milestones, care began to be carried out through psychosocial care. according to federal law no. 10,216, the creation of psychosocial care centers (caps) provided better monitoring, access, reception and bonding; providing a holistic look at the health-disease process. in nursing practice, nursing consultations are the exclusive actions of nurses as an important resource with the user and his/her family, as well as the supervision and training of the nursing team. according to esperidião e, et al, 2013, it was also up to nursing to assume a therapeutic, critical-reflexive attitude, from a humanist perspective and professional autonomy, learning to deal with group techniques and valuing interpersonal relationships. however, it is still possible to frequently perceive the attributions of nurses focused on the individual scope and in the psychiatric hospital environment, still valuing pharmacological treatment, without considering subjective care, despite recognizing its importance and need. article 6 focuses on medicalization and mental health, where it proposes alternative strategies with the objective of demystifying the rooted concept of the biomedical model, which has medicalization as primacy. according to foucault, 2010 and zanella m, et al, 2016 medicine and its pharmacological techniques will be the great dominator of mental illness, shifting all the explanation to the biological entity, in order that society can neutralize this subject. medicine can even end mental illness, just as it did with leprosy, but nothing can suppress man's relationship with his ghosts. however, light technologies are the tools used by health professionals that enable a better understanding of psychic suffering by establishing care based on subjective care. the study exposes that there are ways to work around the situation by building together with the person in mental illness, methods of suppressing the biomedical model, journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.61-69 68 these being some of the instruments: dehospitalization, welcoming, autonomy, family and team co-responsibility, psychosocial care network (raps) and deinstitutionalization of the individual, family and also society. according to zanella m, et al, 2016 are the possibilities of substitute services with the focus of demedicalizing, proposing new therapeutic possibilities to users of the unified health system (sus). one of them would be to develop actions together with caps such as nursing consultation, home visits, therapeutic groups and workshops. the main idea of the above-mentioned article is not to end with medicalization, but to show that each has the right and duty to choose the most appropriate treatment in each case, whether medicated or not; although in some cases there is a need for medicalization in other alternative methods can be used for the benefit of the user, demonstrating that nurses need to feel able to produce care based on empathic attitudes. conclusion it is concluded that the most used method among the forms of treatment among the health professional / patient is the biomedical model, with a focus on the disease and not on the human being in a broad and holistic way, consequently, being carried out only punctual care and not care in order to meet all the biopsychosocial needs of the patient. as a way to improve care and meet the patient's needs, empathy is one of the main tools of care, because with it we can gain trust and establish bonds with the patient, thus gaining an effective relationship for both parties, thus being able to perform an affectionate, integrative and productive care. in the execution of daily care provided by nurses within the mental health scenario, we can observe that empathy is often not put into practice, leaving aside the patient's reception and unfortunately causing damage to the establishment of bonding. empathy is a light care tool that requires only a more attentive and open practice to holistic care. however, empathy is a skill that can be developed by the professional based on their sensitivity, respect, appreciation of the feelings of the other, with this, it is expected that this work can serve as a reflection, contributing to the reorganization of ideas and concepts about essential improvements that are necessary to the current practice of nursing in the field of mental health. conflicts of interest the authors declare that there is no conflict of interest in the publication of this article. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.61-69 69 references dias, a.b., oliveira, l., dias, d.g., santana, m.g. (2008). affective touch according the nurse’s perspective. brazilian journal of nursing, 61(5), 603-607. https://www.scielo.br/pdf/reben/v61n5/a12v61n5.pdf esperidião, e., silva, n.s., caixeta, c.c., rodrigues, j. (2013). the psychiatric nursing, aben and the scientific department of psychiatric and mental health nursing: progress and challenges. brazilian journal of nursing, 66 (spe), 171-176. https://doi.org/10.1590/s0034-71672013000700022 sharon, f., shelly, j.a. (2004). spiritual care of the patient. são paulo: umhe. goleman, d. emotional intelligence. rio de janeiro: objective, 1995. retrieved from https://books.google.co.id/books/about/emotional_intelligence.html?id=xp5gaa aamaaj leal, m. e., delgado, p.g.g. clinic and daily life: caps as a device of deinstitutionalization. (2007). in: pinheiro r, guljor ap, gomes a, mattos ra, organizers. deinstitutionalization of mental health: contributions to evaluative studies. rio de janeiro: cepesc: ims/ lappis: abrasco; p. 137-154. peixoto, m.m., mourao, a.c.n., serpa junior, o.d. (2016). coming to terms with the other’s perspective: empathy in the relation between psychiatrists and persons diagnosed with schizophrenia. science collective health, 21(3), 881890. https://doi.org/10.1590/1413-81232015213.04782015 savieto, r.m., leão, e. (2016). nursing assistance and jean watson: a reflection on empathy. journal of nursing anna nery, 20(1), 198202. https://doi.org/10.5935/1414-8145.20160026 souza, m.t., silva, m.d., carvalho, r. (2010). integrative review: what it is and how to do it. einstein, 8 (1), 102-106. https://doi.org/10.1590/s1679-45082010rw1134 tavares, c.m.m. (2006). permanent education of the team of nursing for the care in the services of mental health. text and context nursing, 15(2), 287-295. http://dx.doi.org/10.1590/s0104-07072006000200013 terezam, r., reis-queiroz, j. hoga, l.a.k. (2017). the importance of empathy in health and nursing care. brazilian journal of nursing,70(3), 669–70. https://doi.org/10.1590/0034-7167-2016-0032 zanella, m., luz, h.h.v., benetti, i.c., roberti junior, j.p. (2016). medicalization and mental health: alternative strategies. portuguese journal of mental health nursing, 15, 53-62. http://dx.doi.org/10.19131/rpesm.0132 https://www.scielo.br/pdf/reben/v61n5/a12v61n5.pdf https://doi.org/10.1590/s0034-71672013000700022 https://books.google.co.id/books/about/emotional_intelligence.html?id=xp5gaaaamaaj https://books.google.co.id/books/about/emotional_intelligence.html?id=xp5gaaaamaaj https://doi.org/10.1590/1413-81232015213.04782015 https://doi.org/10.5935/1414-8145.20160026 https://doi.org/10.1590/s1679-45082010rw1134 http://dx.doi.org/10.1590/s0104-07072006000200013 https://doi.org/10.1590/0034-7167-2016-0032 http://dx.doi.org/10.19131/rpesm.0132 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.94-102 94 the relationship between knowledge, attitude and perception with behavior in consuming herbal medicine in singaraja city nyoman sri ariantini*, eka lutfiatus solehah rana wijaya high school of health sciences singaraja, indonesia corresponding author: nariantini@gmail.com abstract background: the emergence of various diseases such as the covid-19 pandemic is now causing the public to seek various treatments and to strengthen the body's immune system. the transmission of the virus through local transmission causes the number of covid-19 cases to continue to grow. therefore, prevention efforts must be made, namely the breaking of the chain of transmission with self-isolation, early detection, and basic protection. the basic excretion referred to by other children washing hands regularly with soap or using hand sanitaizer, maintaining distance, and consuming healthy foods to improve the immune system. purpose: this study aimed to find out the relationship between knowledge, attitude and perception with behavior in consuming herbal medicine. methods: the design of this study is observationally descriptive with a crossectional approach. singaraja city has an area of 27.98 km2, and its population of 80,500 people is used the type of probability sampling technique simple random sampling. the sample is calculated by the formula obtained as many as 100 respondents. the data was collected with questionnaire instruments and analyzed with chis square tests. results: the results showed a value of ρ for knowledge, attitude and perception < α then this shows a relationship between knowledge, attitude and perception with behavior in consuming herbal medicine. conclusion: the community still gives a positive response to traditional medicine through herbal medicine. this happens because the public already knows enough about the benefits of consuming herbal medicine that can maintain and increase immunity especially in the pandemic period this is needed. keywords: knowledge, attitude, perception, behaviour, herbal medicine. received august 12, 2021; revised august 21, 2021; accepted september 17, 2021 doi: https://doi.org/10.30994/jnp.v5i1.157 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. http://thejnp.org/ mailto:nariantini@gmail.com https://doi.org/10.30994/jnp.v5i1.157 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.94-102 95 background the emergence of various diseases such as the covid-19 pandemic is now causing the public to seek various treatments and to strengthen the body's immune system. the transmission of the virus through local transmission causes the number of covid-19 cases to continue to grow. bali provincial health office data said that the addition of positive cases increased every day where data as of october 13, 2020 the number of postive cases in bali amounted to 10304 people and buleleng regency with the number of positive cases amounted to 965 people.6 therefore, prevention efforts must be made, namely the breaking of the chain of transmission with self-isolation, early detection, and basic protection. the basic protectors in question include washing hands regularly with soap or using hand sanitaizer, maintaining distance, and consuming healthy foods to improve the immune system. world health organization (who, 2003), countries in africa, asia and latin america use herbal remedies as a complement to primary treatment. in africa as many as 80% of the population uses herbal medicine for primary medicine. research in the united states shows that the use of herbal remedies increased from 3% in 1990 to 12% in 1997, and 19% in 2002 (pinzon, 2007). currently the use of cam (complementary and alternative madacine) in the united states reaches 40% and in the united kingdom reaches 20%4. who recommends the use of alternative medicines including herbs in the maintenance of public health, prevention and treatment of diseases, especially for chronic diseases, degenerative diseases and cancers. who also supports efforts to improve the safety and efficacy of traditional medicine. herbal medicine is one of the cultural heritage of the indonesian nation that has been used down and down. the results of basic health research (riskesdas) in 2018 on the use of herbal medicine by the people of indonesia, found that 59.12% of the public still consume herbal medicine and more than 95.6% of them recognize the benefits of herbal medicine for health. according to siswanto (2012) herbal medicine is a traditional drink native to indonesia that has medicinal properties. herbs are served in powder, steeping, pills or liquids. according to the regulation of the minister of health (permenkes) in 2010 herbal medicine is a traditional indonesian medicine3. according to puspitasari (2020) some herbal plants that have been studied and proven to be able to increase immunity include meniran (phylanthus niruri), java chili (piper longum), lime (citrus aurantifolia), turmeric (curcuma longa). in addition, there are herbal processed as herbal medicine that is drunk directly, including rice kencur, turmeric asem, temulawak and traditional herbal drinks5. the behavior of the consumption of herbal medicine as a booster of the immune system is inseparable from the level of knowledge, attitude and perception of a person in the consumption of herbal medicine in the community. a person's level of knowledge will have an impact on his level of trust in something. a person's level of trust will also affect his attitude. knowledge and attitude factors have a major influence on the formation of perceptions in the community and affect the health status of individuals and communities and play an important role in the success of disease management programs and prevention of transmission including covid-19 disease. the hope is that with the increasing consumption of herbal medicine in the community, it will play a role in improving public health status, one of which can maintain or improve the immune system among the public in the midst of the covid-19 pandemic.. methods the level of knowledge, attitudes, and perceptions of urban communities towards the behavior of herbal consumption during the covid-19 pandemic are the issue that learn http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.94-102 96 in this research. design is a type of descriptive research using analytical research design and cross-sectional design (cut latitude). the design of this study was chosen to examine an event at the same time (at the same time). independent variables are the level of knowledge, attitudes and perceptions of urban communities, while dependent variables are the behavior of herbal consumption during the covid-19 pandemic. the sampling technique in this study will use probability sampling, namely simple random sampling, which is sampling in populations that are done randomly regardless of the strata in the population. with an area of singaraja city of 27.98 km2, and its population amounted to 80,500 people. using the formula slovin, the number of samples in this study was obtained amounting to 100 people. the inclusion criteria are people domiciled in singaraja city, accustomed to consuming herbal medicine during the covid-19 pandemic, willing to be respondents and aged 17-60 years, have an internet-connected mobile phone so that they can access googleform online questionnaire, while the exclusion criteria are respondents who are incomplete to fill out online questionnaires or system errors such as duplicated data. the research data was obtained from the collection of questionnaires online with the googleform application that was shared with respondents through a link on the whatsapp application. the data is then processed and analyzed with univariate spss applications with frequency distribution and bivariate with chi square at a confidence level of 95%. results and discussion the result of this study that’s can be explained below: 1. general data table 1 distribution of respondent frequency based on general data in singaraja city no general data frequention % age 1 < 20 years 24 24 2 21-35 years 70 70 3 > 35 years 6 6 gender 1 man 37 37 2 woman 63 63 education 1 senior high school 50 50 2 bachelor 45 45 3 magister 5 5 domicile 1 in the city of singaraja 61 61 2 out the city of singaraja 39 39 salary 1 < rp. 2000.000 65 65 2 rp. 2.000.001-rp.3.000.000 24 24 3 > rp. 3.000.000 11 11 http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.94-102 97 consumption of herbs 1 routine 0 0 2 not 100 100 total 100 100 based on table 1 shows data that based on the age of respondents obtained data mostly aged 21-35 years as many as 70 respondents (70%). based on gender, most of the female sex data was obtained as many as 63 respondents (63%). based on education obtained data half have a high school education background as many as 50 respondents (50%). based on the place of domicile obtained data mostly domiciled in singaraja city as many as 61 respondents (61%). based on income obtained data mostly have income < rp. 2,000,000 as many as 65 respondents (65%). and based on the consumption of herbal medicine obtained data all respondents are not routine in consuming herbal medicine. 2. special data table 2 distribution of respondents' frequency based on special data in singaraja city no special data frequention % knowledge 1 good 39 39 2 enough 51 51 3 less 10 10 attitude 1 negative 45 45 2 positive 55 55 perception 1 negative 41 41 2 positive 59 59 behaviour 1 consumption 53 53 2 not 47 47 total 100 100 based on table 2 shows data that based on knowledge about herbal medicine obtained data most respondents have enough knowledge as much as 51 respondents (51%). based on the attitude obtained data most respondents showed a positive attitude as many as 55 respondents (55%). based on the perception of herbal medicine obtained data mostly have a potitive perception of herbal medicine as many as 59 respondents (59%). based on behavior in consuming herbal medicine obtained data mostly consuming the herbal medicine as many as 53 respondents (53%). http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.94-102 98 3. result of byvariat analysis 1) bivariate analysis between knowledge and behavior table 3. cross-tabulation between knowledge variables and herbal consumption behavior in singaraja city knowledg e consumtion behaviour amount yes not f % f % f % good 28 71,8 11 28.2 39 100 enough 24 47,1 27 52.9 51 100 less 1 10 9 90 10 100 amount 53 53 47 47 100 100 based on the table shows that of the 39 respondents who have good knowledge most consume herbal medicine as many as 28 respondents (71.8%). of the 51 respondents who have enough knowledge, most do not consume herbal medicine as many as 27 respondents (52.9%). and of the 10 respondents who have less knowledge almost all do not consume herbal medicine as much as 9 respondents (90%). based on the results of the chi square test obtained data value ρ = 0.007, α = 0.05 so that ρ = 0.007 < α = 0.05 this means there is a relationship between knowledge and behavior in consuming herbal medicine. some research shows that informants have a positive perception of vulnerability about what herbs they think are susceptible to consumption if the contents are not yet known. this is because not all herbs can be freely consumed without knowledge, experience, information that supports the perception of informants. research conducted by dewi in 2015 on the knowledge of herbal medicine as a menstrual pain reliever in klaten stated that 50% of respondents had a good knowledge of herbal medicine as a menstrual pain reliever, while in the cloud study in 2014 not all respondents had a good perception of traditional herbal medicine. while research conducted by romziyah in 2020 on the relationship of knowledge and public attitudes in using immunomodular herbs in efforts to prevent covid-19 stated that there is no relationship between the level of knowledge and attitude of the community in efforts to prevent covid-19 using immunomodular herbs. another study related to the consumption of herbal medicine conducted by adi in 2018 stated that a person's knowledge of something affects the person's practices or actions in this case is the relationship between knowledge to the practice of consumption of herbal medicine jun.10 according to the assumptions of researchers, the results of this study show that most respondents already have a good enough knowledge about herbal medicine to maintain body health during the covid-19 period. respondents' knowledge supports their actions or behavior in consuming herbal medicine, because with this knowledge respondents can better know and understand what herbs and how to consume them so that it is safe for them to consume in an effort to maintain health and improve immunity during the covid-19 pandemic. a person's knowledge has an important role in influencing a person's behavior or actions in consuming something or service. this shows that the better the knowledge about herbal medicine, the more routine a person will be in consuming herbal medicine to increase immunity during the covid-19 pandemic. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.94-102 99 2) bivariate analysis between attitudes and behavior table 4. cross-tabulation between attitude variables and herbal consumption behavior in singaraja city attitude consumtion behaviour amount yes not f % f % f % negative 16 35,6 29 64,4 45 100 positive 37 67,3 18 32,7 55 100 amount 53 53 47 47 100 100 based on table 4 shows that of the 45 respondents who have a negative attitude most do not consume herbal medicine as many as 29 respondents (45% and from 55 respondents who have a positive attitude mostly consume herbal medicine as many as 37 respondents (67.3%). the results of the chi square test showed that ρ = 0.001 < α = 0.05 then this means that there is a relationship between attitude and behavior in consuming herbal medicine. herbal medicine is a term for traditional medicine in indonesia. herbs are made from natural ingredients in the form of plants, animal body parts and spices. herbal medicine as a traditional medicine plays an important role in the treatment of populations in developing countries. according to wijisekera (1991) about 70-80% of the population in developing countries has a dependence on traditional oabat or herbal medicine. the use of herbal medicine as an alternative to medicine in addition to modern medicine in the community is part of indigenous knowledge community9. the results of the basic health research of the ministry of health of the republic of indonesia in 2018 on the use of herbal medicine by the people of indonesia, found that 59.12% of the public still consume herbal medicine and more than 95.6% of the users recognize the benefits of herbal medicine for health. these results show that the knowledge and practice of public consumption in herbal medicine as a traditional medicine in indonesia is still quite high.1 the results of this study showed that the attitudes possessed by respondents in this study is one of the things or aspects that affect the occurrence of a person's behavior. the attitude shown by respondents in this study illustrates how their response to traditional medicines such as herbal medicine can maintain body health during the covid-19 pandemic. the positive response or attitude will form a positive behavior towards the use of herbal medicine in maintaining body health. negative respondent attitudes occur because respondents still consider that herbal medicine is not too safe to consume than medical drugs or other herbs, because herbal medicine has a greater negative effect or impact than other herbs. this shows that the more positive a person's attitude, the better and routine one will be in consuming herbal medicine. this research is in line with research conducted by tiara et al (2019) proved that repsonden attitudes towards herbal drinking habits have a significant influence.18 http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.94-102 100 3) bivariate analysis between perception and behavior table 5. cross-tabulation between perception variables and herbal consumption behavior in singaraja city perception consumtion behaviour amount yes not f % f % f % negative 15 36,6 26 63,4 41 100 positive 38 64,4 21 35,6 59 100 jumlah 53 53 47 47 100 100 based on table 5 shows that of the 41 respondents who have negative perceptions most do not consume herbal medicine as many as 26 respondents (63.4%) and of 59 respondents who have a positive perception mostly consume herbal medicine as many as 38 respondents (64.4%). the results of the chi square test showed that ρ = 0.006 < α = 0.05 then this means that there is a relationship between persepsu and behavior in consuming herbal medicine. according to puspitasari (2020) some herbal plants that have been studied and proven to be able to increase immunity include meniran (phylanthus niruri), java chili (piper longum), lime (citrus aurantifolia), turmeric (curcuma longa). in addition, there are herbal processed as herbal medicine that is drunk directly, including rice kencur, turmeric asem, temulawak and traditional herbal drinks5. the behavior of the consumption of herbal medicine as a booster of the immune system is inseparable from the level of knowledge, attitude and perception of a person in the consumption of herbal medicine in the community. according to the researchers, the results of this study show that the public still gives a positive response to traditional medicine through herbal medicine. this happens because the public already knows enough about the benefits of consuming herbal medicine that can maintain and increase immunity especially in the pandemic period this is needed. therefore, many people still consider herbal medicine is one of the right alternatives in doing treatment or efforts to maintain health and improve immunity in the covid-19 pandemic. a person's perception is influenced by various factors such as objects, sensing, and attention, in addition to psychological, family and social cultural factors. this research is in line with the research conducted by dewi, et al (2019) about the perception of mayarakat in the consumption of traditional medicine is safer because it is made from natural ingredients.20 4) multivariate analysis table 6. multivariate analysis between knowledge, attitude, perception with herbal consumption behavior in singaraja city behavioura exp(b ) 95% confidence interval for exp(b) lower bound upper bound consumption intercept knowledge 16.48 3 1.793 151.5 51 attitude 1.225 .119 2.644 http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.94-102 101 perception 1.652 .138 19.79 7 based on table 6 above shows that knowledge variables have a higher chance of increasing the consumption of drinking herbal medicine than other variables with an or (expb) value of 16,483 meaning that knowledge has a 16,483 times chance of influencing the behavior of consuming herbal medicine regularly. the results of this study showed that respondents' knowledge of consuming herbal drinking affected respondents' behavior more than attitude and perception variables. because with good knowledge will foster lasting behavior in consuming herbal medicine. conclution most of the respondents' knowledge of traditional herbal medicine in the category is sufficient most attitudes towards traditional herbal medicine are in the positive category most of the respondents' behavior in the category of consuming herbal medicine during the covid-19 pandemic to maintain health some people's perceptions of traditional herbal medicine in katgeori positive there is a relationship between knowledge and behavior in consuming herbal medicine during the covid-19 pandemic as evidenced by the results of the chisquare test which is ρ = 0.007 < α = 0.05 there is a relationship between attitudes and behavior in consuming herbal medicine during the covid-19 pandemic as evidenced by the results of the chisquare test which is ρ = 0.001 < α = 0.05 there is a relationship between perception and behavior in consuming herbal medicine during the covid-19 pandemic as evidenced by chisquare test results that are ρ = 0.006 < α = 0.05 knowledge is the dominant variable in influencing a person's behavior to consume herbal medicine regularly acknowledgment the author is thankful to respondents in singaraja city, bali for their valuable information and their awareness to participate in this research references 1. minister of healthy in indonesia. (2018). hasil utama riskesdas 2018. 2. siswanto. (2012). saintifikasi jamu sebagai upaya terobosan untuk mendapatkan bukti ilmiah tentang manfaat dan keamanan jamu. buletin penelitian sistem kesehatan, 203–211. 3. pemenkes 2010. saintifikasi jamu dalam penelitian berbasis pelayanan kesehatan. peraturan menteri kesehatan republik indonesia nomor :003/menkes/per/i/2010. jakarta 4. ersnt, m. h. c. & j, s. etichal problems arising in evidence based complementary and alternatif medicine. med ethical 30, 56–59 (2004). 5. puspitasari,ika. 2020. mengenal herbal pendongkrak imun tubuh. universitas gajah mada. artikel. 30 maret 2020 6. dinas provinsi bali. jumlah kasus positif covid-19 provinsi bali. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.94-102 102 https://infocorona.baliprov.go.id/ akses 14 oktober 2020 7. sakri, f. (2012). 1001 khasiat & manfaat jamu godog untuk segala macam penyakit. yogyakarta: diandra pustaka indonesia. 8. who 2005. pemastian mutu obat kompendium pedoman dan bahan-bahan terkait. egc. jakarta. 9. wijisekera, r. (1991). plant-derived medicines and their role in global health. florida: crc press 10. pratama adi. (2018) pengetahuan dan praktik konsumsi jamu jun pada masyarakat semarang. indonesian journal of antropology iii/2 76-84 11. maharrani, a. (2018). mempertahankan eksistensi jamu. retrieved from beritagar.id website: https://beritagar.id/artikel/gaya-hidup/mempertahankan-eksistensi-jamu 12. dewi, indri kusuma, yunianto, bambang, 2015, pengetahuan tentang jamu sebagai pereda nyeri haid pada siswi sma n 1 jatinom klaten. jurnal kebidanan indonesia vol 6 no.2 13. awan, nita adi, wijayanti, irfana tri. 2014.analisa faktor yang berhubungan konsumsi jamu tradisional saat menstruasi dengan dismenorhea pada wanita usia reproduksi di desa glonggong kecamatan jakenan kabupaten pati. jurnal ilmu kebidanan dan kesehatan vol 5 (2) hal 20-25. 14. pringgoutomo, s. (2007). riwayat perkembangan pengobatan dengan tanaman obat di dunia timur dan barat, buku ajar kursus herbal dasar untuk dokter. jakarta: balai penerbit fkui 15. sudirga, s. k. (2012). pemanfaatan tumbuhan sebagai obat tradisional di desa trunyan kecamatan kintamani kabupaten bangli. bumi lestari journal of environment, 4(2) 16. supardi, s., & susyanty, a. l. (2010). penggunaan obat tradisional dalam upaya pengobatan sendiri di indonesia (analisis data susenas tahun 2007). buletin peneliti kesehatan, 38(2), 80–89. 17. sari, l. o. r. k. (2006). pemanfaatan obat tradisional dengan pertimbangan manfaat dan keamanannya. majalah ilmu kefarmasian, iii(1), 1–7. 18. kusuma mega. (2019) hubungan tingkat pengetahuan dan sikap terhadap kebiasan konsumsi jamu pada masyarakat magelang. https://journals.ums.ac.id/index.php/pharmacon/article/view/10857/5728 19. sinambela, d. p., mahdiyah, d., dan helmiah, r. (2016). persepsi remaja puteri tentang konsumsi jamu-jamuan untuk mengatasi nyeri haid di sman 8 banjarmasin, dinamika kesehatan volume 7 no.2 20. dewi, r.s dkk (2019). persepsi masyarakat mengenai obat tradisional di kelurahan simpang baru kecamatan tampan kota pekanbaru. jurnal penelitian indonesia vol. 8 no.2 http://thejnp.org/ https://journals.ums.ac.id/index.php/pharmacon/article/view/10857/5728 journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 40 47 pengetahuan kanker serviks dalam tindakan melakukan pap smear pada wanita usia subur (di desa tulungrejo kecamata besuki kabupaten tulungagung tahun 2017) farida, firda oktafia nurhidayah, program studi ilmu keperawatan stikes hutama abdi husada tulungagung poprimf@gmail.com abstract cancer serviks is on the neck ovarian cancer or serviks. the incident the cancer serviks each year always having an increase in. dinkes provincial government jatim mentioned period in 2013 as much as 11,25 % women exposed cancer serviks. to reduce the incident cancer serviks done by the early detection of cancer the inquest pap smears. the study aims to know the relationship knowledge of cancer serviks with a do pap smears at the age of the woman thrive in the village tulungrejo district besuki tulungagung. this study was conducted in march to may 2017. this study used correlation design with cross sectional approach. population of this study is women in productive age in tulungrejo village, besuki district, tulungagung regency by using simple random samplingtechnique as much as 51 people. data collection used questionnaire, data analysis used chi square test. result of study from 51 women in productive age shows that they are mostly has less knowledge and in conducting pap smear 49 (96,1%) people of them are almost never conducting.statistical test of chi square skripsi obtained value of ρ=0.034< α=0.05 that h0is rejected and h1is accepted where there is correlation between knowledge on cervical cancer with pap smear treatment on women in productive age in tulungrejo village, besuki district, tulungagung regency. this study shows that there is correlation between knowledge on cervical cancer with pap smear treatment on women in productive age. therefore, there is needed wider information for society on health especially on cervical cancer. keywords: knowledge on cervical cancer, pap smear treatment, women in productive age. received august 15, 2017; revised september 07, 2017; accepted october 01, 2017 how to cite: farida & nurhidayah, f.o. (2017). pengetahuan kanker serviks dalam tindakan melakukan pap smear pada wanita usia subur (di desa tulungrejo kecamata besuki kabupaten tulungagung tahun 2017). journal of nursing practice. 1(1). 40-47. the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-noncommercialsharealike 4.0 international license. 40 mailto:poprimf@gmail.com journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 40 47 pendahuluan sedangkan riset (globocan, kesehatan reproduksi adalah keadaan international agency for research an yang sejahtera fisik, mental dan sosial secara cancer/iarc 2012) insiden kanker leher utuh yang tidak hanya semata-mata bebas rahim 17 per 100.000 perempuan dari penyakit atau kecacatan dalam semua (kemenkes,2015). menurut dinkes provinsi hal yang berkaitan dengan sistem reproduksi, jatim, 2013 di jawa timur merupakan salah serta fungsi dan prosesnya satu provinsi di indonesia yang mempunyai (prawiroharjo,2011). kesehatan reproduksi jumlah kasus kanker serviks yang cukup pada wanita salah satunya meliputi kesehatan tinggi. di jawa timur sebanyak 11,25 % organ-organ reproduksi pada wanita. secara wanita menderita kanker serviks. anatomi fisiologis, organ reproduksi wanita berdasarkan data dari dinas kesehatan terbagi menjadi dua bagian. alat reproduksi provinsi jawa timur, kasus kanker serviks bagian luar dan alat reproduksi bagian dalam. terjadi di 29 kabupaten dan 8 kota di jawa diantara alat reproduksi bagian dalam timur pada tahun 2013 dengan jumlah total terdapat organ reproduksi servik. serviks sebesar 1884 kasus. merupakan bagian bawah dari rahim yang menurut study pendahuluan yang di berfungsi sebagai jalur lahir dan pemisah lakukan oleh peneliti pada tanggal 01 antara rahim dengan vagina. salah satu desember 2016 dengan metode wawancara penyakit yang dapat menganggu kesehatan bebas terpimpin kepada wanita usia produktif organ reproduksi wanita adalah kanker di desa tulungrejo kecamatan besuki servik, kanker serviks merupakan kanker kabupaten tulungagung bahwa dari 10 yang mengenai leher rahim atau serviks orang wanita usia produktif 90 % belum (kemenkes,2015). mengerti apa itu kanker serviks dan kanker serviks disebabkan oleh human bagaimana pemeriksaan dini tentang kanker papilloma virus (hpv) onkogenik, yang serviks. hal ini mengidentifikasi bahwa menyerang leher rahim. biasanya kanker masih rendahnya pengetahuan wanita usia serviks ini menyerang pada wanita usia subur produktif di desa tulungrejo kecamatan yaitu 15-49 tahun (edianto,2006). menurut besuki kabupaten tulungagung tentang badan kesehatan dunia, wanita resiko kanker serviks dalam deteksi dini tentang terkena kanker serviks di negara kanker serviks. berkembang semakin tinggi dan tetap besar dalam upaya-upaya yang dapat jumlanya. dalam hal ini terjadi karena dilakukan untuk mengurangi angka kesakitan kebiasaan dan perilaku masyarakatnya sering dan kematian akibat kanker serviks dapat melakukan seks bebas sejak dini di luar dilakukan dengan upaya pap smear. pap pernikahan (yki,2013). smear merupakan tindakan untuk melakukan dari data who tahun 2013, insiden deteksi dini (early detection) dan mengambil kanker meningkat dari 12,7 juta kasus pada langkah yang dibutuhkan sebelum terjadi tahun 2008 menjadi 14,1 juta kasus pada stadium akhir. pada negara amerika serikat tahun 2012 (kemenkes,2014). berdasarkan telah dilakukan 50 juta uji pap smear setiap data penelitian kesehatan dasar (riskesdas tahunnya, dalam hal itu berhasil menurunkan 2013), prevelensi kanker di indonesia adalah insiden kanker serviks hingga 70 %. 4,1 per 1000 penduduk, atau sekitar 330.000 sedangkan tingkat pengetahuan dan orang. kanker tertinggi di indonesia pada kesadaran pada perempuan di indonesia perempuan yaitu kanker payudara dan kanker untuk melakukan tes pap smear masih sangat leher rahim (serviks). rendah (mki,2007). 41 journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 40 47 kurangnya pengetahuan wanita usia metode subur tentang kanker serviks dapat berdampak pada tidak adanya motivasi untuk desain penelitian ini menggunakan melakukan pemeriksaan dini dengan desain penelitian survey cross sectional tindakan pap smear, dampak kanker serviks adalah suatu penelitian untuk mempelajari jika tidak segera dilakukan pemeriksaan pada dinamika korelasi antara faktor-faktor resiko organ reproduksi serviks beresiko keadaan dengan efek, dengan cara pendekatan, kesehatannya telah menjadi kritis atau observasi atau pengumpulan data sekaligus penyakit sudah mencapai pada tahap stadium pada suatu saat. artinya, tiap subjek lanjut sehingga dapat berunjung pada penelitian hanya diobservasi sekali saja dan kematian (rasjidi.2010). sebagian besar pengukuran dilakukan terhadap status pada penderita kanker serviks datang berobat karakter atau variabel subjek pada saat sudah pada stadium lanjut. hal ini pemeriksaan (notoatmodjo,2012). dikarenakan kanker serviks tidak populasi dari penelitian ini adalah menunjukan gejala yang spesifik pada seluruh wanita usiasubur di desa tulungrejo stadium dini atau bahkan pada tahap kecamatan besuki kabupaten tulungagung prakanker. maka hal tersebut tidak heran yang berjumlah 105 orang pada bulan kalau kanker serviks ini merupakan februari sampai maret 2017. pembunuh wanita peringkat kedua setelah sampel yang digunakan dalam kanker payudara. memang wanita sendiri penelitian ini adalah sebagian wanita usia tidak menyadari bahwa tubuhnya sedang subur di desa tulungrejo kecamatan besuki “dikudeta” oleh sel-sel dalam tubuhnya kabupaten tulungagung yang berjumlah 51 sendiri (savitri,2015). orang dengan kriteria inklusi dan eksklusi. kurangnya kesadaran masyarakat pengumpulan data yang digunakan khususnya bagi perempuan indonesia pada untuk mengukur pengetahuan tentang kanker bahaya kanker serviks perlu ditanggapi serviks adalah dengan kuesioner tertutup dengan meningkatkan upaya promotifsedangkan untuk mengetahui tindakan preventif. dengan cara melaksanakan melakukan pap smear menggunakan sosialisasi, advokasi, dan edukasi di berbagai kuesioner. elemen masyarakat. pemerintah analisis data dengan menggunakan mentargetkan minimal 80 % perempuan usia spss 16.0 for windows. analisis data yang subur < 20 sampai 49 tahun melakukan digunakan adaah analisis bivariat untuk deteksi dini dalam waktu setiap 5 tahun melihat mengetahui interaksi dua variable, sekali dalam pengendalian kanker serviks baik berupa komparatif, asosiatif maupun salah satunya dengan pemeriksaan pap smear korelatif. yang bertujuan untuk mengetahui (rasjidi,2009). hubungan antara dua variabel. untuk tujuan dari penelitian ini adalah menguji hubungan pengetahuan kanker mengidentifikasi tingkat pengetahuan wanita serviks (variabel independen) dengan usiasuburtentangkankerserviks. tindakan melakukan pap smear (variabel mengidentifikasi tindakan melakukan pap dependen) pada wanita usia subur. sebelum smear pada wanita usia subur. dan dilakukan uji statistik chi square, terlebih menganalisa hubungan pengetahuan kanker dahulu diuji normalitas menggunakan uji serviks dengan tindakan melakukan pap kolmogrof sminorv test, selajutnya baru smear pada wanita usia subur. diuji chi square dan setelah itu baru dapat hipotesis penelitian ini adalah adakah ditarik kesimpulan dengan melihat nilai p hubungan pengetahuan tentang kanker value hasil. serviks dengan tindakan melakukan pap etika penelitian ini yaitu lembar smear pada wanita usia subur. persetujuan menjadi responden (informed 42 journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 40 47 consent, anonimity (tanpa nama) dan pernah tidak confidentiallity (kerahasiaan). pernah f % f % f % baik 0 0% 3 100% 3 100% hasil sedang 2 16, 1 83,3% 12 100% 1. pengetahuan wanita usia subur 7% 0 kurang 0 0% 3 100% 36 100% tentang kanker serviks 6 3,9 4 tabel 1 distribusi tingkat pengetahuan total 2 96,1% 51 100% % 9 wanita usia subur tentang sumber: penelitian tahun 2017 kanker serviks berdasarkan tabel 3 dapat diketahui bahwa dari 51 responden wanita usia subur pengetahuan frekuensi presentase tentang kanker (%) yang memiliki pengetahuan sedang dan serviks pernah melakukan tindakan pap smear baik 3 5,9 % sebanyak 2 orang (16,7%) dan yang tidak sedang 12 23,5 % pernah melakukan tindakan pap smear kurang 36 70,6 % sebanyak 10 orang (83,3%), sedangkan yang jumlah 51 100 % berpengetahuan kurang yang pernah sumber : penelitian, 2017 berdasarkan tabel 1 diatas dapat dilihat melakukan tindakan pap smear sebanyak 0 orang dan yang tidak pernah melakukan bahwa sebagian besar dari responden wanita tindakan pap smear sebanyak 36 orang usia subur mengenai kanker serviks (100%). mempunyai pengetahuan kurang sebanyak 36 pengujian hipotesis penelitian yaitu orang (70,6 %). hubungan pengetahuan tentang kanker 2. tindakan melakukan pap smear pada serviks dengan tindakan melakukan pap wanita usia subur smear pada wanita usia subur di desa tabel 2 distribusi tindakan melakukan tulungrejo kecamatan besuki kabupaten pap smear pada wanita usia tulungagung menggunakan alat analisa data subur uji chi squere. dianalisis menggunakan tindakan frekuensi presentase bantuan program spss 16.00 for windows. melakukan pap (%) hasil uji statistik chi-square smear didapatkan ρ = 0,034, sedangkan α = 0,05 pernah 2 3,9 % karena ρ < α maka h0 ditolak dan h1 tidak pernah 49 96,1 % jumlah 51 100 % diterima. artinya ada hubungan antara sumber : penelitian, 2017 pengetahuan tentang kanker serviks dengan berdasarkan tabel 2 diatas dapat dilihat tindakan melakukan pap smear pada wanita usia subur di desa tulungrejo bahwa hampir seluruh dari responden wanita kecamatan besuki kabupaten tulungagung usia subur yang tidak pernah melakukan tahun 2017. tindakan pap smear sebanyak 49 orang (96,1 %). pembahasan 3. hubungan pengetahuan kanker a. pengetahuan wanita usia subur serviks dengan tindakan melakukan tentang kanker serviks. pap smear pada wanita usia subur. berdasarkan tabel 1 diperoleh data tabel 3 hubungan pengetahuan tentang yang menunjukkan bahwa dari keseluruhan kanker serviks dengan responden sebagian besar berpengetahuan tindakan melakukan pap kurang tentang kanker serviks sejumlah 36 smear pada wanita usia subur responden (70,6%). pengetahuan tindakan total 43 journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 40 47 apabila tingkat pengetahuan responden pengalaman dan pengetahuan baik secara tersebut dikaitkan dengan beberapa faktor langsung maupun secara tidak langsung. yang dapat mempengaruhi tingkat peneliti berpendapat bahwa tidak hanya pengetahuan menunjukkan hasil bahwa dari faktor-faktor yang disebutkan dalam teori faktor pendidikan sebagian besar saja yang berpengaruh terhadap pengetahuan berpendidikan sma sebanyak 18 orang (35,3 responden yang kurang. hal ini mungkin %), apabila dilihat dari faktor usia sebagian disebabkan oleh perbedaan kondisi besar berusia 15-26 tahun sebanyak 18 orang masyarakat, seperti rendahnya arus informasi (35,3%). dan jika dilihat dari faktor diterima masyarakat setempat, pola hidup pekerjaan sebagian besar ibu rumah tangga masyarakat, kondisi geografis serta sebanyak 16 orang (31,4%). dan diketahui perbedaan karakteristik penduduk. dari hasil tabulasi silang pendidikan rendahnya tingkat pengetahuan masyarakat terbanyak pendidikan sma mengenai penyakit kanker serviks di pengetahuannnya baik sebanyak 13 indonesia banyak disebabkan oleh kurangnya responden (25,5%), dan jika dilihat dari tingkat kewaspadaan masyarakat terhadap tabulasi silang berdasarkan umur terbanyak penyakit kanker serviks. 39-49 tahun yang berpengetahuan kurang sebanyak 14 responden (82,4%), sedangkan b. tindakan melakukan tindakan pap dilihat dari tabulasi silang berdasarkan smear pada wanita usia subur. pekerjaan sebagian besar ibu rumah tangga hasil penelitian menunjukkan bahwa pengetahuannya baik sebanyak16 responden sebagian besar responden dalam perilaku (31,4%). tindakan pap smear tidak pernah melakukan mubarak 2007 mengatakan bahwa tindakan pap smear yaitu sebesar 49 tingkat pengetahuan wanita usia produktif responden (96,1%) dan yang pernah tentang kanker serviks, dipengaruhi tingkat melakukan tindakan pap smear sebanyak 2 pendidikan, umur dan pekerjaan. tingkat responden (3,9%). sedangkan dilihat dari pendidikan seseorang sangat mempengaruhi hasil tabulassi silang didapatkan sebagian pengetahuannya. hal ini disebabkan semakin besar pengetahuanya kurang sebanyak 36 baik pendidikan yang diterima, maka responden (73,5%) dan dalam tidak semakin mudah dalam menyerap informasi melakukan pemeriksaan pap smear tidak yang diterima. pada akhirnya makin banyak pernah melakukan. pula pengetahuan yang dimilikinya, tindakan melakukan pap smear pada sebaiknya jika seseorang tingkat seorang wanita usia subur dipengaruhi pendidikannya rendah, akan menghambat berbagai faktor yaitu faktor dari dalam perkembangan seseorang terhadap dirinya sendiri (perilaku wanita usia subur) penerimaan informasi, dan nilai-nilai yang dan dukungan dari lingkungan (dukungan baru diperkenalkan. umur dapat keluarga dalam hal ini secara khusus suami). mempengaruhi tingkat pengetahuan sebagaimana kita ketahui perilaku sangat seseorang menurut pendapat mubarak (2007) mempengaruhi seseorang dalam bertingkah dengan bertambahnya umur seseorang akan laku. menurut laurence w.green (2010), terjadi perubahan pada aspek fisik dan perilaku dipengaruhi oleh 3 faktor utama psikologis (mental) yaitu (bagaimana yaitu : 1). faktor predisposisi yaitu faktor bertambahnya umur tersebut berpengaruh predisposisi timbulnya perilaku seperti umur, pada pengetahuan responden). pekerjaan juga pendidikan, pekerjaan, penghasilan, dapat mempengaruhi pengetahuan. menurut pengetahuan, sikap, kepercayaan, keyakinan, mubarak (2007) lingkungan pekerjaan dapat dan lain sebagainya. 2). faktor pendukung menjadikan seseorang memperoleh yaitu faktor yang mendukung timbulnya perilaku seperti lingkungan fisik dan sumber 44 journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 40 47 sumber yang ada di masyarakat misalnya : hasil uji statistik chi square tersedianya tempat pelayanan pemeriksaan didapatkan p value = 0.034, sedangkan α = yang terjangkau masyarakat dan lain 0.05, karena p < α maka h0 ditolak dan h1 sebagainya. 3). faktor pendorong yaitu diterima. artinya ada hubungan antara faktor yang memperkuat atau mendorong pengetahuan tentang kanker serviks dengan seseorang untuk berperilaku yang berasal tindakan melakukan pap smear pada wanita dari orang lain misalnya : keluarga, usia subur di desa tulungrejo. kelompok, guru, petugas kesehatan dan hasil penelitian ini sejalan dengan teori pengambil keputusan yang mendukung yang diungkapkan meliono (2007) bahwa perilaku tindakan melakukan pap smear. semakin tinggi tingkat pengetahuan peneliti tidak sependapat dengan teori seseorang mengenai kesehatan, semakin diatas, hal ini dibuktikan dengan hasil menyadarka seseorang untuk berperilaku penelitian menunjukkan dari 51 responden , hidup sehat termasuk pastisipasi wanita hampir seluruh wanita usia subur tiidak dalam program deteksi dini kanker serviks pernah melakukan tindakan pap smear dengan tindakan melakukan pap smear. sebanyak 49 responden (96,1%). menurut notoatmojdo (2007) juga mengungkapkan peneliti, pendidikan tidak selalu berhubungan bahwa tingkatan pengetahuan ketiga yag dengan tindakan pemeriksaan pap smear, tercangkup dalam domain kognitif yaitu walaupun pendidikannya tinggi tidak selalu (application) yang diartikan sebagai menjamin perilaku yang lebih baik terhadap kemampuan untuk menggunakan materi yang tindakan pemeriksaan pap smear, mengingat telah dipelajari pada situasi atau kondisi banyak faktor lain yang pempengaruhi sebenarnya. partisipasi wanita dalam perubahan perilaku disamping faktor sosial program deteksi dini kanker serviks ekonomi, pengetahuan dan sikap juga merupakan suatu bentuk dari (application) dukungan dari suami dan keluarga atau orang dalam tingkat pengetahuan tentang kanker terdekat serta norma agama dan adat istiadat serviks. yang diyakini. menurut who (2012), salah satu strategi perubahan perilaku adalah pemberian c. hubungan pengetahuan tentang informasi. dengan demikian informasi kanker serviks dengan tindakan tentang kanker serviks dan bahayanya, maka melaukan pap smear pada wanita usia didapatkan pengetahuan yang akan subur. mempengaruhi sikap seseorang. sikap yang hasil penelitian pada tabel 3 positif menyebabkan wanita berperilaku didapatkan responden yang memiliki sesuai dengan pengetahuan yang dimilikinya, pengetahuan baik dalam tindakan melakukan dalam hal ini adalah partisipasi wanita dalam pap smear adalah sebanyak 2 orang (5,9%) program deteksi dini kanker serviks dengan tidak pernah melakukan tindakan pap smear tindakan melakukan pap smear. dan responden yang memiliki pengetahuan hasil penelitian ini diperkuat oleh sedang dalam tindakan melakukan tindakan darmindro (2007) yang juga menemukan pap smear sebanyak 2 orang (3,9%) pernah hubungan yang signifikan antara melakukan tindakan pap smear sedangkan pengetahuan dengan sikap responden yang memiliki pengetahuan kurang dalam terhadap pap smear. hal ini terlihat dari nilai melakukan tindakan pap smear tidak pernah probabilitas 0,0012 < 0,05. melakukan sebanyak 36 responden (70,6%), sedangkan penelitian yang dilakukan dapat disimpulkan bahwa hampir setengah oleh claeys tahun 2006 pada sampel 634 dari responden yang memiliki pengetahuan wanita niracagua, menyatakan rendahnya kurang belum pernah melakukan tindakan melakukan tindakan pap smear pada wanita pap smear sebanyak 36 reponden (70,6%). niracagua disebabkan beberapa variabel 45 journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 40 47 yaitu tingkat pendidikan yang rendah, diharapkan kepada tenaga kesehatan kurangnya pengetahuan mengenai agar dapat memberikan informasi yang lebih pencegahan kanker serviks, dan tingkat luas kepada masyarakat, khususnya kepada ekonomi yang rendah merupakan alasan para remaja putri tentang kanker serviks dan utama untuk tidak melakukan pap smear. mengajarkan kepada mereka bagaimana berdasarkan dari teori pendukung, melakukan pencegahan terhadap kanker hasil penelitian, dan penelitian sebelumya, serviks dari sekarang dengan cara lebih maka penulis menyimpulkan bahwa ada seringdansecararutinmelakukan hubungan pengetahuan tentang kanker penyuluhan tentang kesehatan reproduksi serviks dengan tindakan melakukan pap remaja dan pada wanita usia subur khususnya smear pada wanita usia subur. dengan tentang kanker serviks. demikian peneliti berpendapat bahwa semakin baik pengetahuan tentang kanker daftar pustaka serviks semakin baik pula partisipasi wanita usia subur dalam program deteksi dini kanker astrid savitri, dkk.2015. kupas tuntas serviks dengan tindakan melakukan pap kanker payudara leher rahim dan smear. dengan adanya pengetahuan yang rahim. baguntapan, bantul, lebih baik tentang kaker serviks dan yogyakarta. permasalahannya, wanita dapat memahami bahaya kanker serviks dan pentingnya edianto, d.2006. kanker serviks, buku deteksi dini kanker serviks bagi kesehatannya acuannasional onkologi ginekologi. sehingga bersedia untuk berpartisipasi aktif yogyakarta. medi pustaka. dalam program deteksi dini kanker serviks dengan cara pap smear. untuk itu disarankan hidayat, a.2007, metode penelitian bagi tenaga kesehatan agar dapat kebidanan dan teknik analisis data. memberikan informasi yang lebih luas jakarta, salemba medika. kepada masyarakat, khususnya kepada para remaja putri tentang kanker serviks dan imron, m. 2011. statistika kesehatan. mengajarkan kepada mereka bagaimana jakarta : sagung seto. melakukan pencegahan terhadap kanker serviks dengan cara pemeriksaan tes pap mki. 2007, pengetahuan, sikap, perilaku smear. perempuan yang sudah menikah simpulan mengenai pap smear dan faktor faktor yang berhubungan di rumah pengetahuan tentang kanker serviks susun klender, jakarta. pada wanita usia subur di desa tulungrejo kecamatan besuki kabupaten tulungagung national cancer institute u.s department of didapatkan 70,6% berpengetahuan kurang health and human service national dan tindakan melakukan pap smear institue of health. what you need to didapatkan bahwa 96,1% tidak pernah know about cervical melakukan pemerikaan pap smear. cancer.www.cancer.gou/publications nilai ρ value = 0,034 artinya ada .(diaskes pada tanggal 11 nopember hubungan antara pengetahuan tentang 2016). kanker serviks dengan tindakan melakukan pap smear pada wanita usia subur di desa notoatmodjo, s. 2010. pendidikan dan tulungrejo kecamatan besuki kabupaten perilaku kesehatan. jakarta: rineka tulungagung. cipta. 46 journal of nursing practice http://jurnal.strada.ac.id/jnp vol.1 no.1 oktober 2017. hlm 40 47 perilaku manusia. yogyakarta: notoatmodjo, s. 2012. metodelogi penelitian nuha medika. kesehatan. jakarta: rineka cipta. wijaya & delia. 2010, “pembunuh ganas nursalam. 2003. konsep dan penerapan itu bernama kanker serviks,” sinar metodelogi penelitian ilmu kejora, yogyakarta universitas. keperawatan: pedoman skripsi, tesis, dan instrumen penelitian. yki. (2013). training of trainers pap tes jakarta: salemba medika. dan iva. (diaskes pada tanggal 05 e=sx5 (nopember 2016). prawirohardjo s. ilmu kandungan. edisi 3. jakarta : pt bina pustaka sarwono prawirohardjo. 2011. pusat data dan informasi kementerian kesehatan ri. 2015. www.pustadin.kemkes.go.id. diaskes tanggal 12 november 2016 pukul 11.43 wib. rahayu, agnes supraptiwi, 2010. inveksi human papilloma virus (hpv) dan pencegahannya pada remaja dan dewasa muda. jurnal biologi papua. volume 2 nomor 2. rasjidi, i. 2009. deteksi dini, dan pencegahan kanker pada wanita. jakarta: sagung seto rasjidi, i. 2010. ephidemiologi kanker. jakarta: sagung seto. ria riksani & re!mediaservice. 2016. kenali kanker serviks sejak dini. ed.1. yogyakarta. sibagarian e, julianie, rismalinda, nurzannah s. 2010. metodelogi penelitian untuk mahasiswa diploma kesehatan. jakarta: trans info median. wawan, a & dewi m, 2011. teori & pengukuran pengetahuan, sikap, dan 47 http://www.pustadin.kemkes.go.id/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.168-175 168 nurse's experience program in implementing intravenal chemotherapy treatment in cancer patients: a phenomenology study eben haezar kristian*, florensius andri, christianus eko purwanto widoroni nursing academy of dharma insan, pontianak, indonesia corresponding author: ebenhaezar02@gmail.com abstract background: cancer or malignant tumor is uncontrolled growth of cells or tissue and spreads from abnormal cells, if the spread is uncontrolled it can cause death. experience is a very dynamic, complex and subjective phenomenon. one of the treatments for cancer patients is chemotherapy. purpose: the purpose of this study was to explore the experiences of nurses in implementing intravenous chemotherapy treatment programs in cancer patients. methods: this study uses a qualitative design with a phenomenological approach model to understand one's life experience and existing perceptions. the sampling technique used snow ball sampling. in this study, researchers will perform a snow ball sampling technique of participants who are at the dr. soedarso general hospital. a total of ten nurses who work in the chemotherapy room participated. result: the perception of nurses in providing intravenous chemotherapy services as a form of carrying out their assigned duties and responsibilities apart from curiosity to carry out chemotherapy and their empathy for patients. support from nurses in providing intravenous chemotherapy services is obtained from the family even though they are reminded to always be careful (protected), from the hospital, especially the improvement of infrastructure and related policies as well as support from colleagues and doctors. obstacles for nurses in providing intravenous chemotherapy services arise from the capacity of nurses and specialists who are less trained, the inadequate reporting system between nurses during service changes including infrastructure such as ppe, room size and medicine. conclusion: recommendations this study is expected to be used as a reference for future researchers related to the topic of nurse experiences that are still related to chemotherapy clients in cancer. keywords: cancer, chemotherapy, nurse’s experience. received august 15, 2021; revised august 22, 2021; accepted september 17, 2021 doi: https://doi.org/10.30994/jnp.v5i1.168 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. http://thejnp.org/ mailto:ebenhaezar02@gmail.com https://doi.org/10.30994/jnp.v5i1.168 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.168-175 169 background cancer is a disease that has become a public health problem in the world and in indonesia. every year, 24.6 million people worldwide suffer from cancer and 7.6 million of them die from cancer. if adequate control measures are not taken, by 2020 an estimated 10.3 million people will die from cancer every year. this incident will occur more rapidly in poor and developing countries international union against cancer (uicc) (2009). the world health organization (who) and uicc predict that there will be a 300 percent increase in cancer sufferers worldwide in 203). in the southeast asian region cancer kills more than 1.1 million people every year. based on the hospital information system (sirs) in 2010 in indonesia cancer became the cause of death number 3. based on riskesdas (2014) the prevalence of cancer in indonesia is 1.4 per 1,000 population and the prevalence in west kalimantan is 0.8 per 1,000 population. according to the centers for disease control and prevention (cdc) (2013) in indonesia cancer is the third leading cause of death after stroke and tuberculosis with an incidence of 6%. meanwhile breast cancer and cervical cancer are the highest types of cancer among other cancers in inpatients and outpatients in all hospitals in indonesia with the proportion of breast cancer (28%), cervical cancer (12.8%), leukemia (10.4%), lymphoma (8.3%), lung cancer (7.8%). in line with that empirical data also shows that deaths from cancer from year to year continue to increase. meanwhile in west kalimantan, especially rsud dr. soedarso pontianak in 2013, data on the number of patients suffering from cancer reached 1559 people who were dominated by lung cancer and breast cancer. of these, 155 of them underwent chemotherapy. based on the initial survey conducted at the dr. soedarso general hospital, it was found that nurses who did chemotherapy initially wanted to seek different experiences outside of ordinary procedures, but they did not fully understand the side effects that could be caused by the implementation of chemotherapy itself. motivated nurses will also get an added bonus for doing so. objective the general objective of this study is to explore the experiences of nurses in implementing intravenous chemotherapy treatment programs in cancer patients. methods this study used a qualitative research design with a phenomenological approach model, namely to understand one's life experience and existing perceptions. in qualitative phenomenological research tends to be believed to have very little sampling, usually 10 participants, with one principle that must be done, namely that all participants must experience the phenomenon and must be able to explain in words. the sampling technique uses snow ball sampling, namely by taking selected participants by previous participants. in this study, researchers will perform a snow ball sampling technique with a fixed participant scope. a total of 10 nurses who worked in the chemotherapy room participated in this study and met the criteria to be a participant, namely willing to participate in research and willing to recount perceptions, support, and obstacles that were felt and expressed with informed consent, working in the chemotherapy unit more than 2 years old, over 25 years old, able to communicate in indonesian clearly and willing to recount his experiences. this research was conducted at the dr. soedarso general hospital with the consideration of being a referral center hospital in west kalimantan province and treating many clients by undergoing chemotherapy. interview activities are carried out in the nursing room. the research was conducted from march to june 2019 http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.168-175 170 the tools used to collect data were interview guides, field notes and an mp3 recorder. previously, researchers tried to use an mp3 recorder recording device. the aim is to test the accuracy of the mp3 recorder that will be used and to validate the accuracy of the interview guide in extracting as much information as possible from the participants in accordance with the research objectives. results this study identified perceptions, supports and barriers, from the results of interviews with 10 nurses. the themes found in this study were about the perceptions obtained by the task theme, about the support obtained from the theme of health services, partners of health workers, families, bpjs services, and about the obstacles obtained from the theme of facilities and infrastructure, hr, service users. discussion the most educational backgrounds are diploma iii in nursing with a total of 8 people. nurses in this hospital are still dominated by d3 education. as is the case in indonesia in general, 80% of the nurses who work in hospitals have diploma iii education, while the rest are diploma iv, bachelor, master, and even spk. the length of time nurses working in chemotherapy range from 3 years to 15 years the similarity of expressions of participants 1 to 10 is indicated by the line relationship from one participant to another. it was also found that participants 2 and 5 had the highest similarity of expressions with a value of 0.899, then participant 7. one of the similarities of the phrase "chemotherapy is only to prevent the spread of the disease suffered by the patient, so it does not help the healing of the term, so it only inhibits cells. so that the cancer cells do not expand, so it is not the meaning of chemo that the disease will disappear, it just inhibits it, helps inhibit the cells from expanding like that". this research identifies perceptions, supports and obstacles, from the results of interviews with 10 nurses. the themes found in this study consisted of specific objectives that explored perceptions and obtained the theme of the task, special goal 2 regarding support was obtained by the theme of health services, health workers partners, family, social security administering body services, and special objectives 3 regarding obstacles to obtain the theme of facilities infrastructure, human resources, service users. according to cano (2009) chemotherapy has a big risk to the officers who carry it out, the nurse is one who has a big role in its implementation. in the implementation of chemotherapy that is according to standards requires nurses who have competence in chemotherapy services. in this study, participants said that they carried out chemotherapy because it was a duty and responsibility at work even though the participants did not fully understand the proper procedure. this was also expressed by participant 10 in the following statement: "we help, indeed we have, there is no feeling tire the feeling sub-theme consists of the sub-themes of anxiety, pleasure, just normal, at this time. the sub-themes of anxiety were expressed by the participants in the following statement: "worried because all this time the common people know what chemotherapy drugs are for people who are seriously ill such as cancer, automatically the medicine is because the drug is especially strong, anxious, we already know the effect. there must be something like that for us". the sub-themes were happy to be expressed by the participants in the following statement: "happy, adding to experience and expanding knowledge, those of us who don't know will know." the risk sub-theme is obtained from the sub-themes of places or facilities, medicine, personal protective equipment, nurse preparation in which there are sub-sub-themes of http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.168-175 171 learning from seniors and never training, and the sub-theme of side effects to nurses. the sub-themes of the place or facility were expressed by the participants in the following statement: "the place of dissolution should not be there, but it is already from inadequate facilities, but now there is a separate room, so it doesn't involve us." the sub-themes of medicine were expressed by the participants in the following statement "drug preparation, if the drug is complete we prepare the tools. if the equipment is incomplete, we cannot chemotherapy, one tool that is incomplete in the procedure, even though there is only one, we still cannot chemotherapy”. the sub-themes of personal protective equipment were expressed by the participants in the following statement: "it is not optimal, for example it must be covered all the body, wear special shoes". the sub-themes of side effects to nurses were expressed by the participants in the following statement "because sometimes people usually refuse chemotherapy, because they are afraid of the risks, the risk is sometimes if people are pregnant they say the effect, so many avoid it. the sub-themes of nurse preparation were obtained from the sub-sub-themes of learning from seniors and never training. the sub-theme of learning from seniors was expressed by the participants in the following statement: "i learn from those who have participated in the training, so those who take part in the training convey it to friends who are here". the sub-theme of never training was expressed by the participants in the following statement: "nothing, usually we immediately take action according to the procedure, most of which will explain later the doctor will explain". the sub-theme of curiosity was expressed by the participants in the following statement: "people can why we can't. if people can, we have to be able, that's what makes me excited about going to chemotherapy. even if we are in the hospital, if we are not appointed for chemotherapy where can we. sub theme of the role of the nurse. the sub-theme of the role of the nurse is obtained from the sub-themes of nursing care, job demands, empathy for patients, procedures, there is no oncology nurse and on call. the sub-theme, there was no oncology nurse, was expressed by the participants in the following statement: "if we do that, maybe we have to prepare personnel who do have certain personnel in chemotherapy installation, but we also lack here. the sub-themes of job demands were expressed by the participants in the following statement: "all nurses must know". the sub-theme of vocations was expressed by the participants in the following statement, "we are already working according to our duties. we hope for incentives, we have been paid, have been paid and all the nurses have done that, there are no other rewards, sincerely, i hope the patient will recover quickly, we will help people in a sincere way ". the sub-theme of procedure was expressed by the participants in the following statement: “so now the method is from the pharmacy, according to the procedure. the sub-theme of empathy for the patient was expressed by the participants in the following statement: "if i urge you, especially if you are like patients, when it is in the final stage, some maggots come out". the ascep sub-theme was obtained from the sub-sub-theme, assess the readiness, during the process and evaluate the side effects to the patient. the sub-sub-theme of the preparatory study was expressed by the participants in the following statement: “the patient is admitted to the hospital, comes, checks the status of the blood pressure measurement, the temperature reports to the doctor, this is a patient who wants surgery, chemotherapy continues to be like this, there is no fever. then for chemotherapy drugs before, the patient is a consul with the doctor, right, that means he's already taking chemotherapy drugs ". the sub-themes during the process were expressed by the participants in the following statement: “if the morning is half an hour, observe half an hour, another half hour, because http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.168-175 172 i am there my patient will be there every half hour, after half an hour there is no reaction, then one hour we observe again. the sub-theme of the evaluation of side effects to the patient was expressed by the participant in the following statement “maybe at the first insertion he had vomiting, there might be nausea. so the nausea is just a little bit like that, but we still evaluate the patient, because if it's not evaluated it's afraid the patient will suddenly vomit or what about it, i'm sorry. " based on the participant's experience, it was found that the nurses' perceptions of implementing chemotherapy because of their duties. participants mentioned four things that underlie this because of their duties, including: the role of the nurse, being at risk, wanting to know, and feeling. the relationship between sub-themes (nodes) in the task theme and participants (sources). the sub-themes that were most discussed by the participants in order were feelings, the role of nurses, risks, and curiosity. experience is a term that is loaded with meaning and meaning. among them we find from real life through events or incidents, real life is in stark contrast to ideals, imagination. other senses refers to knowledge, skills or techniques that result from experience, or to cumulative additions and have residual experiences. all information about various things reaches us through the senses. to understand experience, we must know how experience is formed. experience is formed from perception and sensory through the sensese (erlich, 2018). nurses' perceptions in implementing chemotherapy programs are part of the experience. based on the results of interviews that have been conducted in the study, it was obtained the participants' perceptions of chemotherapy as providing drugs for malignant tumors or so-called cancer patients which function to inhibit cancer cells. chemotherapy is a cancer treatment therapy using chemicals. it also has an important role in cancer therapy. chemotherapy is used for healing and improves patient survival for longer. this therapy is used because it can selectively kill cancer cells beyond normal cells (ignatavicius & workman, 2010). the facts that occur in the field, according to the experience of nurses in implementing chemotherapy, are due to the task even though the participants said they did not understand the proper procedure but were still carried out. in carrying out their duties as nurses, participants feel anxious, this is because the participants are doing chemotherapy without any special preparation in the form of training and lack of knowledge. participants also felt anxious considering the risks that could occur to nurses who administer chemotherapy. participants also stated that doing chemotherapy is a risky task because the place or facilities are inadequate or personal protective equipment does not meet standards. some nurses also carry out chemotherapy using personal protective equipment that does not meet these standards experiencing side effects or exposure to these drugs to nurses such as burning on the skin, dry throat feeling. this shows that the implementation of chemotherapy they do is not in accordance with the theory according to hinkle & cheever (2014) and cano (2009), namely: for safety in chemotherapy treatment for service providers/ nurses/ other medical personnel when doing chemotherapy, they should use safety equipment that is has been established to prevent exposure to nurses as well as implement competency-based education, training on safety procedures during chemotherapy. participants said that in the task of providing chemotherapy, nurses must evaluate the side effects that occur in patients. according to participants, the side effects that often occur in patients are hair loss, nausea, vomiting, and the patient also looks tired. this is in accordance with the research of aslam et al (2014) which states that the most common side effects are weakness, fatigue, nausea, hair loss and vomiting with an incidence of more than http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.168-175 173 70%. other notable side effects include mouth sores, dry mouth and numbness. conversely diarrhea, stomach cramps and memory disturbances are rare side effects. some of the other side effects reported by some patients were increased temperature, constipation, mood swings and weight loss (aslam, 2014). research conducted by waheida et al (2015) revealed that nurses did not comply with the recommended safety regulations. this is due to an increase in workload, lack of knowledge and a lack of equipment and facility studies. this shows that there are not enough steps taken by nurses to treat cytotoxic drugs that have a negative impact on their health (waheida, 2015). based on the results of the interview, the participants said that related to the placement of consumable devices, separations had been made between chemotherapy consumables and devices for patients in general to prevent contamination from the effects of chemotherapy. this is consistent with the theoretical review of the prevention of exposure through inhalation and direct contact according to hinkle & cheever (2014), namely a closed system, puncture and leak-proof container labeled "dangerous: contaminated chemotherapy linen", referenced/ marked, put in a container and managed. in the central dirty laundry room for outpatient settings, referenced/ marked, put in containers and managed in patient rooms and / or dirty laundry rooms for inpatient settings preparation of chemotherapy equipment namely syringes, tubes, empty bottles, clothes and gloves hands should be disposed of in a closed system, puncture and leak-proof container labeled "danger of chemotherapy waste contaminated." based on the results of interviews that have been carried out in the study, participants said that currently the implementation of chemotherapy is in accordance with standard procedures set by the hospital. this is consistent with the theoretical review of hinkle & cheever (2014), which states that in implementing improved quality safe chemotherapy treatment programs which include: standard operating policies and procedures for handling, preparation and disposal of chemotherapy, handling and disposal of spills during chemotherapy, treatment and disposal of blood and body fluids and contaminated material from patients undergoing chemotherapy. one of the reasons the participants took chemotherapy services was because they were curious and sought additional experience outside of ordinary procedures. in doing chemotherapy, initially the nurse did not have much knowledge about chemotherapy so that it increased the anxiety of the nurse. however, in the end, the participants stated that now the anxiety was much reduced due to experience and training in implementing chemotherapy. the participant's statement was also supported by research conducted by veritya (2008) which concluded that almost all nurses said they were afraid and anxious when initially working with chemotherapy. then they become more confident with experience, if supported by knowledge and follow chemotherapy education (verity, 2019). in a study conducted by kassa & kassa (2014) it was found that nurses received the same salary as nurses who worked in other units while the risk burden that threatened life during chemotherapy was higher. one other statement from the participants initially wanted to join the oncology unit to find out how to administer chemotherapy and other pain management measures. after hearing and reading about the side effects of cancer therapy on health workers, she tried to avoid going to the ward, especially if her schedule was for chemotherapy (ali et al, 2012) conclusion the perception of nurses in providing intravenous chemotherapy services as a form of carrying out their assigned duties and responsibilities apart from curiosity to carry out http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.168-175 174 chemotherapy and their empathy for patients. support from nurses in providing intravenous chemotherapy services is obtained from the family even though they are reminded to always be careful, from the hospital, especially the improvement of infrastructure and related policies as well as support from colleagues and doctors. the government, in this case the role of social security administering bodies, is also expressed as supporting the implementation of the provision of chemotherapy services for patients. obstacles for nurses in providing intravenous chemotherapy services arise from the capacity of nurses and specialists who are less trained, the inadequate reporting system between nurses during service changes, including facilities and infrastructure. such as ppe, room size and medicine. the patient's family can also hamper services because they are worried about the work for the nurse. patients and families become obstacles when they do not understand the side effects of chemotherapy, lack of cooperation related to bringing young children to chemotherapy rooms and especially the physical condition of patients who are not ready for chemotherapy. hopefully this research recommendation can be used as a reference for future researchers related to the topic of nurse experiences that are still related to or related to chemotherapy clients in cancer. this research can also be the main capital for future researchers to continue quantitative research related to chemotherapy. acknowledgments thank you to the nurse from dr. soedarso general hospital. conflicts of interest there was no conflict of interest during this research. references international congress and convention association. 2018 country & city rankings. int congr conv assoc [internet]. 2018;85. available from: https://www.iccaworld.org/newsarchives/archivedetails.cfm?id=1100291 national cancer society. children with cancer: a guide for parents. natl cancer inst. 2015;1–79. keperawatan j, tanjungkarang pk. penderita kanker. iseki k. ii. epidemiology. nihon naika gakkai zasshi [internet]. 2010;96(5):869–74. available from: https://www.cdc.gov/traumaticbraininjury/pdf/blue_book creswell jw. research design : qualitative , quantitative , and mixed methods approaches. 2009;35(2):2–4. kemenkes ri. info sehat untuk semua: kanker pembunuh papan atas. mediakom. 2015. 27 p. hartzell r, hues b, karrei i, lejambe v, mercer l, oliver j, et al. standards and competencies for cancer chemotherapy nursing practice. erlich s. experience--what is it? 2018;(december). aslam ms, naveed s, ahmed a, abbas z, gull i, athar ma. side effects of chemotherapy in cancer patients and evaluation of patients opinion about starvation based differential chemotherapy. 2014;(january). waheida sm, abd-elgaffar si, abd g, atia f. evaluation of handling practices of oncology nurses during chemotherapy preparation and administration in menoufia oncology hospital. 2015;2(3):107–19. verity r, wiseman t, ream e, teasdale e. exploring the work of nurses who administer http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.168-175 175 chemotherapy. 2008;(march 2019). ali ts, khan n, zulfiqar k, khowaja a, ali ts. assessment of knowledge , skill and attitude of oncology nurses in chemotherapy administration in tertiary hospital pakistan . nurses in chemotherapy administration in tertiary. 2012;2(june):97–103. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.97-106 97 the description of mental health and emotional mental disorders of students and families during covid-19 pandemic ariani sulistyorini*, tutut pujianto stikes karya husada kediri, indonesia corresponding author: ariani.iqbal@gmail.com abstract background: the covid-19 pandemic could have an adverse impact on both physical and psychosocial conditions. physical distancing encourages a person to be unable to perform activities normally to reduce the likelihood of transmission. physical distancing must be done by everyone, including students and their families. this condition can lead to feelings of loneliness, boredom, and anxiety. another impact that society feels is the onset of unrest due to financial condition, employment, and future life plans. anxiety and anxiety caused by the covid-19 pandemic resulted in the emergence of mental health problems and emotional mental disorders. purpose: this study aimed to find out the picture of mental health and emotional mental disorders in students and families during the covid 19 pandemic. methods: the research design used is a descriptive crossectional. the population in this study was students of nursing diploma 3 study program stikes karya husada kediri and his family. fifty-six students were selected as sample members, through random sampling techniques. the variables in this study were mental health and emotional mental disorders. data retrieval is carried out from 6 to 20 june 2020, with the instrument self reporting questionnaire (srq-29). descriptive analysis of data is performed with the help of frequency distribution tables. results: the results of the study found that there were 2 respondents (3.6%) psychological disorders (anxiety and depression), none (0%) psychoactive disorders/drug use. research data also shows that there are 5 respondents (8.9%) psychotic disorders, as well as 16 respondents (28.6%) ptsd disorder. mental health disorders experienced by respondents are emotional mental disorders with symptoms of fear, worry, anxiety, tension and even excessive headaches. mental health disorders result in impaired daily life activities. conclusion: to prevent an increase in the number of people with emotional mental disorders in students and their families, there needs to be educational efforts that contain how to avoid and overcome emotional mental disorders that occur and the need for psychosocial mental health support in students and their families. keywords: mental health, emotional mental disorders, pandemic, covid-19. received july 27, 2020; revised august 30, 2020; accepted september 25, 2020 doi: https://doi.org/10.30994/jnp.v4i1.119 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:ariani.iqbal@gmail.com https://doi.org/10.30994/jnp.v4i1.119 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.97-106 98 background the covid-19 pandemic can be affected for anyone, both physically and psychosocially. this covid-19 pandemic is a non-natural disaster that can have a physical and psychological impact on every individual whether it is a positively confirmed individual or in society in general. especially with the encouragement of physical distancing causes a person to be unable to carry out the usual routine activities and have to keep a distance with family, friends or relatives to reduce the likelihood of transmission. so is the student and his family. this condition can lead to feelings of loneliness, boredom, anxiety. in addition, this condition can cause unrest related to financial condition, employment, and future life. this is at risk of causing mental health problems and emotional mental disorders. mental health according to constitutions republic of indonesia number 18 of 2014 is a condition in which an individual can develop physically, mentally, spiritually, and socially so that the individual realizes his or her own abilities, can cope with pressures, can work productively, and is able to contribute to his community. every aspect and dimension of man needs a good degree of mental health in order to function optimally. while emotional mental disorders are a condition that indicates an individual undergoing an emotional change that can develop into a pathological state if it continues (rusdi muslim, 2013) corona disease (covid-19) is an infectious disease caused by a new type of coronavirus with common symptoms of fever, weakness, cough, seizures and diarrhea, shortness of breath (who, 2020; repici et al., 2020) covid 19 comes from the word co which means corona, vi for virus and d for disease. transmission from person to person through saliva sparks during coughing and sneezing (droplet) with an incubation period of 1-14 days, where until now the drug and vaccination have not been found. since covid-19 was confirmed in december 2019 to august 2020, who has recorded 21.817.650 confirmed cases of covid-19. of these 772.751 people died, and 14.553.191 patients were declared cured. meanwhile, in indonesia, the latest data on the number of positive cases of coronavirus still shows an increase of 1.821 cases so far the total number of confirmation cases in indonesia reaches 141.370 cases. of the total confirmed cases, patients recovered also increased by 1.355 people, with the addition of patients recovering from the corona as a whole to 94.103 people. and 57 patients died today. thus, overall patients died numbering 6.207 people. in indonesia the province with the highest confirmed cases of coronavirus is in jakarta with positive cases increasing by 538 with a total of 30.092, patients recovering experienced an increase of 208 with a total of 19.916, and patients died an increase of 16 people with a total of 1.011 (kompas.com, 2020). in indonesia the 2nd highest corona virus case is in east java province, with positive confirmed corona increased by 336 with a total of 28.239, the recovered patients experienced an increase of 416 with a total of 21.255 people, and the patients who died increased by 14 people with the total to 2.037 people. in east java itself the area confirmed the highest corona virus cases are in surabaya with patients confirmed positively corona virus cases that increased by 112 people with a total of 10.774 people, patients recovered increased by 212 people with a total of 7.727 people, while the patients who died increased by 4 people with the total number to 858 people (kemenkes ri, 2020) . the covid-19 pandemic has a profound effect on all aspects of life. likewise in the world of education that requires changing all teaching methods, from face-to-face (offline) to online. the online learning process is carried out in the hope that students will still get learning even if they have to stay at home. this is in accordance with the circular number 4 of 2020 from the ministry of education on the implementation of education in the emergency period of corona virus desease (covid-19). as a result not only students are affected but also families. families and students became concerned about the continuity of journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.97-106 99 the study process. in addition, students and families are also worried and anxiety in the event of covid-19 transmission. if the management is not immediately carried out, it does not close the possibility that initially students and families are healthy and fine can become physically and psychologically ill in the form of emotional mental disorders. the responses that appeared were various, ranging from anorexia, headache, sleep not comfort, feeling tense, worried or anxiety. physical distancing also causes daily activities to be disrupted, including student learning activities. tang research (2020); siti nurjanah (2020) explores the prevalence of post traumatic stress disorder and depression in students quarantined to dormitory showing improvement in symptoms of ptsd and depression. dwidiyanti (2018) mentioned about the risk of mental disorders in earthquake victims in lombok west nusa tenggara shows 75 respondents experienced neurosis, 26 respondents experienced symptoms of psychosis and 57 respondents experienced symptoms of ptsd/post traumatic stress disorder. the picture of the emotional mental changes of society in general and students in especially as a result of covid-19 needs to be known in order to be able to do more. one way to get good and relatively inexpensive emotional mental data, easy and effective is to use the self-reporting questionnaire (srq) measuring instrument. it is said to be cheap because it can be done in a fairly short time and does not require special human resources to assess it. srq is effective because it has a fairly good validity in terms of its sensistivity and specificity. srq is a questionnaire developed by who for the screening of psychiatric disorders and research needs that has been conducted in various countries. srq is widely used in developing countries and the level of education of its population is still low. in addition, srq is also very suitable for use in countries where the population is still largely derived from low socioeconomic levels. objective this study aimed to find out the picture of mental health and emotional mental disorders in students and families during the covid 19 pandemic. methods this study used a descriptive crossectional design with a large sample of 56 students and their families, sampling was done by random sampling method. the research variables are the mental health and emotional mental disorders of students and families. data retrieval is carried out from 6 to 20 june 2020. the intrusion used in data retrieval is srq-29 (self reporting questionnaire). the collected data is then analyzed with the help of a frequency distribution table. results characteristics of respondents 1. demographic data an overview of the demographic condition of respondents becomes an important part of the data collection to know the characteristics of the respondent more. the demographic picture of respondents includes age, gender and occupation in detail in table 1. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.97-106 100 table 1: characteristics of respondents based on age, gender and work of students and their families in nursing diploma 3 study program stikes karya husada kediri (6 to 20 june, 2020) no variable frekuensi % 1 age : minimum : 15 maximum : 69 average : 34,88 standard deviation : 15,57 2 gender: male female 23 33 41,1 58,9 3 profession : student private employees entrepreneur/traders/laborers farmer pns/tni/polri hausewife/not working/unemployed 25 7 9 4 6 5 44,6 12,5 16,1 7,1 10,7 8,9 from table 1 above obtained data from 56 respondents minimum respondents age of 15 years, maximal age respondents 69 years, average age of respondents 34.88 years. for the sex of 33 respondents (58.9 %) female, 23 respondents (41.1%) male. for jobs 25 respondents (44.6%) students, 4 respondents (7.1%) as a farmer. 2. respondent history data the respondent's history is part of the characteristics of the respondent, including the type of symptoms felt, symptoms after traveling, the history of close contact, the history of rapid tests and swab tests. the complete data of the respondent's history is listed in table 2. table 2 : characteristics of respondents based on student and family history of nursing diploma 3 study program stikes karya husada kediri ( 6 to 20 june, 2020. no variabel frekuensi % 1 types of symptoms that are felt not having/feeling any symptoms cold cough mild pneumonia chronic diseases 49 1 1 1 4 87,5 1,8 1,8 1,8 7,1 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.97-106 101 2 symptoms after traveling there is there is no 1 55 1,8 98,2 3 close contact history ever never 7 49 12,5 87,5 4 rapid test history ever never 3 53 5.4 94,6 5 swab test history ever never 0 56 0,0 100,0 from table 2 above, of the types of symptoms felt for 30 days during the covid-19 pandemic were 49 respondents (87.5%) not having/feeling any symptoms, 4 respondents (7.1%) have a history of chronic diseases, 1 respondent (1.8%) feel symptoms such as colds, coughs, mild pneumonia. in the history of symptoms after traveling, 55 respondents (98.2%) no symptoms appeared, and 1 respondent (1.8%) there are symptoms after traveling. from a history of close contact with covid patients, 49 respondents (87.5%) never close contact, 7 respondents (12.5%) there is a history of close contact with the patient. of the 7 respondents who were in close contact consisted of 2 students, 1 trader, 1 farmer, 1 nurse, 1 private employee and 1 self-employed. from rapid test history obtained 53 respondents (94.6%) never conducted a rapid test, 3 respondents (5.4%) have done rapid tests. of the 3 respondents who had rapid test, consisted of 1 mahasisa, 1 farmer and 1 trader. from the swab test history, all respondents were 56 respondents (100%) never do a swab test. b. specific data specific data in this study include psychological disorders, psychoactivity, psychotics and ptsd disorders. the specific data of the results of the study on 56 respondents is in full listed in table 3. table 3 : characteristics of respondents based on the picture of mental health and emotional mental disorders of students and families during the covid19 pandemic students and their families, nursing diploma 3 study program stikes karya husada kediri, from june 6-20, 2020. no variabel frekuensi % 1 psychological disorders (anxiety depression) yes no 2 54 3,6 96,4 2 psychoactive disorders/drug use yes 0 0,0 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.97-106 102 no 56 100,0 3 psychotic disorders yes no 5 51 8,9 91,1 4 ptsd disorder (post traumatic stress disorder) yes no 16 40 28,6 71,4 from table 3 above 56 respondents found almost all respondents were 54 respondents (96.4%) not psychological disorders (anxiety and depression), and 2 respondents (3.6%) psychological disorders occured (anxiety and depression), 56 respondents (100%) not experiencing psychoactive disorders/drug use, 51 respondents (91.1%) no psychotic disorders occurred, 5 respondents (8.9%) psychotic disorders, 40 respondents (71.4%) no sympton ptsd and 16 respondents (28.6%) ptsd disorder occurred. the above disorders occurred after being accompanied by various signs and symptoms that appeared in the respondent. there were nine signs and symptoms felt by respondents during the pandemic period. the signs and symptoms felt by respondents are listed in table 4. table 4 : characteristics of respondents based on signs and symptoms that appear no tanda dan gejala frekuensi % 1. headache 10 17,86 2. not sleeping well 7 12,5 3. feeling anxious, tense, or worried 7 12,5 4. find it difficult to enjoy daily activities 9 16.07 5. easily tired 7 12,5 6. something is annoying or something out of the ordinary or yuor mind 3 5,36 7. had heard voices without knowing the source or that others could not hear 3 5,36 8. experiencing disturbing dreams about a disaster/calamity or moments as if experiencing the disaster again 1 1,79 9. interest in friends and the usual activities is reduced 10 17,86 from table 4 above obtained 17.86 % experienced signs and symptoms of headache, 12.5 % experienced signs and symptoms of not sleeping well and feeling anxious, tense, or worried, and easily tired, 16.07% experienced signs and symptoms of find it difficult to enjoy journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.97-106 103 daily activities, 5.36 % something is annoying or something out of the ordinary or yuor mind and had heard voices without knowing the source or that others could not hear, 1.79% experiencing disturbing dreams about a disaster/calamity or moments as if experiencing the disaster again, 17.86 % interest in friends and the usual activities is reduced discussion the results of the study of 56 respondents, obtained by 54 respondents (96.4%) psychological disorders (anxiety and depression), 2 respondents (3.6%) psychological disorders (anxiety and depression), all respondents were 56 respondents (100%) not experiencing psychoactive disorders/drug use, 51 respondents (91.1%) no psychotic disorders occurred and 5 respondents (8.9%) psychotic disorders, 40 respondents (71.4%) no ptsd symptom and 16 respondents (28.6%) ptsd disorder. the emotional mental disorders in this study were determined based on data in which if in quesioner srq obtained 5 or more yes answers on questions 1-20, or experienced one or more complaints on questions 22-24, or experienced one or more complaints on questions 25-29. and the number of respondents who experienced emotional mental disorders was 23 respondents (41.07 %). emotional mental disorders is a state that indicates an individual undergoing an emotional change that can develop into a pathological state if it continues. psychological disorders (anxiety and depression) felt by the 2 respondents showed symptoms or complaints that included headaches as many as 10 respondents (17.86%), found it difficult to enjoy daily activities 9 respondents (16.07%), slept unso soundly, felt anxious, tense, or worried and tired as many as 7 respondents (12.5%). psychological disorders (anxiety and depression) are caused by students and their families having to stay at home and there are restrictions on all activities including direct oscillation activities with those around them as well as online learning systems for students and students aimed at reducing the risk of transmission or contracting covid-19. these anxious and depressive conditions will affect the respondent's physical and psychological condition. according to the american psychiatric association (apa) (2000), when feelings of ansietas appear excessive and significantly impair individual function, they are pathological conditions and are diagnosed as an ansietas disorder in which ansietas disorder centers on irrational experiences and fear or horror that are not proposional so as to elicit both physical and psychological responses. (patricia g, o'brien, 2014). there are several initial symptom responses that occur in response to mental health and psychosocial problems, namely the initial symptoms that include worry, restlessness, panic, fear of losing control, fear of losing control, fear of contracting, irritability, tighter heart palpitations, shortness of breath, shorter and heavier breathing, nausea, bloating and diarrhea, headache, dizziness, itchy skin, tingling, strained muscles, and sleeplessness that lasts for 2 weeks or more (agustina, 2020). the appearance of anxiety and depression is also possible because some respondents have a history of feeling symptoms similar to covid-19 namely 1.8% cold, 1.8% cough, mild pneumonia symptoms1.8% and 7.1% history of chronic disease, history of traveling in pandemic-affected areas, there is a history of close contact as much as 12.5%, and a rapid test history of 5.4%. these factors made respondents feel anxious, fear and depression. psychotic disorders experienced by 5 respondents (8.9%) is a disturbing feeling or unusual thing in the mind as many as 3 respondents (5.36%), have heard a voice without knowing the source or that others can not hear as many as 3 respondents (5.36%). psychosis is a mental disorder characterized by impaired reality. acute and temporary psychotics are also similar disorders, but are acute disorders and have a better prognosis (sadock, 2015). at psychiatric examinations on psychotic disorders obtained a general impression of natural journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.97-106 104 appearance, sad facial romance and sufficient verbal and visual contact, his consciousness is clear, the mood is sad, the afek sad, the harmony seems mismatched (appropiate), on the thought process realistic logical form of thought, coherent thought currents, the contents of preoccupayion tought in the current condition, perception obtained auditoric hallucinations and visual hallucinations, instinctual impulse there is insomnia there is an early type, hypoobuliacence exists, raptus does not exist and psychomotor calm at examination (yustiana et al, 2019). the signs are also experienced by respondents that there are disturbing feelings up to such as hearing voices that are not sourced, in this study, ptsd (post traumatic stress disorder) was the most common disorder in respondents, with 16 respondents (28.6 %). the perceived ptsd disorder was a decrease in interest in friends and activities that were common as many as 10 respondents (17.86%), and 1 respondent (1.79) experiencing disturbing dreams about a disaster/calamity or moments as if experiencing the disaster again. according to the american psychiatric association (2013) ptsd (post traumatic stress disorder) is a mental condition in which a person experiences panic attacks triggered by the trauma of past experiences. ptsd is also a mental disorder that can develop after exposure to highly threatening or horrific events (bonanno ga, 2004; jonathan, 2015: larasuci arini, 2020). koenen's study (2017) in the united states on 5.692 respondents, found 82.7 % were exposed to severe and potentially traumatic events, and 8.3 % of exposed traumas were diagnosed with ptsd. ptsd has clinical manifestations that vary depending on the various factors that affect it including the type of trauma, age, gender, low socioeconomic, education, separation (domestic conflict) trauma before; general childhood difficulties, personal and family psychiatric histories, reporting child abuse, poor social support and initial pretation of reactions to trauma (jitender, 2020) conclusions from the results of the study can be concluded that the impact of covid -19 is at risk of causing mental health problems and emotional mental disorders in the form of psychological disorders, psychotic disorders and ptsd (post traumatic stress disorder) that are shown by the symptoms that arise, namely headache, find it difficult to enjoy daily activities, sleep unsleal, feel anxious, tense, or worried. easily tired, disturbed mind, never heard the sound without knowing the source, lack of interest, dreams about events / disasters experienced before. to prevent an increase in the number of emotional mental disorders that occurred in students and their families during the covid-19 pandemic, education is needed on how to avoid and address emotional mental disorders and the need for psychosisoal mental health support in students and their families journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.97-106 105 references agustina citra fitri, dr,spkj., 2020, manajemen psikososial pada penanganan covid 19, universitas yarsi dwidiyanti, m.,hadi, i., wiguna, r.i., & ningsih, h. e. w, (2018), gambaran risiko gangguan jiwa pada korban bencana alam lombok nusa tenggara barat, holistic nursing and health science, https://doi.org/10.147/10/hnhs.1.2.2018.8291 diatri , (2020), keparahan dampak fisik dan pskis covid 19 kompas.com, 2020, update virus corona di dunia 26 agustus: 24 juta orang terinfeksi/10 negara dengan kasus covid -19 terbanyak, https://amp-kompascom.cdn.amproject.org/v/s/amp.kompas.com/tren/read/08/17/095000665 jitender, sareen. (2020). literature review : post traumatic stress disorder in adult: epidemiologi, pathophysiologi, clinical manifestations, course, assesment, and diagnosis. retrieved from https;//www.uptodate.com/contents/ posttraumaticstress-disorder-in-adult-epidemiologi-pathophysiologi-clinical-manifestationscourse-asses-ment-and-diagnosis kementerian kesehatan ri, 2020, pedoman dukungan psikososial dan kesehatan jiwa pada masa pandemi covid-19 koenen kc, ratanatharathorn a, ng l, et al, 2017, post traumatic stress disorder in the world mental health surveys, psychol med 2017; 47 : 2260 larasuci arini, setiadi syarli, 2020, deteksi dini gangguan jiwa dan masalah psikososial dengan menggunakan self reporting questioner (srq-29), jurnal keperwatan muhammadiyah, http://journal.um-surabaya.ac.id/index.php/jkm patricia g. o’brien, 2014, keperawatan kesehatan jiwa psikiatrik teori dan praktik, penerbit buku kedokteran, egc repici alessandro, md, at all , 2020, coronavirus (covid-19) outbreak: what the departement of endoscopy should know, special article, volume 92, issue 1, p192-197, july 01,2020 rusdi muslim, dr.dr.spkj.,m.kes , 2013, buku saku diagnosis gangguan jiwa, rujukan ringkas dari ppdgj-iii dan dsm-5, bagian ilmu kedokteran jiwa, universitas atmajaya , jakarta sadock bj, sadock va, ruizp, 2015,schizophrenia spectrum and other psychotic disorders, in kaplan and sadock’s synopsis of psychiatry , new york : wolters kluwer, 11 th siti nurjanah, 2020, gangguan mental emosional pada klien pandemi covid 19 di rumah karantina, jurnal ilmukeperawatan jiwa, volume 3 no. 3, hal 329-334, agustus 2020 https://doi.org/10.147/10/hnhs.1.2.2018.82-91 https://doi.org/10.147/10/hnhs.1.2.2018.82-91 https://amp-kompas-com.cdn.amproject.org/v/s/amp.kompas.com/tren/read/08/17/095000665 https://amp-kompas-com.cdn.amproject.org/v/s/amp.kompas.com/tren/read/08/17/095000665 https;/www.uptodate.com/contents/%20posttraumatic-stress-disorder-in-adult-epidemiologi-pathophysiologi-clinical-manifestations-course-asses-ment-and-diagnosis https;/www.uptodate.com/contents/%20posttraumatic-stress-disorder-in-adult-epidemiologi-pathophysiologi-clinical-manifestations-course-asses-ment-and-diagnosis https;/www.uptodate.com/contents/%20posttraumatic-stress-disorder-in-adult-epidemiologi-pathophysiologi-clinical-manifestations-course-asses-ment-and-diagnosis http://journal.um-surabaya.ac.id/index.php/jkm journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.97-106 106 tang, w.,hu,t.,hu,b.,jin,c.,wang,g.,xie,c.,chen,s.,& xu,j .,2020, prevalence and correlates of ptsd and depreeesive symstoms one month after outbreak of the covid-19 epidemic in a sample of home-quarantined chinese university student. journal of affective disorders. undang undang republik indonesia no 18 tahun 2014 yustiana, anastasia venny, aryani, luh nyoman alit, 2019, gangguan psikotik akibat penggunaan ganja (cannabis): studi kasus, medicina 2019, volume 50, number 2: 400-403 p-issn.2540-8313,e-issn,2540-8321 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.51-60 51 irrigation of wounds with red betel 20% and 40% to bacterial numbers in diabetic foot infection (dfi) patients mayusef sukmana*, dwi nopriyanto, alhawaris faculty of medicine, mulawarman university, samarinda, indonesia corresponding author: 200801sukmana@gmail.com abstract background: the most frequent complications of diabetes mellitus are diabetic foot ulcers (dfu), which has a risk of death 2.5 times compared to those without dfu. more than half of them have problems with infection (diabetic foot infections). research on wound washing to control diabetic wound infections originating from phytopharmaca using tropical natural resources such as red betel has not developed. they are a tropical plant that has many benefits containing flavonoids, tannins, alkaloids, saponins. washing the wound with irrigation and swab techniques using red betel 20% effectively reduces the total number of bacteria with diabetic ulcer isolates in white mice alloxan-induced. it reduces staphylococcus growth aureus at concentrations of 10%, 20%, 40%, 80%, 100%. purpose: this study aimed to determine the effectiveness of wound irrigation red betel 20% and 40% of the bacterial rate in dfi patients. methods: this study used a quasi-experiment with pre-post test control group design two treatment groups where bacterial samples were taken before and after irrigation using 20% and 40% red betel extracts while the control group used 0.9% nacl. sampling using consecutive sampling with a large sample of 10 respondents, the total sample swab is 20 samples. the levine technique swab does perform in the area of the diabetic wound. wilcoxon test was used as a different test in each group showing a group. results: the results showed that the wilcoxon test was used as a different test in each group showing a group. of 20% p-value 0,109, group 40% p-value 0,109 and a dick group p-value 0,180. conclusion: there was a decrease in the number of bacteria after irrigation betel leaf extract in all groups. the 40% betel extract irrigation group showed an average reduction in bacterial numbers. the dfi wound had an average difference in all groups but was not significant. the suggestion for research follows: taking more samples, the use of red betel extract as an alternative for infection control in wounds. further research can be done by isolating the red betel content need for more sampling. keywords: wound washing, red betel, piper crocatum, dfi, bacterial numbers. received june 25, 2020; revised july 28, 2020; accepted august 10, 2020 doi: https://doi.org/10.30994/jnp.v4i1.108 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:200801sukmana@gmail.com https://doi.org/10.30994/jnp.v4i1.108 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.51-60 52 background complications of diabetes mellitus in the form of diabetic foot ulcers 20% have problems expanding infection (dfi), healing old wounds, gangrene, amputation, and death (armstrong, boulton, & bus, 2017). open wound infection makes it easy for germs to enter. infection does characterize by fluid wounds or exudates that are many, smelly. wound healing is prolonged (smith et al., 2016). bacteria form a layer called biofilms, infection develops, decreases the immune system on the wound surface, and interferes with wound healing (smith et al., 2016). the uncontrolled disease continues osteomyelitis, bacteremia, and sepsis. (i made sukma wijaya, 2018) infection control does influence by wound washing. this type of washing of electrolyzed strong water acid wounds has a bactericidal effect. it is useful in reducing bacterial colonization (pramesti, andiyanti, & effendi, 2017b). superoxidised (oxum), propyl betaine-polihexanide, povidone-iodine, 2% hydrogen peroxide, chlorine dioxide are bactericidal, whereas nacl 0.9% and tap water do not have them (pramesti, andiyanti, & effendi, 2017a). form of antiseptic soap to control infections, effectively reducing bacterial colonization compared to ordinary soap (yusuf & tahir, 2018). research on wound washing to control diabetic wound infections originating from tropical nature such as betel has not developed. betel has many benefits, easily cultivated in a tropical climate. the content in the form of flavonoids destroys bacterial extracellular integrity. tannins destroy bacterial cell membranes. alkaloids can inhibit glycan peptides so that bacterial cells do not develop fully (mustofa, 2017). betel reduces odor in diabetic wounds (sutrisno & hidayat, 2018). irrigation and swab wound washing using 20% betel effectively reduces the total number of diabetic ulcer isolate bacteria in alloxan-induced white rats (purwaningsih, 2016). the combination of 0.9% nacl irrigation and 40% red betel infusion in diabetic ulcers proved to be more effective in the process of healing diabetic wounds (pashar, 2018). ethanol red betel extract has an inhibitory effect on the growth of staphylococcus aureus at concentrations of 10%, 20%, 40%, 80%, 100% (candrasari, romas, & astuti, 2011). bacteria in the second most dfi staphylococcus aureus 30%. (gaol, erly, & elmatris sy, 2017). research problem formulation: how is the effectiveness of wound irrigation using 20% and 40% red betel (red betel) against the bacterial reduction in dfi patients?. objective this study aimed to determine the effectiveness of wound irrigation red betel 20% and 40% of the bacterial rate in dfi patients. methods the research design was a quasi-experiment using pre-post group control: group i treated with wound irrigation using 20% leaf extract. group ii treated with a wound. irrigation using 40% betel leaf extract. group iii treated with wound irrigation using 0.9% nacl. wound swab collection was carried out before wound irrigation and after wound irrigation using betel leaf extract in all three groups. several stages have carried out as follows: making ethanol extract 20% and 40% betel leaf is done by maceration. fresh betel leaves are washed clean and finely sliced, then dried in the shade, continued drying in the drying cabinet for three days. material that has been dried, blended with a blender to form a powder. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.51-60 53 1. finely ground powder with blander is weighed, mixed with 96% ethanol, and filtered. the next step is evaporation using a rotary vacuum evaporator with a temperature of 50 ° c. 2. the making 20% extract liquid, the extract is taken as much as 20 mg and diluted with 100 ml nacl and 25 mg dmso. the extract does obtain a concentration of 20%. the 40% extract was weighed as much as 40 mg and diluted with 100 ml nacl and 25 mg dmso. the extract does obtain a concentration of 40%. (sutopo, bestari, & sintowati, 2017) (eka wisnu kusuma, 2019) (badan pom ri, 2010). 3. the extract with a concentration of 20% was put into the syringe as much as 20 ml. the needles obtained containing the extract concentration of 20% do use for the treatment group of 20% extract irrigation of 5 respondents. 4. the extract with a concentration of 40% was put into the syringe as much as 20 ml. it was used for the treatment group to extract 40% irrigation as many as five respondents. all extracts that have incorporated into syringes do sterilize with a combination of heat and ultraviolet sterilizers. the temperature used is 120 ° c for 30 minutes and together with ultraviolet exposure for 30 minutes. figure 4.3 delusion extract process figure 4. 2 weighing, giving ethanol dan rotary evaporator figure 4. 1 washing, then dried, sliced, blanded journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.51-60 54 5. the wound was irrigated with the diluted extract at a 20 ml dose using a 20 ml syringe the size of an 18 gauge needle (attached to the sampling sop). the frequency of wound irrigation treatment for respondents does only once. the swab is taking specimens in the area to be examined. several types of swabs, such as simple techniques, z-stroke techniques, and levine swab techniques, were often used because they have a high sensitivity reaching 52.9% (beta subakti nata'atmadja, 2013). levine's technique is more reflective than others. the method carried out using a swab rotation with a slight pressure on the wound area of 1 cm2 of granulation tissue to remove the exudate for 5 seconds. (baranoski & ayello, 2015) the measurement of bacterial was used by the total plate numbers (eka wisnu kusuma, 2019). the examination of bacterial numbers by the total plate count method (plate count total / pct) carried at the uptd health laboratory in east kalimantan province. the calculation of bacterial cells in the cup used in units of cfu / ml. cfu stands for colony forming unit, which means colony forming units or units. results characteristics of respondents can be seen in the table below as follows: table 5. 1 characteristic of respondents based on age, sex, length of wound care, grade pedis characteristics amount f (%) age a. 20-30 1 10 b. 31-40 1 10 c. 41-50 1 10 d. 51-60 2 20 e. 61-70 5 50 total 10 100 sex a. laki-laki 1 10 b. perempuan 9 90 total 10 100 duration of wound care a. 2 month 6 60 b. 3 month 3 30 c. 4 month 1 10 figure 4. 4 swab of wound figure 4.5 plate count bacterial journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.51-60 55 total 10 100 grade pedis a. grade 2 7 70 b. grade 3 3 30 total 10 100 table 5.1 shows the most dominant age characteristic is 61-70 years, with many 5 respondents (50%). female sex numbered 9 respondents (90%). the longest wound treatment was 2 months, with 6 respondents (60%) and pedis 2 grade of 7 respondents (70%). tabel 5.2 calculate bacterial numbers before irrigation, after irrigation and decrease rates in all groups respondents group the bacterial count of before irrigate (cfu) bacterial count after an irrigation (cfu) difference (cfu) a1 20% 372 60 312 a2 20% 1 1 0 a3 20% 45266 41533 3733 a4 20% 147000 11125 135875 a5 20% 1 1 0 b1 40% 62500 57300 5200 b2 40% 19133 11 19122 b3 40% 68 1 67 c1 nacl 0,9% 6300 2300 4000 c2 nacl 0,9% 79622 10000 69622 source: primary data on 2019 (uptd east kalimantan provincial health laboratory) all respondents count the number of bacteria has decreased from before irrigated and after irrigated. the decrease in the number of bacteria is in line with previous studies where irrigation can reduce the number of bacteria in diabetic wounds (yusuf & tahir, 2018). irrigation using betel leaf extract is one method to reduce the number of bacteria (saputri, 2014). wound washing is essential in reducing bacterial numbers (pramesti et al., 2017b) figure 5.1 bacterial number samples journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.51-60 56 discussion from the table above shows the most significant decrease in bacterial numbers is in a4 respondents from 147000 cfu to 11125 cfu with the difference in the reduction of 135875 cfu. the study is in line with previous studies where wound washing by wound irrigation using betel extract, 20% can reduce the total bacterial number of diabetic ulcer isolates in white mice alloxan-induced (purwaningsih, 2016). red betel extract contains flavanoid, polyphenolate and tannin compounds that function antibacterial (eka wisnu kusuma, 2019) from the five respondents, wilcoxon statistical tests carried out, the data in the table below obtained as follows: the group giving 20% red betel extract in diabetic foot infection wounds showed no significant difference in the count of bacteria before and after giving 20% betel extract with a significant value of 0.109. small differences in clinical results can be statistically significant if the number of subjects is huge. conversely, very striking clinical differences can be statistically meaningful if the subjects are too few, this phenomenon formulated. too many subjects prove everything; too few subjects prove nothing. (sastroasmoro, 2014) limited research time resulted in insufficient sample size from table 5.2 above shows, the most significant decrease in bacterial numbers was in b2 respondents from 19133 cfu to 11 cfu with a difference in the reduction of 19122 cfu. wound irrigation using 40% red betel infusion can accelerate wound healing, wound healing that is quickly influenced by the decrease in the number of bacteria in the wound where the number of bacteria is an inhibiting factor in wound healing (pashar, 2018). contamination of bacterial colonies on wounds increases the burden of bacteria on wounds prolonging healing and growing cases of chronic wounds (atiyeh et al., 2009) the group giving 40% red betel extract in diabetic foot infection wounds showed no significant difference. small differences in clinical results can be statistically significant if the number of subjects is huge. conversely, very striking clinical differences can be statistically meaningful if the subjects are too few; this phenomenon can be formulated. too many subjects prove everything; too few subjects prove nothing. (sastroasmoro, 2014) the number of bacteria before and after giving betel extract 40% with a significant value of 0.109. from table 5.2 shows the most significant decrease in bacterial numbers was on c2 respondents from 79622 cfu to 1000 cfu with a difference of 69622 cfu reduction. washing wounds using nacl can reduce bacterial numbers (pramesti et al., 2017b) (pramesti et al., 2017a). wound washing is an essential step in a series of wound care that can control infection and accelerate wound healing. controlling bacterial colony contamination is an excellent wound care measure (atiyeh et al., 2009). the control group with 0.9% nacl irrigation in diabetic foot infections wounds showed no significant difference in the number of bacteria before and after nacl irrigation 0.9% with a significant value of 0.180. from the table above, the average value of the 20% group has decreased in bacterial count 10544 cfu. the average amount of the 40% group has reduced in bacterial count 19104 cfu, and the average value of the control group has decreased 6150 cfu. the most significant decrease in bacterial count in the three groups was in the group giving 40% red betel extract irrigation, which was 19104 cfu. the 25% red betel extract can maintain inhibitory levels and minimal kill rate against streptococcus aureus bacteria (juliantina, m, & nirwani, 2009). in conditions of levels of more than 10%, 20%, 40%, 80%, and 100% can inhibit staphylococcus aureus, the higher the concentration, the more inhibitory inhibition against bacteria (candrasari et al., 2011). one of the most bacteria in diabetic foot infections is a staphylococcus aureus (jneid et al., 2017) journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.51-60 57 table 5.6 frequency distribution calculate the bacterial numbers in all three groups pre20 (n=5) post20 (n=5) pre40 (n=3) post40 (n=3) precontrol (n=2) postcontrol (n=2) mean 38528 10544 27233 19104 42961 6150 median 372 60 19133 11 42961 6150 range 146999 41532 62432 57299 73322 7700 minimum 1 1 68 1 6300 2300 maximum 147000 41533 62500 57300 79622 10000 calculate the number of bacteria before and after administration of 20% red betel irrigation on dfi wounds, which has an average difference of 10544 cfu. calculate the number of bacteria before and after the administration of 40% red betel irrigation in dfi sores with an average difference of 19104 cfu. calculate bacterial numbers before and after administration of 0.9% nacl irrigation in dfi sores, with an average difference of 6150 cfu. calculate the number of bacteria in giving red betel irrigation 20%, 40%, and nacl 0.9%. study limitations this study has several limitations, as follows: 1. the inspection of samples cannot be done at any time because samples can be received during working hours from 8:00 to 11:00 so that the swab wound sampling can only be done in the morning. 2. the number of samples is limited so that it affects the results of statistical tests 3. the results of irrigation using red betel extract reduce the number of bacteria in the wound. but they have not been able to identify which betel content has the most role in reducing the number of these bacteria, so that isolation or separation of red betel content needed in observing research respondents in full daily cannot yet be carried out. conclusions there was a decrease in the number of bacteria after irrigation betel leaf extract in all groups. the dfi wound had an average difference in all groups but was not significant. the suggestion for research follows: taking more samples use of red betel extract as an alternative for infection control in wounds. further research can be done by isolating the red betel content. acknowledgment all research funding came from the faculty of medicine mulawarman university grant, and i am expressing my gratitude to the faculty of medicine for providing the opportunity to participate in this research. this research has received approval from respondents, and the publication of articles with the principle of confidentiality of respondents. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.51-60 58 references armstrong, d. g., boulton, a. j. m., & bus, s. a. 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(2015). diabetic foot infections: what have we learned in the last 30 years? international journal of infectious diseases, 40, 81–91. https://doi.org/10.1016/j.ijid.2015.09.023 wolcott, r. d., hanson, j. d., rees, e. j., koenig, l. d., phillips, c. d., wolcott, r. a., … white, j. s. (2016). analysis of the chronic wound microbiota of 2,963 patients by 16s rdna pyrosequencing. wound repair and regeneration, 24(1), 163–174. https://doi.org/10.1111/wrr.12370 yusuf, s., & tahir, t. (2018). study literatur penggunaan sabun antiseptik untuk pencucian luka terhadap penurunan kolonisasi bakteri pada pasien dengan luka diabetes. jurnal luka indonesia, 4(september), 108–122. retrieved from https://www.researchgate.net/profile/takdir_tahir/publication/326080305_liter atur_review_study_literatur_penggunaan_sabun_antisept ik_untuk_pencucian_luka_terhadap_penurunan_kolonisasi _bakteri_pada_pasien_dengan_luka_diabetes_how_to_cite_noth ing_nothing_conflict_of_interes/links/5b36e5b44585150d23e50eb4/literatur -review-study-literatur-penggunaan-sabun-antiseptikuntuk-pencucian-luka-terhadap-penurunan-kolonisasibakteri-pada-pasien-dengan-luka-diabetes-how-to-cite-nothingnothing-conflict-of-interes.pdf https://doi.org/10.1016/j.ijid.2015.09.023 https://doi.org/10.1111/wrr.12370 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https://www.researchgate.net/profile/takdir_tahir/publication/326080305_literatur_review_study_literatur_penggunaan_sabun_antiseptik_untuk_pencucian_luka_terhadap_penurunan_kolonisasi_bakteri_pada_pasien_dengan_luka_diabetes_how_to_cite_nothing_nothing_conflict_of_interes/links/5b36e5b44585150d23e50eb4/literatur-review-study-literatur-penggunaan-sabun-antiseptik-untuk-pencucian-luka-terhadap-penurunan-kolonisasi-bakteri-pada-pasien-dengan-luka-diabetes-how-to-cite-nothing-nothing-conflict-of-interes.pdf journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.146-154 146 association between personality traits toward culture shock among indonesian caregiver in japan under economic partnership agreement erwin yektiningsih1*, norma risnasari2, endah tri wijayanti2 1nursing program of stikes pamenang, indonesia 2diploma nursing program, nusantara pgri kediri university, indonesia corresponding author: erwiny.parefortune@gmail.com abstract background: among indonesian nurses who worked in japan under economic partnership agreement (epa). they were placed in hospitals as nurses and nursing homes as caregivers. they experience cross-cultural tend to culture shock because of the personality traits needed socio-cultural to adaptations skills to live new environment. purpose: this study aimed to increase professionally among indonesian nurses placement job in japan with enhancing adequate personality traits for adaptation cross-cultural live and health facility job in japan that can preventive culture shock. methods: this study used a cross-sectional approach with a non-probability sampling method. the population study was 307 among health professionals migration indonesian in japan, and obtained a sample of 180 respondents of indonesian caregiver in nursing home japan, that passing the national board examination (nbe) and have not. selected using a random sampling technique. the data were collected using questioner. data analysis used a contingency coefficient. results: the results of research culture shock participants were 17% and normal 83%. this showed study extraversion have a significant association with culture shock (ρ value = 0. 042) and openness (ρ value = 0.109), conscientiousness (ρ value = 0.518), agreeableness (ρ value = 0.213), neuroticism (ρ value = 0.592) were not a significant association with culture shock. conclusion: the nursing institutions plants to curriculum containing material for increasing nursing resources study cross-cultural skills in an abroad workplace to avoid culture shock who need very good mentally with increase competence of reinforcing positive personality traits. keywords: caregiver, culture shock, japan, personality traits. received august 12, 2021; revised august 21, 2021; accepted september 17, 2021 doi: https://doi.org/10.30994/jnp.v5i1.165 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. http://thejnp.org/ mailto:erwiny.parefortune@gmail.com https://doi.org/10.30994/jnp.v5i1.165 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.146-154 147 background the japan demographic changes reported population total ages 65 over increased elderly to 23,4% in 2011. that condition japan is causing growing problems for nursing care (mari kinkawa et al., 2014). with the signing of the bilateral economic partnership agreement (epa), japan also began accepting foreign nurse trainees from indonesia in 2008 occupancy placement japan to nurses are working as nurses (kanggo-shi) in hospitals and as caregivers (kaigo fukushi-shi) in nursing homes (sae tanaka, hitomi matsunaga et al., 2016). indonesian nurses migrated to work in japan with government to government (g to g) placement mechanism under the indonesia japan economic partnership agreement (ijepa) which was facilitated by indonesian migrant workers protection agency (bp2mi) and japan international corporation of welfare services (jicwel) (bp2mi, 2020). beginning from 2008 until 2019 indonesian nurses sent to japan have reached 2,793 people. those who returned to indonesia have reached 1,475 people. that can be concluded to indonesian under ijepa total was being lived in japan of 1,318 people. placement of nurses and caregivers under ijepa in the last 5 years shows a higher graduation rate than the previous period of 38.2% (kurniati anna et al., 2020). personality traits are a psychological component that affects the adjustment of professional workers to work abroad (huff et al., 2014). personality traits characterize how a person feels, thinks, and most importantly behaves (takase et al., 2018). the personality of immigrant employees who work in new places tend to culture shock, in order to survive new workplaces, they carry out adjusting behaviours that are influenced by combination skill mental and personal abilities (mahmood & burke, 2018). the mental ability component consists of psychological cross-cultural in order to be able to adapt for manage daily life in a new cultural context in a way that can cope with emotional stress, depression, anxiety, and barriers from culture shock (doki et al., 2018). while the personal abilities of the professional migrants in workers workplace suitable sociocultural adaptation are personality types, work experience, foreign language proficiency (renand, 2013). which can be aligned with personality traits to control emotions using constructive coping mechanisms of sociocultural adaptation that affect individual behaves tolerantly in interacting in a new place (yao et al., 2018). the health professionals migration to a new environment can negatively affect, including mental well-being confusion living in a new country with a different socio-culture and living and working environment can trigger a culture shock condition (doki et al., 2018). the results yektiningsih, e et al., (2021) reported among indonesian nurses working in hospital japan based on an economic partnership agreement to experience culture shock level a poor of 40% and moderate of 11%. the current study found among indonesian worker migrants in hongkong to experience culture shock level a poor of 72%, moderate of 82,88% and high of 5,4% (iqbal, muhammad and verdaningrum, 2016). among migrants who experiences culture shock trying to adapt socioculturally by using response coping mechanisms. culture shock can be treated to indications individuals adapt acculturation responses to the host culture. when the individual fails to adjust, it results in a maladaptive response causes an acculturative stress response (mahmood & burke, 2018). the negative impact of culture shock in everyday life on mental health is depression, anxiety and feelings of helplessness resulting in impaired concentration in learning new cultures, problems solving problems and making decisions. it can cause a decrease in motivation to adapt to new conditions that are likely to become enemies of the host country's citizens, which can lead to defects in interpersonal relationships (renand, 2013). http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.146-154 148 the impact of culture shock in the workplace is experiencing physical stress and mental that have a negative impact on motivation, performance, and productivity that causes low-quality human resource competitiveness (doki et al., 2018). a professional migrant worker decides to return to his home country before the employment contract expires. this phenomenon can be a big loss for the company, considering the cost of sending professionals is not cheap, the loss of market share, and relations with clients and local government officials are not good (mahmood & burke, 2018). a study was conducted to indicate mental problems among indonesian nurses and care workers to work in japan under the ijepa program of 22.5%. some mental problems have been caused by routine stress (nugraha, susiana and hirano, 2016). general self-efficacy modifies the effect mental problems of stress on burnout in nurses with different personality types. the involvement of personality has been reported in the development of burnout, and some individuals with a certain personality trait are more susceptible to job-related burnout (yao et al., 2018). objective the objectives of this study are to clarify health professionals migration indonesian migrate to work in japan to a cross-cultural adaptation process experiencing culture shock is influenced personality traits. important nursing competence about positive personality traits are tended to adapt in the workplace abroad to experience could enhance workplace learning. for indonesians in japan may enhance a mutual understanding between indonesian and japanese health professionals migration, leading to better utilization of human resources. methods research design this study was conducted a type of descriptive-analytic research with a crosssectional design. research participants and location the population this study were 307 among health worker indonesian in japan under ijepa program and obtained a sample of 180 respondents of indonesian caregiver have been working in japan nursing home both passing the national board examination (nbe) and have not. random sampling was used to recruit the participants. inclusion criteria were participants who care giver arrived more 1 years to work in nursing home japan passed the nbe and who unpassed. the exlusion criteria was incooperative. the independent variable was personality traits. the dependent variable was culture shock research instruments this study has used two questionnaires including the basic traits inventory (bti) was used to measure the big five personality traits consists of 20 items by focusing personality traits on big five scale (openness, conscientiousness, extraversion, agreeableness, neuroticism). the answer choices of the ptq in this study used a likert-type scale poor, average, good (hee, 2014). the bti has been tested for reliability and validity, and the cronbach’s alpha of 0.915, with a sensitivity ranged from 0.504 to 0.950. the culture shock questionnaire (csq) consists of 12 items by focusing on two major areas: the core culture shock items component and the interpersonal stress items. the answer choices of the csq in this study used a likert-type scale poor, average, good (david bardwell mumford, 2000). the indonesian-language version of the csq has been tested for reliability and validity, and the cronbach’s alpha of 0.906, with a sensitivity ranged from 0.461 to 0.869. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.146-154 149 data collection and ethical consideration the researcher permited and coordinated to indonesian migrant workers protection agency (bp2mi) to obtain respondent data in accordance with the researchers' criteria. the explanation of the terms and conditions of the study and informed consent for study participation was obtained. all respondents were assured of the voluntary and confidential nature of the study. a total of 32 questionnaires items were distributed online in link google during october to december 2020. the questionnaire was set up with a default one response per respondent to avoid any duplicate responses. the bp2mi has given notification of the complete a questionnaire was automatically sent to the respondent’s email of private message address. prior to the data collection, approval to conduct the study was obtained from the ethics committees at the health research ethics commission of the faculty of medicine, universitas brawijaya (reference no.141/ec/kepk-s2). the ethical requirements and respondent rights have been fulfilled throughout the research process to collect the data online in google form link was not cause harm and was not disturbed. data analysis this research was conducted with ibm spss statistics 24. the analysis of the research used univariate analysis of frequency distribution, then the bivariate analysis of contingency coefficient with a significance level of ρ < 0.05. results table 1 saw the distribution of data dominant of personality traits and culture shock level study participants. the average dominant of personality traits of agreeableness study participants were of 84 (47%). then the average study participants were not culture shock or normal level of 150 (83%). table 1. respondents were dominant of personality traits and culture shock (n=180) variable n % personality traits openness 56 31 conscientiousness 18 10 extraversion 8 4 agreeableness 84 47 neuroticism 14 8 culture shock level normal 150 83 culture shock 30 17 table 2 presents the mean of predictor variables between personality traits toward culture shock. this showed study extraversion have a significant association with culture shock (ρ value = 0. 042) that indicated an association between variables. the results of further analysis related to extraversion and culture shock level of the normal category had extrovert traits participants of 144 (80%). personality traits of openness (ρ value = 0.109), conscientiousness (ρ value = 0.518), agreeableness (ρ value = 0.213), neuroticism (ρ value = 0.592) were not a significant association with culture shock. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.146-154 150 table 2. association between personality traits toward culture shock (n= 180) personality traits culture shock level total normal culture shock ρ value n % n % n % openness 0.109 inovatif 142 79 26 14 168 93 konvensional 8 5 4 2 12 7 conscientiousness 0.518 positive 144 80 28 16 172 96 negative 6 3 2 1 8 4 extraversion 0.042 ekstrovert 144 80 26 14 170 94 introvert 6 3 4 2 10 6 agreeableness 0.213 kooperative 140 78 26 14 166 92 inkooperative 10 6 4 2 14 8 neuroticism 0.592 emosional positive 124 69 26 14 150 83 emosional negative 26 14 5 3 30 17 table 3 saw the distribution of data characteristic of the study participants. the average gender of study participants were female of 126 (70%), with subjects were single status of 112 (62%). the average bachelor of nursing education study participants were of 96 (53%). the average religion study participants were islam of 114 (63%). the average study participant did not pass nbe of 152 (85%). table 3. characteristics respondents (n=180) characteristic n % gender female 126 70 male 54 30 religion islam 114 63 protestant 40 22 catholic 8 5 hindu 18 10 status single 112 62 married 60 33 widower/ widow 8 5 less 2 years job experience in medical facility no 117 65 yes 63 35 passed nbe no 152 85 http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.146-154 151 yes 28 15 education nursing associate’s degree 84 47 bachelor 96 53 discussion this research identified the average normal culture shock of 83% care giver working nursing home in japan. the results sae tanaka, hitomi matsunaga et al., (2016) reported results a comparative study to the cross-cultural tolerance between indonesian immigrants of travellers, students, internship, health workers who come to japan, that the health professional under ijepa have the highest ability to tolerate cross-cultural to adapt to culture shock. so that they acculturation living in japan because cross-cultural tolerance skills had been related relevant by graduated from a nursing college or vocational school background with health services job experience history, they have received japanese culture and language training. that appropriate this result study all respondents had education nursing were associate’s degree of 47% and bachelor of 43%, then experience in medical facility of 35%, as indicated in tabel 3. the migrants experience acculturation which cultural tolerance process to a new culture develops relationships with the host culture and maintains immigrant native culture (hariyadi, 2013). migration adapting to individual duration time contact with host culture stays to improve cross-cultural tolerance competency that can reduce stressor precipitation (doki et al., 2018). the health professionals under ijepa experienced reasonable difficulties due to the long duration of time of more than one year in japan which tended to be able to study actual competency sociocultural adaptation (nugraha & ohara-hirano, 2016). the immigrants culture native were contact host culture stays in long periods that associated increasing psychological adjustment which can be tolerance competency enhancement social support contact quality for communication cross-cultural to better understand each other (hatanaka, kaori and tanaka, 2016). this study identified the average personality traits dominant of agreeableness, that tends to be submissive and obedient to the rules in the workplace. the agreeableness types consist cooperative type is easy to agree with, trusts others and the uncooperative type is difficult to agree with because it focuses on one's own needs (takase et al., 2018). that appropriate these result study respondents had cooperative of 78% and uncooperative of 14%, as indicated in table 2. the current study found that the culture shock predictors are associated with type extraversion personality traits. extraversion is a personality type that assesses the quantity and intensity of interpersonal interactions, the level of need for support in carrying out activities, and the ability to feel happy (takase et al., 2018). type extraversion personality traits are one of a psychological component that affects the adjustment of professional workers to work abroad (renand, 2013). two types of extraversion personality traits, namely extroverts tend to be friendly, open, likes many friends and introverted types tend to be closed, like to be alone (jelavic sanda rasic., 2021). an extrovert is emotional stability flexibility and social initiative open-mindedness (yao et al., 2018). emotional stability flexibility personality personals will assume situational conditions of cultural differences in abroad workplace can pose a threat aspect so culture shock as a stress trigger. meanwhile, the initiative open-mindedness personality type person has an open mind tends to occur to adaptive responses to cultural differences situations, so that they feel challenging aspects for career development working abroad (van der zee & van oudenhoven, 2013). that http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.146-154 152 appropriate these result study respondents had culture shock level of the normal category had extrovert traits participants average of 80%, as indicated in table 2. the current study foud culture shock was not associated with personality traits kind of openness, conscientiousness, agreeableness and neuroticism, that are relevant in intercultural competence that can reduce stressor precipitation culture shock. openness is a dimension for knowing interest, conscientiousness is a dimension of motivating ability to achieve goals, agreeableness is a dimension of obeying rules and neuroticism is a dimension of controlling emotions (takase et al., 2018). obtained from various studies, there are various personality trait triggers culture shock immigrant. the current study found shaifa & supriyadi (2013) study results personality types capable of adaptive adjustment to culture shock were agreeableness and openness. while the conscientiousness, extraversion, and neuroticism personality types were maladaptive so they tend to experience culture shock. the current study found novikova et al., (2017) reported 388 foreign students studied in russian universities. the research results on personality types that had intercultural competence so that they can adapt to culture shock were openness, conscientiousness, extraversion, agreeableness. while personality traits difficult to adapt occur culture shock was neuroticism. personality traits are a psychological component that affects the adjustment of professional workers to work abroad (renand, 2013). each individual has a unique personality type that can arise from relatively permanent character patterns and unique characters that have consistency and uniqueness in individual behavior (takase et al., 2018). each individual has cognition, affect, and different ways of behaving in different situations and times. although the majority of individuals in a country have almost similar values so that the behaviour, mindset, and morals of the people in that country look the same, each individual still has his own uniqueness (jelavic sanda rasic, aleksic anna, 2021). worker profesional immigrants have different adaptation strategies depending on the adjustment of an expatriate to the host culture. cross-cultural adaptation can be understood in the social learning paradigm and refers to how well individuals are able to manage daily life in a host cultural context (harlinda, 2018). one of the personality theories used to explain a person's personality traits is the big five personalities, there are five dimensions of openness, conscientiousness, extraversion, agreeableness, neuroticism(shaifa & supriyadi, 2013). conclusion based on the results of this study, it can be concluded indonesian immigrant caregivers professionals in japan, who have culture shock 17%. this study of result trigger a culture shock was caused to a type of extraversion personality traits that attend to ability interpersonal maladaptive. the personality traits, such as openness, conscientiousness, agreeableness and neuroticism tend to be submissive and obedient to adapt in workplace abroad to experience could enhance workplace learning and nursing competence. average this study result kind dominant of agreeableness personality traits than skill tendency to comply with workplace rules. hopefully, the results of this study can be used nursing institutions curriculum containing material for increasing nursing resources. the graduate nurses for working abroad are study cross-cultural skills who sociocultural adaptations skills in an abroad working environment to avoid culture shock who need very good mentally with increase competence of reinforcing positive personality traits and creating an environment that matches nurses’ personality traits are necessary in order to facilitate workplace learning and to improve nurses’ feeling of competence. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.146-154 153 acknowledgment i would also like to thank bp2mi has helped collect data online and all the respondents who took the time to participate conflicts of interest the authors declare that there is not conflict of interest. references bp2mi. 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(2018). general self-efficacy modifies the effect of stress on burnout in nurses with different personality types. bmc health services research, 18(667), 1–9. https://doi.org/https://doi.org/10.1186/s12913-018-3478-y yektiningsih, e., astari, a. m., & utami, y. w. (2021). a correlation between working environment and job experience toward culture shock among indonesian nurses in japan. jurnal ners, 16(1), 1–9. https://doi.org/http://dx.doi.org/10.20473/jn.v16i1.23284 http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.13-22 13 beta binaural beats and its effects on the cognition of nursing students in a private higher education institution julie ann dy1, april ross ladera1, joshua paul cabato1, monique librando1 johnny j. yao jr2* 1college of nursing, velez college, philippines 2research office, velez college, philippines corresponding author: johnnyyaojr@gmail.com abstract background: studying nursing comes with a certain expectation to work hard and take a certain amount of time. a promising method called beta binaural beats is thought to improve cognitive functions. purpose: this study aimed to determine whether listening to beta beats is an effective method for improving cognition among nursing students. methods: a double-blinded experimental research design was utilized and measured the effects of the intervention towards memory, abstract reasoning and reading comprehension. results: a total of 89 subjects participated in this study. only the score of reading comprehension showed a significant difference (t=2.38, p= .02). conclusion: the findings suggest that beta beats is an effective way in enhancing reading comprehension. however, findings show that beats aren’t effective in enhancing memory and abstract reasoning. therefore, this may be used as a method to enhance learning. keywords: beta binaural beats; cognition; memory; reading comprehension; abstract reasoning; nursing students. received may 17, 2020; revised june 20, 2020; accepted july 30, 2020 doi: https://doi.org/10.30994/jnp.v4i1.102 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:johnnyyaojr@gmail.com https://doi.org/10.30994/jnp.v4i1.102 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.13-22 14 background a student carries a lot of responsibilities and one essential key of responsibility is to study. many students enter college expecting good times, friendship and a good sense of direction. however, that is not always the case, students later figure out how challenging and struggling college life is. a study from dy et al, (2015) entitled “stressors and stress responses of filipino college students” stated that out of 258 students, 72% manifested cognitive stress responses due to academic stressors. moreover, studying nursing comes with a certain expectation to work harder on average than most other students. they deal with lectures and practical taking up a great deal of time. in addition, nursing is considered to be one of the most stressful career choices. it entails student to gain knowledge and skill through classroom lectures, long exam, return demonstration and rotating shift works in the hospital and participate in community programs (mann et., al 2017). a nurse is required to know anatomy and physiology, biology, pharmacology and other areas of nursing science. however, nursing students have difficulty in remembering too much information. a study conducted by potter et al (2005) stated that nurses who have lower working memory capacity are more likely to make medical errors. furthermore, at often times most students read and highlight terms or definitions they don’t even understand (conca, 2010). although remembering concepts are significant, it is highly important to be able to comprehend as well since nurses play a huge role in providing patient education. according to zeng-treitler (2008) prior studies show that many patients do not fully understand or recall the instructions received from the nurse. as early as their first year, nursing students are introduced to abstractly think outside the box. they are trained and practiced to develop critical thinking skills. nurses are faced with decision-making situations in patient care, and each decision they make impacts patient outcomes. nursing critical thinking skills drive the decision-making process and impact the quality of care provided (vest, n.d. as cited in ericksen, 2017). as students in the chosen profession for the present study, the researchers have witnessed the need for improving cognitive processes: memory, reading comprehension and abstract reasoning. students often complain on how to attain memory retention while being able to comprehend medical terms and as to how to choose the best answer in situational questions during long exams. based on literature, there is a promising tool used to enhance cognitive functions called binaural beats. binaural beats, discovered by heinrich wilhelm dove, is the difference between two pure tones with different frequencies introduced to each ear separately that is perceived by the brain (oster, 1973). it has shown to entrain brainwaves from one state to another. binaural beats is thought to exert effect on cognitive functioning and mood (lane et al, 1998) specifically beta binaural beats. a study conducted by garcia-argibay (2017) revealed significant findings of beta frequency binaural beats amounting to 20 hertz to the subjects who performed free recall and recognition tasks. exposure to beta frequency binaural beats yielded a great proportion of correctly recalled words and a higher index in recognition tasks. another study on the effects of beta binaural beats conducted on college students showed a significant increase in their memory (kennerly, 2013). in summary, most of the studies focus on memory alone however the researchers wanted to study a wider scope of cognitive processes including memory, reading comprehension and abstract reasoning. the researchers would want to test whether listening to binaural beats is an effective method for improving cognition among fourth year nursing students. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.13-22 15 objective this study aimed to determine whether listening to beta beats is an effective method for improving cognition among nursing students. methods design an experimental research design was utilized in the study wherein an intervention or treatment was introduced. experimental studies are designed to test causal relationships to test whether the intervention caused changes in or affected the dependent variable (polit & beck, 2017). the dependent variables are the quality of memory, reading comprehension, abstract reasoning and the independent variable is the use of binaural beats. the researchers aimed to determine whether there are correlations in the following variables binaural beats and memory, binaural beats and reading comprehension, binaural beats and abstract reasoning. research locale the study was performed in an institution offering five programs of study: nursing, medical technology, physical and occupational therapy and biology. the subjects were from the fourth-year nursing students. experiment was done in an arts and sciences building on a saturday for section a and friday for section b. the room can accommodate up to 50 people and is air conditioned and well ventilated. during data collection, section b had a number of subjects who were tired from the day’s activities of having long hour classes and quizzes. this caused them to be quite restless. section a, however, was more lenient. the research instructor gave further instructions and the class was not as tired with the day’s activities. research subjects and data collection the researchers decided to utilize the total population of the fourth-year nursing students, which is a total of 100 subjects excluding the researchers. they are divided into two sections. section a has 52 students while section b has 48 students that were enrolled during the first semester s.y. 2018-2019. only 89 subjects participated (45 for experimental group, 44 for control group) in the study since eight of these students had another important school activity to attend to, two of the students had an important family event and one was excluded from the study due to a heart problem (premature ventricular contractions). the subjects were screened first with a researcher made screening tool which required them to write their names and age. a yes or no question screening tool was given since there were certain conditions which were contraindicated with binaural beats such as seizure, individuals with pacemakers and heart problems and to know if the subjects had their own earphones and smartphones. the researchers lent smartphones and earphones for those who didn’t have. research instruments to test for memory, a researcher made tool was given in which 20 random medicalrelated words were mentioned for a maximum of five minutes and then the research subjects were asked to write as much as they can remember after they took the reading comprehension exam. for reading comprehension the international english language testing system will be the instrument used. it is the most appropriate instrument to measure the variable. the ielts is an international standardized test of english language proficiency. ielts has four parts which are the following: listening, reading, writing which are completed in one sitting and speaking. only the reading part of the ielts was utilized by the researchers. it is composed of 13 items in which they have to answer questions regarding the story or article they have read. for abstract reasoning, the non-verbal figurative test by getmyuni was journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.13-22 16 used. it is composed of 15 items in which they were to choose from the choices on which figure was missing. the scores were interpreted by getting the mean score for each test and then standard deviation was used to measure how scores differ from the mean score. the greater the standard deviation the farther it is to the mean score and the lesser the standard deviation the nearer it is to the mean score. data analysis statistical analysis was done using spss with p <0.05 as the significant value. demographic data were processed using descriptive statistical analysis. in addition, the differences between and within groups were analyzed using the paired t-test, and independent t-test results a total of 89 subjects participated in this study. they were allocated into two groups. the control group (n=44) received the delta binaural beat while the experimental (n=45) received the beta binaural beat. table 1. demographic profile of fourth year nursing students note: *mean= 19.76; sd= 0.88 as observed in table 1, in a total number of 89 subjects, they ranged from about 18-23 years old. the average age is 20 years old. table 2. pretest scores of experimental and control group note: m=mean, sd=standard deviation, ci=confidence interval, ll=lower limit, ul=upper limit profile f % age* 18 1 1.12 19 37 41.57 20 39 43.82 21 7 7.87 22 4 4.50 23 1 1.12 gender male female 15 74 16.85 83.15 control experimental ci variable m sd m sd t p ll ul memory 6.27 2.20 6.33 2.71 .12 .91 -.98 1.10 reading comprehension 5.95 2.01 6.04 2.24 .20 .84 -.81 .99 abstract reasoning 9.18 2.04 8.73 2.30 -.97 .33 -1.36 .47 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.13-22 17 an independent t-test further revealed that that there is no significant difference in pretest scores of both groups for memory (t =.12, p =.91), reading comprehension (t =.20, p =.84) and abstract reasoning (t =-.97, p =.33). table 3. pre-test and post-test scores of experimental and control group pretest post-test ci variable m sd m sd t p ll ul experimental memory 6.44 2.83 7.28 3.30 -1.62 .11 -1.90 .21 reading comprehension 5.95 2.35 6.95 2.19 -2.33 .03* -1.87 -.13 abstract reasoning 8.82 2.32 8.69 2.37 .30 .76 1.73 .99 control memory 6.20 1.81 6.86 3.19 -1.17 .25 -1.80 .48 reading comprehension 6.03 2.08 5.71 1.71 .75 .46 -.53 1.16 abstract reasoning 9.40 2.05 8.66 2.93 1.37 .18 -.36 1.85 note: m=mean, sd=standard deviation, ci=confidence interval, ll=lower limit, ul=upper limit *p<0.05 to test if there is a significant difference between the experimental and control group’s pretest and post test scores, a paired t test was done. the paired t-test revealed that there is no significant difference in the control group in terms of memory (t =-1.17, p=.25), reading comprehension (t =.75, p =.46) and abstract reasoning (t =1.37, p = .18). on the other hand, the experimental group showed a significant difference in reading comprehension (t =-2.33, p =.03). table 4. post-test scores of experimental and control group control experimental ci variable m sd m sd t p ll ul memory 7.05 3.32 7.04 3.18 .001 0.99 -1.37 .37 reading comprehension 6.00 1.84 7.00 2.11 2.38 .02 .16 1.84 abstract reasoning 8.59 2.67 8.51 2.31 -.15 .88 -1.13 .97 note: m=mean, sd=standard deviation, ci=confidence interval, ll=lower limit, ul=upper limit *p<0.05 an independent t-test further revealed that there was no significant difference in post-test scores of both groups for memory (t =.001, p =0.99) and abstract reasoning (t =-.15, p=.88). however, there is significant difference in the post test score for reading comprehension (t =2.38, p =.02). table 5. adverse effects experienced by the research subjects experimental control total headache 2 4 6 ringing of ears 2 3 5 both 2 2 4 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.13-22 18 none 39 35 74 total 45 44 89 as seen in the table above, a total 15 people experienced adverse effects. six people experienced headache, five people experienced ringing of the ears, and four people experienced both. discussion the researchers have observed that there are more women than men who took up the nursing course. according to the philippine commission on women, more women have enrolled in the higher education compared to men. as stated by pcw, “…during the school year 2005-2006, females accounted for more than half of the total 2,483,645 enrollees at 54.48 percent compared with males at 45.52 percent.” (pcw, 2014). nursing has also been stereotypically viewed as a profession for women. due to this constant view, nursing remains to be predominantly taken up by women. (everynurse.org, 2011). it also observed that most of the subjects are 20 years of age. this is because the subjects were not affected by the recent k-12 implementation. according to department of education, the high school graduate class of 2015 is the last batch that will not be affected by the k-12 implementation (deped, n.d). the pre-test scores between scores indicates that both, the experimental and control group, are more or less likely of the same level in terms of cognition specifically in memory, reading comprehension as well as abstract reasoning. this would reflect a successful randomization of subjects between the two groups. randomization pertains to the random selection of each subject to a group of either experimental or control with its primary function to secure comparable groups for equality with respect to extraneous variables. it is considered to be the most effective method of controlling extraneous variables and eliminates selection bias in which the random selection of subjects to either the experimental or control group is not achieved (polit & beck, 2017). those in the experimental group had higher scores in reading comprehension compared to the control group. this suggests that the beta binaural beats is effective in reading comprehension. this is in line with the helmholtz's theory which states that a frequency following response is made by the brain to match the frequency of the stimuli which entrains the brain into a beta brainwave pattern. beta brainwaves is associated with attention. moreover, it is said that the higher the attention span, the more likely it is for reading comprehension to increase (educationcorner, 2018; yildiz, et. al., 2017). this suggests that the beta binaural beats is effective in reading comprehension. studies show that an enhanced reading comprehension skill improves reading fluency. it increases the accuracy of word recognition and would allow you to understand structured sentences clearly while skimming and scanning. these studies have also stated that reading comprehension is associated with attention. as per verbalized by one of our subjects, “for me, i was able to answer more properly because i was more focused after listening to the beats.” in line with that, studies have shown that beta binaural beats can increase attention (sarnson, 1999; vendoza, 2013; colzato, et. al., 2017 and cvijetic, 2017). however, the paired t-test in the experimental group revealed that there is no significant difference for memory (t =1.62, p =.11) and abstract reasoning (t =.30, p =.76). this is contradicting to several studies which stated that beta binaural beats is an effective method in facilitating memory. (argibay m., et. al., 2017; huang & charyton 2008; kennerly, 2018). no studies have been found with regards to the effects of beta binaural beats on abstract reasoning. the researchers imply that there may be no significant difference journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.13-22 19 possibly due to a small sample size since a small sample size decreases statistical power and increases the margin of error (deziel, 2018). after the intervention was done, the scores of the experimental group in terms of reading comprehension improved. improving reading skills will reduce unnecessary reading time and enable a person to read in a more focused and selective manner. the person will also be able to increase their levels of understanding and concentration. among other studies, an effective result in memory was shown after using beta binaural beats as an intervention (argibay et. al, 2017; hwang and charyton, 2008; kennerly, 2013). on the other hand, no studies were found about the effects of beta binaural beats on abstract reasoning. there are different potential risk when using binaural beats, it can trigger seizure in those who have epilepsy, and it can cause a mild headache and anxiety. it may also alter heart rhythms so people with heart problems and with pacemakers may experience unwanted side effects. (servidio, 2013). ringing of the ears was a side effect based on experience by the subjects. however, studies show that binaural beats can actually heal tinnitus (david et. al., 2010; american hearing aid association 2011; british tinnitus assocation, n.d.). on the other hand, studies have also shown that people with tinnitus exhibits a decrease delta activity and an increase beta activity. this means that a person may experience tinnitus if the brain activity is altered into frequency level. (osinska, et al. 2013). for the subjects who experienced adverse effects, they were given the choice whether they would want to continue to participate in the study. the researchers assessed the characteristic and severity of the adverse effects. medication was given to those who couldn’t tolerate the pain. they were also advised to sleep. in the event that the adverse effect would not subside after sleeping, the researchers assured the subjects that they would be accompanied to the clinic and all medical funds would be shouldered by the researchers. however, all 15 subjects who experienced adverse effect claimed that they were relieved after sleeping. there may be some potential limitations to this study. only the 4th year nursing students were included in the study since there were no enrollees for school year 2017-2018. therefore, a larger population may increase the significant relationship. the study was conducted in the afternoon wherein the subject was already exhausted due to their morning classes. lastly, there are unavoidable external noises that may have altered the result of the study. although only reading comprehension showed a significant difference and a few of the research subjects experienced certain adverse effects, the researchers imply that the environment and the situation they are in may have altered the way they answered the questionnaire. conclusion nursing students had improved their reading comprehension while using beta binaural beats. it is effective in reading comprehension, but not in memory and abstract reasoning. therefore, beta binaural beats may use as a way of boosting cognition specifically reading comprehension. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.13-22 20 references basic brainwave benefits – alpha, theta, delta. 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(2008). improving patient comprehension and recall of discharge instructions by supplementing free texts with pictographs. retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2656019/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2656019/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.271-280 271 deep breathing relaxation techniques to lowering systolic blood pressure in the elderly: randomized control trial novian mahayu adiutama1*, hera hijriani2, wawan kurniawan2, wardah fauziah1, chiou feng lin3 1politeknik negeri subang, subang, indonesia 2stikes ypib majalengka, indonesia 3department of microbiology and immunology, taipei medical university, taiwan *corresponding author: adiutamanovian@gmail.com abstract background: continuous high blood pressure causes the heart to work extra hard, eventually this condition results in damage to the blood vessels of the heart, kidneys, brain, and eyes. hypertension management is recommended to minimize pharmacological therapy with the aim of avoiding side effects. non-pharmacological efforts that can be done in patients with hypertension are by controlling various aspects such as deep breathing techniques. purpose: this study aims to determine the effect of deep breathing relaxation techniques to reducing blood pressure in the elderly with hypertension. quasy-experiment pre-post-test with control group was conducted on 108 elderlies with hypertension at a puskesmas located in subang with simple random sampling technique. methods: this study was conducted by providing deep breathing techniques to the elderly in the treatment group for 3 months. the statistical test used was the independent t test and chisquare. results: the deep breathing relaxation technique given at a dose of 15 minutes 3 times a day for 3 months has been shown to have an effect on reducing blood pressure in the elderly. conclusion: future research can conduct research on deep breathing by paying more attention to confounding variables such as stress, anxiety, and diet. keywords: deep breathing, hypertension, relaxation received march 10, 2022; revised april 1, 2022; accepted april 29, 2022 doi: https://doi.org/10.30994/jnp.v5i2.213 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:adiutamanovian@gmail.com https://doi.org/10.30994/jnp.v5i2.213 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.271-280 272 background hypertension basically reduces the life expectancy of the sufferers. this disease is the estuary of various diseases that can lead to death. continuous high blood pressure causes the heart to work extra hard, eventually this condition results in damage to the blood vessels of the heart, kidneys, brain and eyes (wittler, 2016). williams (2018) conducted a study on primary hypertension clients by doing breathing control exercises to reduce blood pressure, the results showed that there was a decrease in systolic blood pressure of 0.91 mmhg and a decrease in diastolic blood pressure of 1.81 mmhg. until now, the effect of deep breathing relaxation techniques on lowering blood pressure is not known. the ten diseases that cause the highest outpatient care are hypertension (sismulyanto, 2021). based on the results of the study on morbidity and disability in the indonesian health profile, it shows that the prevalence of hypertension sufferers is 68-79% annually (kemenkes ri, 2018). in addition, increasing age is closely related to an increase in arterial stiffness (friedman et al., 2016). the results of the indonesian ministry of health report, the number 3 cause of death in 15 districts/cities is hypertension, 4.4% of deaths at the age <50 years, while those aged >50 years are 4.6% (health, 2018). the results of a preliminary study conducted on january 28, 2022 at the research location found that 58% of the elderly suffer from hypertension. consumption of green bananas, green tea and exercise every friday is considered not to have a significant impact. independent actions that can be taken by nurses to control blood pressure are by applying distraction techniques on an ongoing basis, one of which is deep breathing relaxation techniques. hypertension in addition to causing a high mortality rate also has an impact on the high cost of treatment and care that must be borne by the sufferer. it should also be remembered that hypertension also has an impact on decreasing quality of life. if a person has high blood pressure and does not get regular treatment and regular control, this will lead to serious cases and even death. hypertension requires treatment without causing side effects which aims to prevent morbidity and mortality and maintain normal blood pressure (mitchell et al., 2016). this is reinforced by guyton & hall (2014) that with the aim of treating clients with hypertension is to reduce blood pressure to near normal and one of the management actions of hypertension management is recommended to minimize pharmacological therapy with the aim of avoiding side effects. non-pharmacological efforts that can be done in patients with hypertension are by controlling various aspects such as deep breathing techniques. deep breathing technique is one part of independent nursing intervention that aims to provide various benefits. according to ahern (2017) the effects of deep breathing techniques include a decrease in blood pressure, a decrease in pulse, a decrease in muscle tension, a decrease in metabolic rate, an increase in global awareness, a feeling of peace and well-being and a relaxed period of alertness. the advantage of this deep breathing technique is that it can be done anytime, anywhere, the method is very easy and can be done independently by the client without a medium and can relax tense muscles (wittler, 2016). according to the functional consequence theory, hypertension is a negative functional consequence, while deep breathing interventions will produce positive functional consequences with the aim of relaxing and comfortable so that the h.p.a axis is activated which causes the hypothalamus to decrease crf so that in the pituitary there is also a decrease in acth (kramer et al., 2019). this causes the adrenal medulla to decrease the production of catecholamines resulting in vasodilation of blood vessels which ultimately has an optimal impact in the form of positive consequences, namely a decrease in blood pressure (williams, 2018). thus, deep breathing relaxation that is done correctly and regularly is believed to be able to lower blood pressure, so it is necessary to do a lesson for people with hypertension so https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.271-280 273 that they can do deep breathing relaxation correctly and regularly (dorans et al., 2018). deep breathing is a series of breathing actions performed to circulate air throughout the lung fields which consists of the process of inhaling slowly and deeply for 4 counts, then holding for 3 seconds and exhaling slowly for 6-8 counts or according to the patient's tolerance. this deep breathing exercise is done 5 to 10 times for 15 minutes 3 times a day (hamasaki, 2020). based on the above phenomenon, researchers are interested in conducting research that aims to explain the effect of giving deep breathing relaxation techniques to reducing blood pressure in employees with hypertension. objective this study aims to determine the effect of deep breathing relaxation techniques to reducing blood pressure in the elderly with hypertension. methods quasy-experiment pre-post-test with control group was conducted on 108 elderlies with hypertension at a puskesmas located in subang with simple random sampling technique. this study was conducted by providing deep breathing techniques to the elderly in the treatment group for 3 months. the statistical analysis was conducted using independent t test and chisquare. the criteria for the sample of the intervention and control groups were the same to maintain the equality of characteristics between the two groups. patients who were recruited to become respondents were who diagnosed with hypertension by a doctor, elderly with hypertension for more than 6 months, and willing to take part in the study to completion, these criteria are made so that there is no research bias. elderly people with dementia, suffer from acute respiratory disease, the elderly who do not do deep breathing exercises completely, elderly who resigned in the middle of the research, elderly who died were excluded from the study. the respondents were recruited using the simple random sampling. data was collected from september 1 to december 1, 2021. this study was conducted by providing deep breathing techniques to the elderly in the treatment group for 3 months. the statistical test used was the independent t test and chi-square (α = 0.05). results the socio-demographic characteristics in table 1 show that 108 respondents in this study gave a 100% response. based on the results of the chi-square test, it shows that there is no difference in the characteristics of the respondents on gender, age, and marital status with a p value > 0.05, meaning that the two groups are equal. table 1. socio-demographic characteristics (n=108) group p-value treatment (n=54) control (n=54) n % n % gender male 32 65.6 28 53.1 0.309 female 22 34.4 26 46.9 age 56 65 29 56.3 30 59.4 0.801 > 65 25 43.7 24 40.6 occupation https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.271-280 274 working 27 81.3 29 56.3 0.061 nor working 21 18.7 25 43.7 marital status married 18 56.3 17 53.1 0.802 unmarried 14 43.7 15 46.7 the following will present a bivariate data analysis. the data presented is the mean pretest and post-test systole values in each group, along with the difference/difference (delta) between pre and post-test in each group. according to ghozali (2014) to analyze the effect of variable x on y by using two or more independent sample groups, the data tested is the data difference (delta) between the pre-test and post-test in each group, this is aims to avoid bias due to inhomogeneous data so that it can meet the assumptions of parametric tests. table 2. paired t –test of blood pressure systole before and after intervention (n=108) data blood pressure systole mean delta δ p value before intervention 158.64 -5.91 0.005 after intervention 152.73 paired t test results showed that there was a significant difference between the mean systolic blood pressure values before and before the intervention in the treatment group (p = 0.005). table 3. paired t-test before and after intervention data blood pressure systole mean delta δ p value before intervention 161.36 -0.45 0.724 after intervention 160.91 the results of the paired t test showed that there was no significant difference between the mean pre and posttest systolic blood pressure values in the control group (p = 0.724). table 4. independent t-test between treatment and control group group mean (delta) p value treatment -5.91 0.015 control -0.45 the results of further statistical analysis using an independent t test between the treatment and control groups showed that there was a significant difference in the systolic blood pressure delta value with p = 0.015, this value indicates that the difference in the preand posttest systolic blood pressure values in the treatment group has a difference. which is significant when compared to the difference between the pre and post-test values of the control group, meaning that relaxation techniques are proven to reduce systolic blood pressure. discussion the results of the study found that the systolic blood pressure (pretest) in the treatment and control groups respectively showed a mean value of 158.64 mmhg and 161.36 mmhg. diastolic blood pressure (pretest) in the treatment and control groups respectively showed a mean value of 93.64 mmhg and 91.82 mmhg. the results found in this study indicate that the https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.271-280 275 respondents in this study on average suffered from hypertension with the classification of stage 1 hypertension based on the classification of hypertension (wittler, 2016). according to williams (2018) those aged 46-65 years tend to experience an increase in blood pressure which is influenced by various risk factors, including gender and associated with increasing age. the researcher believes that the factor that causes hypertension in this study is the age factor, because in this study most of the respondents in both groups were aged 56-65 years, namely 45.5% in the treatment group and 54.5% in the control group. according to bundy et al. (2018), adult blood pressure increases with age, especially when entering old age, blood pressure increases due to a decrease in the elasticity of blood vessels. this study is in accordance with research conducted by ahmadi et al. (2021) which states that most of the incidence of hypertension increases rapidly at the age of 50 years and over with a prevalence of 69.7%. based on this, the researcher argues that the older you get, the higher the risk of suffering from hypertension, this is related to changes in anatomical and physiological structures, especially from the cardiovascular system due to the aging process. this occurs due to decreased elasticity of blood vessels, decreased tensile strength of blood vessels, and decreased smooth muscle relaxation. factors that contribute to thickening and stiffness of vascular endothelium in the aging process include increased collagen, reduced elastin, calcification, fat deposits and increased calcium (williams, 2018). the increase in blood pressure at the age approaching the respondent may also be caused by gender, the results of this study found that sex with the highest proportion in both groups was female, namely 63.6% in the treatment group and 72.7% in the control group. this shows that most of the respondent who suffers from hypertension has a female gender. this statement is supported by the theory according to cernes & zimlichman (2017) which states that women are strongly influenced by several hormones including the hormones estrogen and progesterone which function to protect women from hypertension and its complications including thickening of blood vessel walls or atherosclerosis. after menopause the protective effects provided by hormones begin to wear off, as women's hormone levels drop rapidly. based on this, researchers argue that women have a higher risk of suffering from hypertension than men after menopause. this is because most of the female respondents in this study had entered menopause, resulting in changes in the hormones estrogen and progesterone. this opinion is also in accordance with research by hassoun (2021) which states that hypertension tends to be higher in women (58.3%) compared to men (41.7%). the results of the study found that the systolic blood pressure (pre-test) in the treatment and control groups respectively showed a mean value of 152.7 3mmhg and 160.91mmhg. meanwhile, the diastolic blood pressure (pre-test) in the treatment and control groups respectively showed a mean value of 88.64 mmhg and 92.72 mmhg. the decrease in systolic and diastolic blood pressure in this study was only found in the group of respondents who received deep breathing relaxation techniques for 7 days. this study agrees with guyton & hall (2014) which explains that a slow breathing rate can increase vasodilation of blood vessels which activates the hering-beurer reflex which in turn can reduce chemo reflex sensitivity and increase baroreflex. another effect is to lower blood pressure and sympathetic nerve activity. when blood pressure decreases, the sympathetic nerves will be stimulated, post-ganglionic sympathetic nerve neurons will secrete the neurotransmitter norepinephrine (ne), commonly called adrenergic fibers, which in turn will cause vasoconstriction and contraction of the heart muscle. conversely, if blood pressure increases, the parasympathetic nervous system will be stimulated, the post-ganglionic parasympathetic neurons will secrete the neurotransmitter acetylcholine (ach). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.271-280 276 acetylcholine will be captured by acetylcholine receptors (ach-r) found on endothelial cells. as a result, endothelial cells will synthesize and secrete nitric oxide (no) also called endothelium derived relaxing factor (edrf), a powerful vasodilator that also causes relaxation of the heart muscle and blood vessels (guyton and hall, 2014). sympathetic stimulation increases heart activity, heart rate, and pumping power. while the parasympathetic system causes a decrease in heart rate and a slight decrease in heart muscle contractility (wittler, 2016). in the control group after 7 days, it was found that the average increase in diastolic blood pressure was 92.72 mmhg; the increase experienced was 0.91 mmhg. in this control group, there were 2 respondents, who experienced an increase in diastolic blood pressure, this happened because during the posttest the respondents said they were having trouble sleeping due to stress. according to bundy et al. (2018) stress is anything in which non-specific demands require an individual to respond or act. the occurrence of stress because the stressor is felt and perceived by the individual as a threat, causing anxiety which is a common and early sign of physical and psychological health disorders. symptoms that can arise include fatigue, headaches, muscle tension, heart palpitations, increased pulse rate, and increased blood pressure. according to nursalam et al. (2022), to avoid stress, nurses must treat hypertensive patients with culturally sensitive caring. and to improve the symptoms that arise according to yuliana et al. (2017), it is necessary to do treadmill exercise. the researcher argues that there are 2 respondents who experienced an increase in blood pressure due to stress which affects the increase in blood pressure so that the functional consequences become negative. this is supported by the opinion of bundy et al. (2018) that one of the modifiable risk factors for hypertension is stress. stress increases peripheral vascular resistance and cardiac output and stimulates sympathetic nerve activity, then hypertension can occur. the results of the study found that the systolic blood pressure (pre-test) in the treatment and control groups respectively showed a mean value of 158.64 mmhg and 161.36 mmhg. after being given a deep breathing relaxation intervention for 7 days, it was found that the mean value of systolic blood pressure in the treatment group experienced a significant decrease to 152.73 mmhg, while in the control group the results tended to be persistent, namely 160.91 mmhg. diastolic blood pressure (pretest) in the treatment and control groups respectively showed a mean value of 93.64 mmhg and 91.82 mmhg. after being given a deep breathing relaxation intervention for 7 days, it was found that the average value of diastolic blood pressure in the treatment group decreased significantly to 88.64 mmhg, while in the control group there were no significant results or tended to stay with a value of 92.72 mmhg. the data obtained in this study meet the assumptions of the parametric test, because all the data obtained have a normal distribution. test of normality using kolmogorov-smirnov shows the following values: systole pre-test = 0.104; pre-test diastole = 0.272; systole pot-test = 0.740; post-test diastole = 0.082. all data shows a value of more than 0.05, meaning that all data in this study are normally distributed, so hypothesis testing can be continued using parametric tests. the results of the paired t test showed that there was no significant difference between the mean systolic blood pressure values before and after the intervention in the control group (p = 0.724). the results of the paired t test showed that there was a significant difference between the mean systolic blood pressure values before and after the intervention in treatment group (p = 0.005). the results of further statistical analysis using an independent t test between the treatment and control groups showed that there was a significant difference in the systolic blood pressure delta value with p = 0.015, this value indicates that the difference in the pre https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.271-280 277 and post-test systolic blood pressure values in the treatment group has a difference which is significant when compared to the difference between the pre and post-test values of the control group, meaning that relaxation techniques are proven to reduce systolic blood pressure. the results of the paired t test showed that there was a significant difference between the mean diastolic blood pressure values before and after the intervention in the treatment group (p = 0.008). the results of the paired t test showed that there was no significant difference between the mean diastolic blood pressure values before and after the intervention in the control group (p = 0.441). the results of further statistical analysis using an independent t test between the treatment and control groups showed that there was a significant difference in the diastolic blood pressure delta value with p = 0.021, this value indicates that the difference in the pre and post-test diastolic blood pressure values in the treatment group has a difference which is significant when compared to the difference between the pre and post-test values of the control group, meaning that relaxation techniques have been proven to reduce diastolic blood pressure. according to williams (2018) in the theory of functional consequences states that a person tends to experience negative functional consequences. the negative consequence experienced by respondents in this study was an increase in blood pressure. this study proves that through the provision of independent nursing interventions, deep breathing relaxation can change negative consequences into positive ones, namely a decrease in blood pressure. this is in accordance with the opinion of bundy et al. (2018) that deep breathing is useful for relaxing tense muscles, decreasing metabolic rate, increasing feelings of peace and alertness, and lowering blood pressure. according to the theory from hamasaki (2020) the purpose of deep breathing is to lower blood pressure, induce relaxation, reduce anxiety, reduce stress, reduce pain, increase vocal strength, and reduce the risk of respiratory infections. according to cernes & zimlichman (2017) breathing exercises in the form of slow breathing cause changes in the interval of breathing patterns and an increase in the interval of breathing patterns which results in an increase in baroreflex efficiency so that it can reduce blood pressure. this can also change the functional consequences experienced by someone who initially had negative functional consequences in the form of an increase in blood pressure by being given independent nursing interventions in the form of deep breathing, causing blood pressure to drop and turn into positive functional consequences. the researcher argues that the role of gerontic nursing is to identify the factors that cause negative functional consequences after starting deep breathing interventions that will produce positive functional consequences with the aim of making relaxation, relaxing, and comfortable so that the h.p.a axis activation occurs which causes the hypothalamus to decrease crf so that the pituitary also occurs decrease in acth. this causes the adrenal medulla to decrease the production of catecholamines resulting in vasodilation of blood vessels which ultimately gives an optimal impact in the form of positive consequences, namely a decrease in blood pressure in respondents who intervene in deep breathing. this is supported by williams (2018) which states that a slowed breathing frequency triggers a general decrease in impulse travel for the respiratory and cardiovascular systems. the respiratory and cardiovascular systems have the same regulatory mechanisms. changes in one system will affect the function of other systems, deep breathing also maximizes lung expansion when breathing and the existence of a breath holding phase aims to maximize oxygen diffusion in the lungs for better oxygen fulfillment for metabolism. all the facts found in this study, both in terms of the control group and the treatment group, all prove that the administration of deep breathing relaxation techniques with a dose of 15 minutes 3 times a day for 7 days with three combinations of movements in accordance with https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.271-280 278 standard operating procedures can reduce blood pressure. conclusion the deep breathing relaxation technique given at a dose of 15 minutes 3 times a day for 3 months has been shown to influence reducing blood pressure in the elderly. nurses can provide deep breathing relaxation techniques independently to clients, so that they can be used as independent nursing interventions (non-pharmacological) in dealing with hypertension cases. future research can conduct research on deep breathing by paying more attention to confounding variables such as stress, anxiety, and diet. deep breathing exercises can also be considered as additional material for practicum activities for students in dealing with mild and moderate hypertension patients non-pharmacologically. the results of this study can also be used as additional data in the teaching and learning process, especially for medical surgical nursing. health workers at the puskesmas can socialize and provide health education to hypertensive clients by using independent nursing interventions in the form of deep breathing relaxation techniques to reduce systolic and diastolic blood pressure. health workers at the puskesmas can recommend deep breathing as a companion to pharmacological therapy because it can be done anywhere, anytime, and is economical for employees with hypertension. acknowledgments the author is thankful for respondents for their valuable information and its awareness to participate in this research. we also thank to stikes ypib majalengka and politeknik negeri subang for providing financial and motivational support to complete this study. conflicts of interest the author declares that they have no conflict of interest. references ahern, r. l. (2017). management of hypertension. journal of hypertension, 23(1). ahmadi, m., amiri, m., rezaeian, t., abdollahi, i., mansour rezadoost, a., sohrabi, m., bakhshi, e., author, c., & abdollahi assosiated professor in physiotherapy, i. (2021). different effects of aerobic exercise and diaphragmatic breathing on lower esophageal sphincter pressure and quality of life in patients with reflux: a comparative study. middle east j dig dis, 13(1), 61–66. https://doi.org/10.34172/mejdd.2021.205. bundy, j. d., mills, k. t., chen, j., li, c., greenland, p., & he, j. (2018). estimating the association of the 2017 and 2014 hypertension guidelines with cardiovascular events and deaths in us adults an analysis of national data. https://doi.org/10.1001/jamacardio.2018.1240. cernes, r., & zimlichman, r. (2017). role of paced breathing for treatment of hypertensiontle. current hypertension report, 6(19). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.271-280 279 dorans, k. s., mills, k. t., liu, y., & he, j. (2018). trends in prevalence and control of hypertension according to the 2017 american college of cardiology/american heart association (acc/aha) guideline. journal of the american heart association, 7(11). https://doi.org/10.1161/jaha.118.008888). friedman, e. h., bowden, & jones, d. (2016). a family systems nursing approach for families following a hypertension: family health conversations. journal of family nursing, 21(1). ghozali, i. (2014). structural equation modeling metode alternatif dengan partial least squares (pls) (iv). badan penerbit universitas diponegoro. guyton, & hall. (2014). hypertensions diet among adult patient. journal of hypertension, 31(2). hamasaki, h. (2020). effects of diaphragmatic breathing on health: a narrative review. medicines. https://doi.org/10.3390/medicines7100065. hassoun, p. m. (2021). pulmonary arterial hypertension. the new england journal of medicine, 25(385). health, m. of. (2018). hasil utama riskesdas 2018. kemenkes ri. (2018). profil kesehatan indonesia tahun 2018. in ministry of health indonesia. https://doi.org/10.1002/qj. kramer, h. j., townsend, r. r., griffin, k., flynn, j. t., weiner, d. e., rocco, m. v, choi, m. j., weir, m. r., chang, t. i., agarwal, r., & beddhu, s. (2019). kdoqi us commentary on the 2017 acc/aha hypertension guideline. american journal of kidney diseases, 4(73). mitchell, a., boucek, l., hospers, h. j., troxel, a., nicholas, d. b., patterson, j. g., zikmund, w. g., & ayala, r. a. (2016). associations between social family support, psychological well‐ being, decision making, and family resilience among elderly with hypertension. journal of gerontological nursing, 3(1). nursalam, yunitasari, e., & ellina, a. d. (2022). caring berbasis budaya (n. m. adiutama (ed.); 1st ed.). penerbit lakeisha. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.271-280 280 sismulyanto. (2021). the butterfly system of nursing community (n. m. adiutama (ed.); 1st ed.). malang: ahlimedia press. williams, b. (2018). guidelines for the management of arterial hypertension, 2018. journal of hypertension, 36, 1953–2041. https://doi.org/10.1093/eurheartj/ehy339. wittler, r. r. (2016). general guideline of atrial hypertension. heart and lung the journal of acute and critical care, 22(1). yuliana, f., adiutama, n. m., hilmi, m. a., & kurniawan, s. (2017). treadmill exercise for increasing walking function after stroke. 8 th international nursing conference “education, practice and research development in nursing,” 8, 183–188. https://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.126-135 126 a comparison of pain scale on neonates in a top refferal hospital in indonesia nenty septiana1, yeni rustina2, defi efendi2,3* 1nursing academy, kesdam iskandar muda banda aceh, banda aceh, indonesia 2faculty of nursing , universitas indonesia, indonesia 3neonatal intensive care unit, universitas indonesia hospital, indonesia corresponding author: defiefendi@ui.ac.id abstract background: pain assessment scale in neonates is the cornerstones of pain management so that the impact of pain can be prevented to maximize neonatal growth and development. purpose: this study aimed to identify the most appropriate pain assessment scale used for neonates in indonesia. methods: a cross sectional study design was used in 30 neonates hospitalized using neonatal infant pain scale (nips), neonatal infant acute pain assessment scale (niapas) and pain assessment tool (pat). pain assessment was performed by nurses (n=30) and expert nurses (n=5) participated in the validation of scales. statistical analysis using validity (content, construct and concurrent validity) and reliability (inter-rater reliability and internal consistency) test. results: nips instrument have excellent validity, reliability, and feasibility value compared with niapas and pat. conclusion: nips was shown a valid, reliable, and practical scale for assessing pain in neonates. it allows nurses to identifying pain and help to provide of appropriate pain management. keywords: neonates, pain assessment, neonatal infant pain scale, neonatal infant acute pain assessment scale, and pain assessment tool. received august 12, 2021; revised august 21, 2021; accepted september 17, 2021 doi: https://doi.org/10.30994/jnp.v5i1.163 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. http://thejnp.org/ mailto:defiefendi@ui.ac.id https://doi.org/10.30994/jnp.v5i1.163 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.126-135 127 background neonates are often exposed to painful procedures while being treated in the neonatal intensive care unit (nicu) (witt et al., 2016), with an average of 10-16 painful procedures per day (carbajal et al., 2008). persistent pain stimulation at the beginning of life will result in physiological instability (leena-mari & riikka, 2016), a high risk of intraventricular hemorrhage (evans et al., 2005), damage to infant brain development, neurobehavioral development disorder (cong et al., 2017), as well as contribute to future’s learning and behavior disorders (badr et al., 2010). pain management in neonates depends on early identification of the pain itself. pain assessment is a challenge for nurses since neonates cannot verbally express the pain (pölkki et al., 2014). however, neonates give pain cues through physiological, hormonal, and behavioral changes (leena-mari & riikka, 2016). pain assessment in neonates is crucial to identify the pain felt by using a screening tool (cong et al., 2013). pain assessment in neonates requires instruments that are valid, reliable, practical and must be multidimensional in observing the behavior and physiology shown by the neonate when feeling pain, it is to accurately determine the level of pain (o’sullivan et al., 2016) so that proper pain management can be performed. multidimensional pain screening tools consist of behavioral parameters (facial expressions, crying, body movements, muscle tone, skin color and sleep/wakefulness of the infant) and physiological parameters (heart rate variability, respiratory rate, blood pressure and oxygen saturation) (holsti et al., 2011). based on observations during practice in the perinatology room, nurses performed the screen pain for each baby treated using the pain assessment tools (pat) instrument. the results of interviews with five nurses perinatology found that the parameters assessed in the pat instrument are still general, incomplete identifying pain in neonates, the score of each parameter is considered less representative of the parameters assessed, does not identify pain in neonates using intubation, and the difference between pain scores and no pain is two. this will affect the results of the infant's pain assessment. according to hockenberry & wilson (2015), the pat instrument is used to assess postoperative pain not for procedural pain. whereas what happens in the perinatology room, most neonates experience pain due to procedures such as peripheral blood sampling, heel prick, and suction (mehrnoush et al., 2016). the validity and reliability of this instrument were not mentioned by the authors (hockenberry & wilson, 2015). based on these data, researchers are motivated to explore appropriate pain instruments in assessing pain in neonates and can be applied in perinatology rooms. the author choose nips because multidimensional pain instrument that has adequate psychometrics because it has very good construct validity, concurrent validity, predictive validity, and inter-rater reliability which are important things in making an accurate assessment (malarvizhi et al., 2012; obiedat & al-maaitah, 2020). in addition, nips is easy to identify procedural and postoperative pain in neonates without requiring special skills or tools in assessing pain and has been used worldwide (pölkki et al., 2014). meanwhile, niapas was chosen because it is a new pain instrument developed by (pölkki et al., 2014) with more specific and valid and reliable parameters. objective this study aimed to identify the most appropriate pain assessment scale used for neonates in indonesia http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.126-135 128 methods design dan samples the design of this study was cross sectional. 30 neonates were selected by consecutive sampling according to inclusion criteria, namely 23-42 weeks' gestational age who were undergoing treatment and were going to undergo blood sampling procedures. neonates who are analgesic or sedative and/or have a central nervous system (ivh grade 3 or 4) damage are exclusion criteria. the content validity of the nips, niapas, and pat instruments was assessed by five expert nurses (primary nurses, nurses at the level of ners education and nurses with work period > 5 years) by rating each physiological and behavioral indicators of the three pain instruments with a value of 1,2,3, and 4 (1 = not suitable, 2 = quite appropriate, 3 = suitable, 4 = very suitable). the accuracy of an instrument includes validity (construct and concurrent validity) and reliability (inter-rater reliability and internal consistency). internal consistency was assessed by nurses (n=30) using video recordings on the niapas, nips, and pat instruments. inter-rater reliability instruments were conducted to assess the suitability of the two observers to the pain assessment in neonates by two observers, which are expert nurses as perinatology primary nurses with work experience> 5 years and nurses at the level of ners education and both observers did not know the respondents who conducted the study (blind observation). feasibility of the three instruments included the ease and duration of filling assessed by thirty nurses (n=30). duration of filling instruments used the stopwatch. to investigate the ease of the instruments using open-ended question that are asked to nurses to measure how easily pain scale can be scored and interpreted, and how these instrumen can be used in clinical practice. research instrument and data collection neonatal infant acute pain assessment scale (niapas): niapas describes the level of pain before, during and after invasive procedures in neonates with a gestational age of 2342 weeks including 5 behavioral parameters (alertness, facial expressions, crying, body movements, reactions to touch); 3 physiological parameters (breathing pattern, oxygen saturation and heart rate); and gestational age. each parameter has a score of 2, 3 or 4 and the total score of all parameters reflects the level of neonatal pain (pölkki et al., 2014). neonatal infant pain scale (nips): nips can describe the level of neonatal pain of 28-40 weeks gestation carried out by invasive and postoperative procedures and is often used as a standard for screening pain in neonates, consisting of 6 parameters which are 5 behavioral parameters (facial expressions, crying, arm movements, limb movements, and awake status) and 1 physiological parameter (breathing pattern). each parameter has a score of 0, 1, or 2 and the total score of all parameters can reflect the level of pain in neonates. a minimum score is 0 and a maximum score is 7. the higher the score, the higher the level of pain in neonates (lawrence et al., 1993). pain assessment tool (pat): pat is used to measure neonatal pain/discomfort of gestational age of 27-40 weeks undergoing surgery with the type of postoperative pain. pat consists of 10 parameters which are 5 behavioral parameters (posture/tone, sleep patterns, facial expressions, crying, and skin color), 4 physiological parameters (respiration, heart rate, saturation, and blood pressure) and nurse's perception. each parameter has a score range of 0-2. the minimum score is 0 and the maximum score is 20. the higher the score, the higher the level of pain in neonates (hodgkinson et al., 1994). http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.126-135 129 data collection pain assesstment is carried out in the perinatologi room in referral hospital, jakarta . data collection stages included: 1) sample identifications according to inclusion and exclusion criteria and identifying neonatal characteristics; 2) the three instruments were translated into indonesian by two translators. a week later, a back translation was carried out into english to assess the similarity of the words of the 3 instruments; 3) the researcher contacted the parents of neonates to explain the study procedure and informed consent. this study is voluntary and confidentiality is maintained. there are no extra painful procedures on neonates because of the study and clinical staff were advised to relieve pain of each neonates based on standard daily routine care in the unit. 4) camera videos are positioned to get a clear picture of the neonates so that physiological parameters can be observed on a camera screen. taking routine blood procedure on the heel or peripheral by clinical staff should be according to the standard hospital procedures. only neonates participating in the study were recorded during the data collection period.; 5) recording one minute before, during, and 3 minutes after blood drawn; 6) neonatal pain assessment is carried out in three phases, one minute before, during, and three minutes after the blood draw procedure through video recordings which are performed 2-3 times on each research subject to confirm the neonatal response. the pain assessment for each neonate was assessed by one nurse using three pain instruments namely nips, niapas, and pat; 7) the researchers interviewed nurses who performed pain assessments related to the ease of these three instruments; 8) researchers calculate the duration of filling each pain instrument. data analysis: univariate analysis was assessed to add up the characteristics of the respondents and the feasibility of the niapas, nips, and pat instruments, while the duration of the fill of the three instruments (minutes) used the mean value. the construct validity test uses the repeated anova test in three phases of pain level measurement (before, during, and after blood collection), followed by the bonferroni post hoc test to identify the differences between phases. the construct validity of an instrument is considered to be significantly good if the p-value <0.05. each item statement of the three instruments is evaluated using a content validity index (i-cvi). content validity is said to be very good if the mean i-cvi is ≥ 0.78 and the value of s-svi / ave ≥ is 0.90 (polit & beck, 2012). concurrent validity was performed to see the correlation between items of statement of each instrument using the pearson correlation test. inter-rater reliability uses the bland-altmann test to assess the suitability of the two observers for the assessment of neonatal pain. conformity is said to be good if it has a value of p> 0.05 (dahlan, 2014). internal consistency is assessed using the cronbach's alpha test and is said to be good if the cronbach's alpha value> 0.70 and very good if the value is in the range 0.80-0.9 (scholtes et al., 2011);(devellis, 2017). http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.126-135 130 results the characteristics of respondents consisted of gender, birth weight, gestational age, form of breathing, length of stay and painful procedure. tabel 1. respondent’s demographic characteristic (n=30) demographics f (%) mean (sd) range gender male 17 (56.7) female 13 (43.3) birth weight (g) 1934.4 935-4140 less than 1000 4 (13.3%) 1000-1999 15 (50%) 2000-2999 6 (20%) 3000 or more 5 (16.7%) gestasional age at birth (week) 33.6 (3.75) 27-39 less than 28 weeks 2 (6.67) 28-31 weeks 8 (26.7) 32 – 36 weeks 10 (33.3) 37 weeks or more 10 (33.3) form of breathing need for mechanical ventilation 7 (23.3) need for continous positive airway pressure 9 (30) spontaneous breathing 14 (46.7) length of stay (days) 15.13 (18.97) 1-69 location blood draws heel lance 8 (26.7%) peripheral 22 (73.3%) figure 1. pain score before, during, and after blood draw procedure (n=30) 1.8 10.2 4.17 0.57 5.73 1.71.6 10.6 3.27 before procedure during procedure after 3 minute procedure pain neonates score niapas nips pat http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.126-135 131 table 2. validity niapas, nips, and pat instrument instrument validity content (s-svi/ave-value) validity construct validity concurrent (r-value) before (p-value) during (p-value) after (p-value) niapas 0.75 p=0.000 p=0.000 p=0.002 0.391-0.825 nips 0.91 p=0.000 p=0,018 p=0.000 0.58-0.84 pat 0.63 p=0.000 p=0.000 p=0.09 0.495-0.813 table 3. reliability, feasibility & clinical utility niapas, nips, and pat instrument instrument inter-rater reliability internal consistency (cronbach’s alpha) feasibility & clinical utility before (p-value) during (p-value) after (p-value) easy to administer and decode scoring of pain scale (%) duration of filling in minutes (mean (sd)) niapas 1 0.635 0.67 0.822 8 (25.7%) 6.82 (4.65) nips 0.814 0.13 0.74 19 (63.3%) 19 (63.3%) 3.85 (2.49) pat 0.814 0.057 0.74 4.71 (2.27) 3 (10%) 4.71 (2.27) discussion the results showed the highest level of pain was during blood collection phase and the lowest was before blood collection phase. this is due to the painful stimulus, so that the infant responds to the stimulus through physiological and behavioral responses. infants of gestational age <37 weeks are more sensitive to pain, have a low threshold of touch, more reflex responses to touch are seen, weakness of tone and muscle strength, and experience an increase in pain waves during blood sampling procedures compared to term infants (8,18,19). exposure to recurrent pain and treatment that is not done causes changes in pain threshold, pain perception, and tolerance to pain throughout life. this happens because the pain pathway continues to develop during infancy and childhood. besides, neonates will experience hyperalgesia (increased response to pain stimulus due to peripheral nerve sensitivity) and lower pain threshold will potentially lead to increased physiological and behavioural responses to painful events that may occur in the future (ball et al., 2010) and will cause disruption in growth and the development of the infant's brain nervous system (cong et al., 2017). pain assessment in neonates requires a multidimensional, valid, reliable, and practical instrument for assessing pain levels (o’sullivan et al., 2016). instrument quality is determined by 3 domains, which are validity, reliability, and feasibility (scholtes et al., 2011). validity is a major component of an instrument (tay & jebb, 2017) and refers to the accuracy of measuring an instrument (dharma, 2011) needed to show the credibility of a study (sullivan, 2011). validity consists of 3 components, such as construct validity, content validity, and concurrent validity (devellis, 2017). the results showed that pain level in each phase of the niapas and nips instruments had decent construct validity compared to pat. this can be seen from the significant increase in pain level in niapas, nips, and pat instruments from the phase before to http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.126-135 132 during the blood draw (p = 0.00), the phase before to after the blood draw (p = 0.002; p = 0.00; p = 0.091), and the phase during after the blood draw (p = 0.00, p = 0.018, p = 0.00). of the three pain instruments, niapas has the top construct validity value. the construct validity can evaluate the extent to which an instrument can measure what must be measured when compared with similar measurements it will interpret the same results (scholtes et al., 2011). furthermore, nips has the best content validity value compared to the others with the value of i-cvi≥0.78 for all statement items. content validity is said to be very good if the average i-cvi≥0.78. the content validity of a measuring instrument is determined by its ability to measure the overall contents of the instrument to be measured (polit & beck, 2012). concurrent validity was performed to see the correlation between items of each instrument statement using the pearson correlation test (scholtes et al., 2011). the results showed that the correlation between niapas and nips in all three phases (before, during, and after) was in the range of 0.391 0.825. then the correlation between pat and nips is in the range 0.492-0.813. lawrence et al. in his research showed that the correlation between nips and vas in the phases before, during, and after blood collection was in the range of 0.58-0.84. this shows that nips has the best concurrent validity compared to niapas and pat (lawrence et al., 1993). besides validity, reliability is also fundamental in an instrument (devellis, 2017). reliability is the level of consistency of measurement (sullivan, 2011) including inter-rater reliability and internal consistency (scholtes et al., 2011). the analysis showed that niapas had the best match between observers, and was followed by nips. furthermore, the highest cronbach's alpha value was seen in the nips instrument compared to niapas and pat which was 0.896 so it was said that nips had the best internal consitency by showing a good correlation between statement items. the final results of the study indicate that nips is a valid and reliable pain instrument in assessing pain in neonates (premature and aterm). nips has the best content validity value, the best concurrent validity, good construct validity, proper match among the observers, and the best internal consistency compared to niapas and pat. according to da motta, schardosim, & da cunha, pain instruments in neonates must be reliable, valid, and easy to use so that nurses could provide the optimal pain management easily (da motta et al., 2015). multidimensional pain assessment is the best effort in assessing pain in neonates, it is by examining physiological and behavioural indicators. physiological indicators can be seen from the saturation, frequency, and breathing pattern. on the other hand, behavioural indicators are seen from facial expressions, crying, body movements. physiological and neonatal behavioural indicators are pivotal in assessing the level of pain in the neonate to determine the appropriate pain management in accordance with the level of neonatal pain (cong et al., 2013). the american academy of paediatrics recommends that pain studies be carried out 4-6 hours routinely every day (keels & sethna, 2016), however, only 10% of neonates receive routine pain assessments while infants with mechanical ventilation are often not subjected to be assessed during treatment (anand et al., 2016) nips has a sensitivity and specificity value of 85.94% (95% ci: 72.15-95.6%) and 92.61% which means nips has an educated ability to detect pain experienced by neonates and specifically identify painless neonates (ge et al., 2015). moreover, nips also has the shortest filling duration compared to others. niapas has the longest filling duration of 6.82 minutes compared to nips and pat. this is due to the difference between the calculation of the two parameters niapas (oxygen saturation and pulse frequency) so it requires a lot http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.126-135 133 of time to calculate the difference in oxygen saturation/pulse frequency before and during blood draw. the ease of using the instrument is also largely determined by the nurse's perception of the instrument because nurses are key in assessing pain in neonates (pölkki et al., 2014). the results of this study indicate that nips is the most easily filled and understood pain instrument compared to niapas and pat. da motta et al. explained that nips is a screening tool that is easy to understand and practical to use and requires a short time in detecting pain as well as describing nips as an efficient instrument for pain assessment in neonates (da motta et al., 2015). the results of applying the nips pain instrument can be applied because it is easy to understand, practical, and specific in assessing pain in neonates. this is in accordance with the conditions of nurses in a room that has a high workload. mehrnoush et al., (2016) suggested that some barriers to effective pain management include workload, lack of personnel, lack of knowledge, lack of pain protocols, lack of time, lack of trust in pain assessment instruments. strategies for improving the pain management including: providing education, using the latest journals, developing guidelines and providing support to nurses, developing pain assessment instruments that are clinically appropriate, providing adequate staff and proper workload, and the need for proper supervision and monitoring. the limitation of this study is that the use of video recording tool to assess pain scores makes it easier for different nurses to assess the pain scores. however, differences in the quality of the results of the recording will affect the level of accuracy of nurses in providing pain scores to infants compared to direct assessments. conclusion this study concluded that nips has the best content validity, good construct validity, and very good concurrent validity, good inter-rater reliability value, excellent internal consistency, great sensitivity, and specificity value, has feasibility (ease, accuracy, and filling duration) that are better than niapas and pat instruments. relevance to clinical practice the researcher recommends nips as a valid, reliable, easy, and practical instrument to be used in assessing pain in neonates. this could help nurses in assessing pain so that the pain management can be given appropriately and optimally. acknowledments we appreciate all the respondents and all the nurse perinatology room of dr. cipto mangunkusumo top referral hospital jakarta, indonesia for contribution during the data collection. conflict of interest we declare there is no conflict of interest in this study references anand, k. j. s., eriksson, m., & boyle, e. m. 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(2011). what makes a measurement instrument valid and reliable? injury, 42(3), 236–240. https://doi.org/10.1016/j.injury.2010.11.042 sullivan, g. m. (2011). a primer on the validity of assessment instruments. journal of graduate medical education, 3(2), 119–120. https://doi.org/10.4300/jgme-d-1100075.1 tay, l., & jebb, a. t. (2017). scale development scale development. the sage encyclopedia of industrial and organizational psychology, january. https://doi.org/10.1007/978-3-8349-6891-3_3 witt, n., coynor, s., edwards, c., & bradshaw, h. (2016). a guide to pain assessment and management in the neonate. current emergency and hospital medicine reports, 4(1), 1–10. https://doi.org/10.1007/s40138-016-0089-y http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.8-12 8 effectiveness of mindfulness based stress reduction on depression in elderly: a systematic review linlin lindayani*, agus hendra, lia juniarni, gina nurdina stik ppni west java, indonesia corresponding author: linlinlindayani@gmail.com abstract background: the elderly are individuals who have entered the age of 60 years (hurlock, 2004). one of the most common elderly problems that is more commonly found is depression. currently increasing research and reviews support the efficiency of psychotherapy treatments for depression. based on traditional interventions mindfulness based stress reduction (mbsr) therapy is recommended for geriatric depression. mbsr therapy focuses on is one type of mindfulness-based therapy that focuses on training awareness through meditation techniques. by practicing observing body sensations (body scan meditation), individuals can achieve a mindful condition in their daily lives, including when carrying out routine activities such as walking, eating, standing. mbsr aims to change individual relationships with stressful situations and thoughts. this is achieved by decreasing emotional reactions and increasing. purpose: this study aimed to determine the effectiveness of mbsr therapy on the level of depression in the elderly. methods: literature searches conducted through google scholar and pubmed studies published in english, there were 778 articles obtained but only 5 journals met the search criteria. results: the results of this review show that mbsr therapy has an influence to reduce the level of depression in the elderly and mbsr therapy has no side effects compared to pharmacological therapy. conclusion: it is hoped that health workers can implement mbsr therapy to reduce the level of depression in the elderly. keywords: mindfulness based stress reduction therapy, depression, elderly. received may, 8, 2020; revised june 15, 2020; accepted july 28, 2020 doi: https://doi.org/10.30994/jnp.v4i1.101 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:linlinlindayani@gmail.com https://doi.org/10.30994/jnp.v4i1.101 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.8-12 9 background the elderly are individuals who have entered the age of 60 years (hurlock, 2004). entering a happy old age is identified with readiness to accept all changes in aspects of life (indriana, destiningrum, & kristiana, 2011). the elderly are also a group that must be considered because the numbers are quite large and will continue to increase throughout the year. based on data from the world population prospects (2015), in 2015 there were 901 million people aged 60 years consisting of 12% of the total global population. meanwhile, according to susenas data (national socio-economic survey) in 2019, the number of elderly people in indonesia reached 29 million people, equivalent to 11% of the total population of indonesia in 2019. increasing the number of elderly people has changed health problems and social maps due to decreased productivity of the elderly towards body organs such as cell damage in the aging process, so that the impact on the production of enzymes, hormones, and substances that the body needs for immunity is reduced (maryam, 2011). elderly experiencing various problems in health, especially those related to the aging process including: hypertension, cancer, mental disorders, and man made disease (degenerative diseases) are increasing (ministry of health republic of indonesia, 2017). the erikson development stage states that the elderly are in a phase of integrity, but if this development is not achieved there will be a problem of despair. psychological integrity phase is a phase when an individual conducts a life review and evaluates it which reflects on a person's life experience, and interprets life changes (santrock, 2013). these life changes include retirement, partner death, the need to care for a partner, and physical illness or disability (nevid, rathus & greene, 2005). high stressors and unpleasant life events cause mental and psychological problems in the elderly such as short term memory (memory loss), frustration, anxiety, loneliness, to depression (hawari, 2011). according to the world health organization (who, 2017), the prevalence of depression in the elderly is around 1236% of the elderly undergoing outpatient care due to depression. this figure increases to 3050% in the elderly with chronic illness and long-standing care who are depressed (azizah, 2011). the prevalence in indonesia is based on the information center for noncommunicable diseases, the elderly who experience depression by 11.6 & (kemekes, 2017). the discovery of syukra (2012), in accordance with the phenomenon of empty copulation (empety nest) that is usually experienced by the elderly, is a crisis in oneself caused by the sense of loss of children who have lived independently, entering retirement, menopause, and the death of a partner (lu , 2010). some of the major conflicts experienced by the elderly are the relinquishment of their position and authority, as well as an assessment of the abilities, successes, and satisfaction obtained previously (post power syndrome). this can have an impact on decreasing the physical and psychological condition of the elderly (hawari, 2007). psychological well-being, according to ryff and keyes (1995), is the full achievement of one's psychological potential and a state when individuals can accept the strengths and weaknesses of what they are, have a purpose in life, develop positive relationships, become an independent person, be able to control the environment and continue to grow personally. newman (2006) states that psychological well-being also depends on the ability to regulate or continue to be involved in valuable roles and activities. there are many ways to improve psychological well-being, namely by providing social support (destiningrum, 2014), classical music therapy (jasmarizal, literature & yunita, 2011), elderly group psychotherapy (zulfiana, 2014), elderly exercise (pratiwi, 2013), and mindfulness therapy (kinasih & sukma, 2010). journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.8-12 10 mindfulness is an awareness that arises as a result of giving attention to a current experience intentionally and without judgment in order to be able to respond by accepting the experiences experienced everyday (kabat-zinn, 2003). mindfulness is the nature of attention and full awareness that is stable and consistent in self that encourages individuals to continue to act (teasdale, 2002). mindfulness is rooted in buddhist philosophy and is a form of skill that can help individuals to have awareness and not react to what is happening now, a way to interpret events that are positive, negative, or neutral so that they are able to overcome feelings of depression and generate self-prosperity (germer , siegel, and fulton, 2005). according to its operational definition, mindfulness is the capacity for: (a) observing: the ability to observe and realize the presence of thoughts, feelings, perceptions, and sensations, (b) describing: describing with words, (c) acting with awareness: acting with awareness , (d) nonreactivity: being non-reactive to personal experiences, and (e) nonjudge: behaving without an assessment of personal experiences (roeser et al, 2012). mindfulness based stress reduction (mbsr) is a type of mindfulness-based therapy that focuses on training awareness through meditation techniques. by practicing observing body sensations (body scan meditation), individuals can achieve a mindful condition in their daily lives, including when carrying out routine activities such as walking, eating, standing, etc. (germer, siegel, and fulton, 2005). mbsr aims to change individual relationships with stressful situations and thoughts. this is achieved by decreasing emotional reactions and increasing cognitive assessment positively. various studies show the benefits of mindfulness programs, according to research (gercia-banda & martin-asuero, 2010), can reduce stress, research (davis & hayes, 2011), can increase attention and concentration, research (chen, yang, wang, & zhang, 2013), can reduce anxiety and stabilize blood pressure, research (fortney, et al, 2013), can increase job satisfaction, research (bazarko, et al, 2013), can improve the quality of health, and according to research (white, 2013 ), can improve the quality of therapeutic services to patients. mindfulness therapy trains individuals not to make automatic assessments of the events being experienced. automatic assessment will make individuals not make an objective assessment, so that coping is often done inappropriately and results in coping being ineffective (corhorn & millicic, 2016). mindfulness interventions can facilitate individuals to learn to deal with each experience more openly and without judgment. the mindfulness method uses a series of exercises designed to train the mind to remain focused and open to everyday conditions including stressful conditions (chielsa & malinowski, 2011). white (2013) states that the mindfulness program for nurses can be useful as self-care and the development and improvement of their well-being. the concept of mindfulness starts from releasing the suffering experienced by humans. suffering can include stress, depression, anxiety, interpersonal conflict, confusion, excessive worry and irrational fears (mace, 2008). mindfulness is believed to reduce suffering and promote well-being (grossman & van dam, 2011). elderly who are not psychologically prosperous tend to have more complaints about disease disorders (khotimah, 2011). if the elderly are psychologically prosperous, this will ease the family in taking care of the elderly. everyone will enter old age, so attention to welfare becomes essential. the importance of mindfulness-based stress reduction therapy programs on psychological well-being in the elderly with depression is important to study. so the purpose of this research is to conduct a systematic review of the effectiveness of mindfulness based stress reduction on the level of depression in the elderly. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.8-12 11 methods this research is a systematic review of the existing literature to evaluate subjective responses after the application of mindfulness-based stress reduction (mbsr) therapy to psychological well-being in the elderly with depression. search strategy the search strategy aims to find articles that have been published. data from this review literature was obtained through an online search process. the search is done through google scholar and pubmed. the keywords used are a combination of older or eldery and mindfulness or mind-fulness and depression. the search focused on journals using mindfulness-based stress reduction (mbsr) therapy on psychological well-being in the elderly with depression published until may 21, 2019. the research included in this review is based on inclusion criteria: english and indonesian, published from 2015 to 2020, human participant, clinical trial, and research searches conducted in elderly patients who are depressed. screening article article screening is carried out through the initial title and then abstract screening is carried out to identify which articles have the potential to meet the desired criteria. after that a review of all articles considered significant at initial screening was conducted. additional articles not found in the initial literature search were obtained by reviewing the references in the study. two reviewers reviewed each abstract based on inclusion criteria. the first reviewer checks all the titles and abstracts the aim is to avoid repeating the article. separately, the second reviewer rated the title and abstract samples according to the same criteria to be chosen. furthermore, the two reviewers agreed on which articles met the inclusion criteria. data extraction each article is processed data by making a summary of each article which includes, author, year, country of origin of the study, type of study, sample (including the number of samples and inclusion criteria), interventions, results, and research limitations. study quality study assessment of the quality of each article is carried out using the standard format of the critical appraisals skill program (casp), which is already in indonesian. the criteria used to evaluate whether each study is of good quality and a minimum risk of bias consists of 3, namely whether the results of the study are valid, what are the results, will the research results help locally. there are a total of 11 checklist items that are used to do the assessment with answer choices yes / not reported. result from the results of searches conducted through google scholar and pubmed. a total of journals were obtained using a combination of older keywords. then as many as 778 journals were obtained using a combination of keywords eldery and mindfulness, and as many as 157 journals were obtained using a combination of the keywords mindfulness and depression. so that a total of only 5 articles met all search criteria (figure 1). journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.8-12 12 figure 1. diagram flow articles obtained (n:157) articles obtain (n=52) not relevant based on review of the title and abstract (n=453) incomplete text (n:105) included in the inclusion criteria (n=5) outcome results do not match (n:38) articles obtain (n=14) search electronics at pubmed and google schoolar (n=778) journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.8-12 8 table 1. summary of included studies author / year sample design results casp score piyanee et al (2019) elderly aged 60-85 years who live in the community, and meet petersen's operational criteria for mild cognitive impairment randomize d control the results from one-way ancova showed significant differences between the map and hep groups in depression (f = 7.88, p <0.001), controlling for depression scores at baseline. 10 maja et al (2015) it consists of 36 participants with an average age of 65-80. participants with difficulties related to long-term mourning randomize d control the results of this study are (hedges'g = 0.88, p = 0.09) there are 29% who have improved symptoms of depression both with anova statistical methods. 10 autumn et al (2015) consisting of 200 participants aged 65 -> 70 years who did not experience congnative disorders randomize d control anova test shows the results of the assessment assessment showed a significant group time for the psqi global score (p = 0.006); the mbsr group experienced a decrease in the global psqi score (p = 1.12). 10 jia-xu zhang et al (2015) participants consisted of 60 people with inclusion criteria: 1. age> 75 years 2. minimum duration of insomnia is 6 months (chronic insomnia) 3. complaints of dysfunction during the day a randomized. controlled, single blind clinical trial there was a significant time group interaction for the psqi global score (p = .006). the mbsr group had a decrease in the psqi global score (cohen d = 1.12) while the control group did not (cohen d = -0.06). 10 petra et al (2016) consists of 55 participants aged 52-81 years with exclusion criteria including previous heart attacks, heart surgeries, neurological diseases (for example: stroke, marbus parkinson), severe orthopedic disease, dementia or psychiatric disorders. randomize d control the results showed that there was a significant main effect of time regarding sf-12 mental summary scores (p = 0.27), n2 = .10) indicating that perceived mental health improved significantly from preassessment to post assessment. however, there was also a significant interaction effect of group time (p = .05, n2 =.12). 10 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.8-12 8 summary of research results based on the above table, according to research conducted by piyanee klaininyobas, et al (2019), with the title the effect of mindfulness and health education program on the emotional state and cognitive function of elderly individuals with mild cognitive impairment which aims to determine the effectiveness of mindfulness practices on the emotional state and cognitive function of the elderly who live with people with mild cognitive impairment. this type of research is an experimental study, the number of respondents 55 patients were randomized into 2 groups, the experimental group (map) (n = 28) and the control group (hep) (n = 27). obtaining results in the map group, the average score for depression and anxiety showed a downward trend at 2 (three months) and 3 (nine months) compared with time 1 (baseline). likewise, a downward trend in depression and anxiety was found in the hep group. cognitive function (measured by mmse and cdr) varies slightly between times for both groups. however, all ways are below the conventional cutoff value (<0.5) for dementia. the results from one-way ancova showed significant differences between the map and hep groups in depression (f = 7.88, p <0.001), controlling for depression scores at baseline. note that the map group had a depression score at baseline. however, the increase in depression scores was greater than the map group at three months (mean difference = 1.72, p <0.001). the difference was not statistically significant at nine months (mean difference = 1.15, p = 0.05). according to research conducted by maja o connor, jacob piet, esben hougaard, et al, in 2015, with the title the effects of mindfulness based cognitive therapy on depressive symptoms in elderly vibrated people with loss-related distress aiming to investigate the potential effectiveness of mbct for parents with long-term difficulties associated with mourning, several years after the death of their partner. this type of research is an experimental study, the number of respondents consists of 36 participants with an average age of 65-80 years. participants with distress related to long-term mourning. the results obtained from the results of the study showed a significant decrease. in the control group the average score (hedges'g = 0.84, p = 0.04) and after 4 weeks it became (hedges'g = 0.88, p = 0.02). in the intervention group (hedges'g = 0.84, p = 0.04) and after 4 weeks it became (hedges'g = 0.35, p = 0.09). according to the research of autumn m. galleos et al (2015), titled emotional benefits of mindfulness based on stress reduction in older adults: the moderating roles of age and depressive symptom severity which aims to see the effects of age and severity of depressive symptoms in the elderly. this type of research is an experimental study, the number of respondents consisted of 200 participants aged 65 -> 70 years who did not experience congnative disorders. anova test showed the assessment assessment results showed a significant time group for the psqi global score (p = 0.006); the mbsr group experienced a decrease in the global psqi score (p = 1.12). according to research ja-xu zhang, et al (2015), with the title mindfulness based stress reduction for chronic insomnia in adults older than 75 years aimed at seeing a mindfulness program can be a useful treatment for reducing the level of depression in adults aged 75 years and over. this type of research is an experimental study. participants consisted of 60 people with inclusion criteria: age> 75 years, duration of insomnia at least 6 months (chronic insomnia). showing significant time group interaction results for the psqi global score (p = .006) the mbsr group had a decrease in the psqi global score (cohen d = 1.12) while the control group did not (cohen d = -0.06). among the psqi components, there was a significant time x group interaction for daytime dysfunction (p = .048) cohen from the mbsr group was 0.76. whereas cohen's d from the control group is -0.04. there was no journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.8-12 9 significant time x group interaction for sas scores (p = .116), whereas for gds there was a significant time x group interaction (p = .039), cohen rated for the mbsr group was 1.20 and 0.12 for the control group. according to research by petra jansen, et al (2016), with the title minfulness training on emotional well being and cognitive performance in leter life which aims to compare the effects of karate and mbrs training on emotional well-being, subjective health and cognitive performance. this type of research is an experimental study. participants consisted of 55 participants aged 52-81 years with exclusion criteria including previous heart attacks, heart surgeries, neurological diseases (for example: stroke, marbus parkinson), severe orthopedic disease, dementia or psychiatric disorders. obtaining results in the mbsr group, there was a tendency for stress reduction (p = 0.09), while there was a tendency for an increase in postassessment in the control group (p = 0.085). in conclusion, this study provides insight into the effects of karate training and mbsr training on emotional wellbeing, subjective health, and cognitive function. although the effect is small overall, the findings indicate that karate training and mbsr are acceptable interventions among the elderly. methodological assessment results research on the implementation of mindfulness-based stress reduction (mbsr) therapy on psychological well-being in the elderly with depression has proven to be able to cope with stress, depression, anxiety in the elderly and can be applied because it is easy to do and requires no cost. aside from depression, mindfulness-based stress reduction (mbsr) therapy can also make the elderly feel comfortable being noticed because there are friends to talk to and interact with. discussion based on the journal explained in the previous chapter, it was found that the outcome measured in this study was an intervention / therapy of mindfulness-based stress reduction (mbsr) on psychological well-being in the elderly. mindfulness-based stress reduction (mbsr) therapy can be used as a safe and dangerousless method as an adjunct therapy in addition to pharmacotherapy. utilizing mindfulness-based stress reduction (mbsr) therapy on psychological well-being in the elderly with depression. the results of this study are recommended to be used as further development of research in this field and to prepare clinical guidelines for using therapy in the social care center of werdha. with the conclusion of the exclusion criteria: elderly aged between 60-85 years, elderly with cognitive function problems and emotional well-being issues such as biopsychotic stress to depression, willing to intervene, when to intervene, elderly in good mood / healthy mood and healthy physical condition . exclusion criteria: psychiatric conditions especially major depressive disorders, terminal diseases such as cancer, neurological conditions such as epilepsy and / or parkinsonism, vision and hearing loss, the program consists of four meetings with each meeting consisting of two sessions, each session lasting for 65-75 minutes . mindfulness techniques used are breath meditation, walking, detection and bodily sensations, releasing desires, sober and love, daily activities and evaluation. as for the mindfulness-based stress reduction (mbsr) therapy guide, it is recommended to be with nurses or psychology. conclusion it is hoped that the nurse profession can facilitate the provision of mindfulness-based stress reduction (mbsr) therapy on psychological well-being in the elderly with depression. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.8-12 10 so that in addition to pharmacotherapy, the provision of mindfulness-based stress reduction (mbsr) therapy to psychological well-being in the elderly with depression. references autumn m. galleos, michael hoerger, nancy l. talbot, et al. 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(2002). life-span development (6th-ed). new york: brown and benchmark publisher. syukra, a. (2012). hubungan antara religiusitas dengan kejadian depresi pada lansia di panti sosial tresna werdha (pstw) sabia nan aluih sicincin kabupaten padang pariaman. universitas andalas. indonesia. white, l. (2013). mindfulness in nursing: an evolutionary concept analysis. journal advanced nursing. world health organization (who). depression. depression and other common mental disorders. geneva: who; 2017. world population prospect: 2015. new york: united nations desa. zulfiana, u. (2014). meningkatkan kebahagiaan lansia di panti werda melalui psikoterapi positif alam kelompok. jurnal sains dan praktik psikologi. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.23-33 23 peri-operative care for suspected or confirmed covid-19 cases: a major concern for the public health: a review article krishnaprasad gopalkrishna vanthichal1, arijit ray2, debashish paul3* 1department of anaesthesiology, military hospital kirkee; pune, india 2inhs asvini, mumbai, india 3department of anesthesiology, armed forces medical college, pune, india corresponding author: drdpaulamc@rediffmail.com abstract background: personal protective equipment (ppe) including gown, shoe cover, face mask, eye goggles, cap, face shield and gloves for health-care professional in operation theatre is a must in order to contain covid-19 pandemic. it is imperative to mention that a surgical patient whether suspected or confirmed cases of covid-19 must receive peri-operative care as it is the mainstay in care of surgical patient which cannot be denied to anyone. if we look at the incidences and the trend of spreading the covid-19 infection, any breech in the personal and professional preventive steps to this infection in peri-operative care imposes greater risk to the public health as it affects the health care workers. anesthetisologist and other staffs and health care workers (hcws) in the operating room are in close proximity to patients. they are always in events of increased aerosol production from an infected patients, whether it is intubation, bag and mask ventilation or suctioning of the airway and life saving procedures.the major route of spread is contact transmission.cross-infection is the major hindrance to seamless healthcare service to covid-19 patients. hand-washing is the universal viral transmission containment step. but it will not suffice to the preventive goal of these hcws. though operation rooms are maintained with negative pressure atmosphere which is ideal to minimize infection risk but this is the time to rehearse and practice other aspects too. conclusion: the peri-operative care providers’ face several challenges in operation theatre and during per-operative care while treating suspected or confirmed cases of covid-19 and thus pose a greater risk to the society. we tried to summarise these vital points and practices, dissemination of which is of utmost importance at this pandenmic scenario. keywords: covid-19, operation room, perioperative care. received may 17, 2020; revised june 28, 2020; accepted july 29, 2020 doi: https://doi.org/10.30994/jnp.v4i1.103 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:drdpaulamc@rediffmail.com https://doi.org/10.30994/jnp.v4i1.103 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.23-33 24 background the virus sars-cov-2 infection originated in hubae province, wuhan city, china (ruan, et al, 2020) zoonotic origin (bats) of sars-cov-2 has been confirmed. molecular investigation revealed the virus to be genetically related to sars-cov-1. the major route of spread is droplet and contact transmission. incubation period of sars-cov-2 in healthy host has been confirmed at 14 days (zhang, et al, 2020). almost every country in the world has been affected by covid-19 (d'adamo, et al, 2020). the early and mild symptoms of covid-19 involve dry cough to fever, and at later stages acute respiratory failure or multiorgan failure. the casualty index of covid-19 is very high (baud d, et al, 2020). higherage groups have been reported very susceptible to covid-19. on other side, paediatric population showed relative resistance against covid-19 (lee, et al, 2020). pandemicity: the novel sars-cov-2 (covid-19) has been confirmed in large number of countries. hence, on 11th march 2020, world health organization (who) declared covid19 as pandemic. as on 28th april 2020, this ongoing pandemic has affected more than 185 countries. covid-19 is responsible for more than 216,000 deaths worldwide. first confirmed death in china, outside china and europe was reported on 09th january 2020, 01st february 2020 and 14th february 2020, respectively. the first case of covid-19 reported in india was on 30th january 2020 (sun, et al, 2020). as on 28th april 2020, the ministry of health and family welfare have confirmed a total of 29,974 active infections and 937 deaths (singhal, 2020). almost every country is facing severe socioeconomic disruption due to covid-19 pandemic (adhikari, 2020). operation theatre, anaesthesia and surgery operations on confirmed covid-19 cases should be undertaken in an airborne infection isolation room (aiir). aiir is an advanced version of operation theatre (ot) wherein the ot is modified to maintain negative pressure with an adequate seal. regular and time-bound careful inspection of the aiir by safety engineers is mandatory. a dedicated infection controls team should draft protocols, guidelines, monitor staff movements. protocols for safety and handling of aiir must be rigorously followed by all the concerned health-care operators. this team must ensure timely notification to anaesthesiologists, nurses and surgeons taking care of the operation. this team must also establish protocols for decontamination of ot after the surgery (sohrabi, 2020). perioperative care: peri-operative care is the most critical activity for comprehensive management of covid-19 patients. both, the infected patient and the front-line healthcare worker require peri-operative care. anaesthesiologist and other peri-operative care provide are at higher risk while providing respiratory care and during tracheal intubation (greenland, 2020). hospital set up: management of covid-19 warrants collaborated efforts. there should be minimum number of people in the operating room during induction. the hospital set-up must maintain airway patency, to avoid coughing and must promote compulsory hand hygiene (liang, 2020), conducting trainings to provide information about the disease transmission and prevention (liang, 2020; wu, 2020). personal protective equipment (ppe): all the healthcare professionals must use ppe for the management of covid-19 infected patients. ppe includes gown, shoe cover, face mask, eye goggles, cap, face shield and gloves (who, 2020). gowns: gowns are important when taking care of patients especially when a contagious disease is suspected or confirmed. gowns protect the wearer from contracting and spreading of the infectious disease from liquid and solid material. long length, full-sleeved gown and journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.23-33 25 shoe covers that are water resistant are essential which provide protection from any spillage of oral, nasal secretions or vomitus (feng, et al, 2020). table 1: list of gowns for managing blood-borne pathogens sn name of gown features 1 surgical gown surgical gowns are mandatory for all levels of risk. it is categorized by fda as a class ii medical device 2 surgical isolation gown surgical isolation gowns are mandatory for high microbial risk procedures. it is categorized by fda as a class ii medical device 3 non-surgical gown non-surgical gown is categorised by fda as class i device. it is used for general purpose and low risk procedures. they should not be used for surgery purposes. various gowns have been illustrated in table-1(above) and table-2 below. full-face shield or mask full-face shield or respirator mask provides adequate protection to healthcare professional against sars-cov-19 transmission. it is essential to assess the proper fit of mask because improperly fitted shield/mask will expose frontline healthcare worker (feng, et al, 2020). eye protection protection of eyes by goggles, surgical mask with integrated visor, polycarbonate safety spectacles or full-face visor is important. also, it is essential to avoid close eye examination and opthalmoscopy of suspected/confirmed covid-19 patients (ng, et al, 2020). gloves wearing sterile, disposable latex, rubber or nitrile gloves is mandatory for all the healthcare professionals. peri-operational care providers should wear double gloves when treating the airway, blood, urine, and other body fluid of patients to prevent cross-contamination. after procedure, the outer glove should be used to replace cap, shoe cover and face shield while the inner glove should be removed as soon as possible and disposed of in a double-zip plastic journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.23-33 26 container with all other supplies. any suggestion that the glove is soiled also reproaches its removal and replacement with fresh pair of gloves (ng, et al, 2020). table 2: list of gowns for managing air-borne pathogens sn name of gown features 1 coverall gown coverall gown provides protection against liquid splashes. such gowns should not be used in high-temperature or inflammable conditions. 2 nuclear protective nuclear protective gown provides complete protection against nuclear contamination and radioactive leakages. operation theatre (ot)-a new set up for covid-19 to prevent the spread of infection, all known or suspected covid-19-positive patients needing surgical intervention in the ot must be treated as positive unless proven otherwise health care workers (hcws) who care for these patients must have protocol-guided and clearly defined pathways. to mitigate covid-19 distribution, the allocation of committed senior staff to key management positions is critical. both staff must be specifically qualified to collect, doff and dispose off personal protective equipment (ppe). inside the coa filter area, the patient's receiving staff must conduct hand hygiene and wear full ppe. operator with a beard should pay special attention to the mask fit to ensure adequate safety. increased corona virus transmission has associated these procedures likely to produce aerosolized particles: tracheal intubation, non-invasive ventilation, tracheostomy, cardiopulmonary resuscitation, manual ventilation prior to intubation and bronchoscopy. therefore, operators operating closer to the patient during such procedures will wear an ffp3 mask. given the susceptibility of the conjunctiva to viral transmission, it is necessary to wear visors or goggles to protect the eyes against potential exposure to viral particles (willan, 2020). anaesthesia equipment we suggest effective preparation to avoid any possible infection. one must be aware of the procedures which can pose risk for aerosol production. these procedures have been summarised in table3. table 3: list of procedures performed in operation theatre that are considered aerosol generating sr.no procedure 1 surgical 2 tracheostomy 3 surgery involving high-speed drilling 4 anaesthetic 5 mask ventilation 6 intubation and extubation journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.23-33 27 7 oxygenation through high flow nasal cannula 8 non-invasive ventilation 9 sputum suctioning 10 cardiopulmonary resuscitation (cpr) airway equipment which is available should be preferred. during laryngoscopy and intubation medical and nursing personnel must be wearing ffp3 masks. to prevent repeated instrumentation of airway, intubation methods with the highest chance of first-time success should be chosen. intubation box: the intubation box is a cost-effective and reusable safety system originally developed in taiwan by dr. hsien yung lai to protect hcws. the intubation box (fig.1) operates by sitting over a covid-19 patient's head and neck. the acrylic box serves as a protective shield between the patient and the hcw, with the goal of minimizing exposure to corona virus (covid-19). though most of the literatures ask for the acrylic box to be washed with a solution of bleach or alcohol after each intubation but experience from the ground zero at nodal center for covid patients show that bleach or alcohol deface the boxes. so we have started practicing disinfecting the acrylic boxes with detergent solution instead. figure 1: intubation box fiberscope intubation should be avoided as it can produce aerosolisation, unless explicitly stated. to prevent manual ventilation and possible aerosolisation, rapid sequence intubation (rsi) should be considered. whenever practicable, disposable equipments should be used to prevent cross contamination. a dedicated anaesthesia machine should be earmarked for use in positive or suspected positive covid-19 patients in the operation theatre. a hme viral filter should be attached to the patient end of the breathing circuit if a general anaesthetic is needed, and another between the expiratory limb and the anaesthetic machine (ti, et al, 2020). preparation of ot operation theatres with negative pressure atmosphere are ideal to minimize infection risk. a high rate of air exchange (around 25 cycles / h) effectively decreases the viral load in operating theatres. in a hospital where negative pressure operating rooms are unavailable, the positive pressure system and air conditioning must be turned off. temporary conversion of otherwise positive pressure ors to negative pressure should be preferred with independent provision of air conditioning and humidification. a separate air-conditioning and humidification systems is essential (huh, 2020). journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.23-33 28 equipment kept and used on a case-by-case basis must be reduced and used when appropriate. normal anaesthetic trolleys with limited but sufficient stock should be replaced with dedicated prepared trolleys. all appropriate surgical material (i.e., stitches, scalpel blades) must be stored preventively in a sterilizable basket of steel wire. dedicated infectious risk health waste (irhw) containers should be used for devices which are contaminated and sharp disposable. alcohol containing solution should be used for hand hygiene. disposable material in general should be preferred, including linen (chen, 2020). disinfection/sterilization hand washing is the universal viral transmission containment step. before wearing, before and after touching any infected area, anaesthesia trolley, airway cart or other instruments and after removing gloves, everyone must strictly follow the basic nine steps of handwashing with alcohol-based hand rubs (cheung, 2020). biomedical waste management (who, 2020) management of biomedical waste is an extremely important transmission containment step. the biomedical waste must be double-bagged and labelled ‘covid-19’ with the credentials of the identity like the name of the institute, name of the department, date of the biomedical waste, time of the biomedical waste and the category of the biomedical waste. in a special rigid plastic tub the sharps used in the operating rooms must be disposed off. dedicated wellidentifiable containers for health waste at infectious risk (irhw) should be used for disposables that are potentially contaminated. any containers that are clearly damaged shall be replaced promptly. containers should be closed and sealed until they are moved to the point of collection. to dispose of all infected discarded material and ppes easily, the collection point with a dedicated container for hazardous medical waste must be located right outside the operating room. all hcw involved in the project shall remove their ppe and place the ppe in a designated waste bag in an anteroom. ppe should be removed in the order summarised in fig.2. non-disposable personal protective equipment should be packed into medical waste bags and placed in a designated area. before being taken out of the contaminated area, all the packing bags should be sealed and sprayed with chlorinated disinfectant or covered with an additional bag and sealed. pre op preparation emergency surgery: covid-19 infected patients require emergency operations under anaesthesia. pcr tests should be conducted twice with separate specimens preoperatively in covid-19 infected patients needing an immediate or emergency procedure, to compensate for asymptomatic covid-19 infected patients. the surgical procedures for patients contaminated with covid-19 should be completed as far as possible in the last order of the day (spinelli, 2020). shoe covers ↓ gloves ↓ hand hygiene ↓ goggles/face shield ↓ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.23-33 29 hand hygiene ↓ the gown ↓ hand hygiene ↓ the protective mask ↓ hand hygiene ↓ the head cover ↓ hand hygiene ↓ shower ↓ change into personal clothing. fig. 2: steps of ppe removal elective surgery: elective surgery in covid-19 patients should be delayed until symptom resolution while an emergency operation should be performed with due consent, as this is a completely new clinical scenario for anaesthesia and operation (spinelli, 2020). pre anaesthetic check up: along with routine and disease specific pre-op laboratory findings, investigations of covid-19 is also essential. epidemiological and clinical studies may be paired with case isolation and quarantine of near contacts would be beneficial. rtpcr and serological testing to diagnose cases of covid-19 will help to establish links between clusters (tian, et al, 2020). several healthcare facilities have initiated covid-19 testing for all patients coming to the hospitals and some outpatient clinics for scheduled surgeries, procedures and emergency department treatment. this is a change from previous practice of testing only those with illness symptoms and recommended by their primary care doctors. intra-operative period identification of high-risk procedures in the operating theatre is essential and enlisted (tian, et al, 2020) in table 3. anaesthesia general anaesthesia: general anaesthesia has been recommended for suspected/confirmed covid-19 patients. general anaesthesia mitigates the chances of covid-19 patients coughing and bucking, which can generate airborne material and droplets. certain other types of anaesthesia can be chosen depending on the form of operation and the needs of the particular patient (ti, et al, 2020). airways management (innovations during airways management): as per the recommendations of the consensus guidelines on the prevention of healthcare workers', the choice of personnel engaged in airway management, the training needed and the selection of equipment are addressed. in these settings, the basic principles of airway management are defined for: emergency tracheal intubation; anticipated or unforeseen difficult tracheal intubation; cardiac arrest; anaesthetic care; and tracheal extubation. nebulized local anesthetic should be avoided. tran tracheal injection of local anesthetic should also be journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.23-33 30 avoided, as it is likely to generate a cough. sedation should be administered sparingly during ‘awake intubation’ and titrated to effect, to minimize the need for supplemental oxygen or airway manipulation (cook, et al, 2020). regional anaesthesia: regional anaesthesia, most commonly spinal anaesthesia is still recommended as the primary choice of anaesthesia. the patient with covid-19 should always wear a surgical mask or n95 mask. in case supplementary oxygen is needed, the oxygen mask is applied over the surgical mask or n95 mask. general anaesthesia can be used as a backup plan in case spinal anaesthesia fails or intraoperative conversion to general anaesthesia is indicated (lie, et al, 2020). ultrasound and covid-19: several studies have shown that lung ultrasound is effective in the identification of pulmonary diseases, from bacterial and viral pneumonia to acute respiratory distress syndrome. the use of ultrasound is now necessary for the safe management of covid-19 outbreaks, as it can enable the same doctor to conduct clinical examination and pulmonary imaging at the bedside. lung ultrasound may have some benefits compared with stethoscope use (such as decreased sensitivity of health staff to infected patients, repeatability during follow-up, low costs and simpler use in low-resource settings). lung ultrasound has been shown to be non-inferior to x-ray chest. several clinicians therefore recommend that covid-19 would facilitate ultrasound in the lung (baud, 2020). cardiopulmonary resuscitation during perioperative period cardiopulmonary resuscitation was reported as a cause of the spread of sars infection among hcw. cpr’s dynamic nature comes with high risk of airborne transmission (maier, et al, 2020). when handling covid-19, it will be helpful to consider apnoeic oxygenation instead of providing breaths through bag valve mask to preserve airway patentability and ventilation. early intubation can help reduce the aerosol generation during resuscitation. temporarily holding chest compressions during intubation will reduce the intuitive clinician's risk of inhaling infective aerosols. use the lucas chest compression device to provide automatic compressions, if available, reduces the number of healthcare workers required close to the patient (brewster, 2020). postoperative management transfer of patients: during the intra-hospital settings, the transfer of patients from operation theatre to covid operating area (coa) and/or vice versa must be maintained to minimum, if possible. if essential, this transfer should be swift. a designated and dedicated passageway/corridor between operation theatre (maintained at negative-pressure) to coa must be maintained. a dedicated elevator ideally covered by disposable plastic material, which can be disposed of immediately and lift sanitized after the transfer can be useful. where any unforeseen contamination occurs during transportation (i.e. vomiting of the patient or otherwise), sufficient dedicated sanitization will occur. a dedicated 24/7 cleaning team specially trained from the local contract cleaning company could prove a valuable resource. care must be taken, wherever and whenever possible to transfer the infected patients while keeping them away from other patients and other healthcare resource personnel within the area of the hospital. this step will help to limit the chances of infection. during the transfer of patients contaminated with covid-19, all patients must wear waterproof gloves, disposable hat, and shoe covers with an operating mask. this surgical mask will help to contain infected droplet transmission. to reduce aerosol-generation, it is important to maintain the lowest possible oxygen flow to maintain oxygenation. transferjournal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.1. october 2020. page.23-33 31 responsible health care staff should use droplet and touch safety, and should limit patient interaction with the switch. the transporting nurse and doctor must carry all ppes. use of a stretcher as the medium of transport also entails all the precautionary measures for booth patient and the health-care personnel responsible for the transfer. after successful transfer completion, the stretcher must be immediately sanitized. prior to shifting to the operation theatre, all the infected covid-19 patients should be administered with necessary antiviral medicines. all intubated and on assisted ventilation must be transferred with hme viral filter via special bain circuit (connected to a drain). the filter location must be between the endotracheal tube connector and y-limb to avoid the movement of aerosol from the patient to the portable ventilator, and vice versa. hfnc or bi-pap therapy should be avoided because of the increased aerosol production. until transfer, the patient must be provided intravenous sedation and muscle relaxation to avoid any coughing and agitation that could lead to tube disconnection and droplet dispersion. during the inter-hospital settings, the transfer of covid-19 infected patient a dedicated transport vehicle. specifically qualified driver who is fitted with ppes must drive this transport vehicle. in the transport vehicle the patient's compartment is preferably kept separate from the driver. the protocol for covid-19 patient safety and health personnel safety remain same as intra-operative transfers. if covid-19 patient is stable after surgery and does not meet the criteria for admission to the icu, he or she should be transferred directly back to the negative-pressure ward or isolation ward after extubation in the operating room. during transfer, the circulating nurse and anaesthesiologist should wear proper personal protective equipment outside the operating room. the patient should be covered with one disposable operating sheet and then transferred to the negative-pressure or isolation ward through a dedicated lobby and elevator. during transfer, the patient must wear a surgical mask or n95 mask. surfaces of passageways and the elevator should be cleaned and covered. if the patient is kept intubated, a single-patient-use respiratory bag must be used during transfer. it is not recommended to use a ventilator during transfer (shen, 2020). future in peri operative management peri-operative care providers face major difficulties when caring for patients with the covid-19 in icu or peri-operative environments. as part of the effort to cope with the current pandemic, all hospitals will coordinate dedicated protocols and work force preparation. as many aspects of covid-19 are changing, our management plan is preliminary, and future changes will be needed. this article suggests the creation of clinical mechanisms for patients covid-19-positive who need urgent, non-deferrable surgical treatment. conclusion the covid-19 is a highly contagious disease which imposes an enormous burden on the health care system. it is also our responsibility to protect healthcare staff and other patients from contracting the disease in delivering adequate peri-operative treatment to patients. we discussed peri-operative problems in this post, and suggested strategies for overcoming possible obstacles. disease transmission can be reduced with proper preparation and implementation of steps to prevent infection. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 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7:216-4. cheung jc, ho lt, cheng jv, cham ey, lam kn. staff safety during emergency airway management for covid-19 in hong kong. the lancet. respiratory medicine. 2020 apr;8(4):e19. world health organization. water, sanitation, hygiene, and waste management for the covid-19 virus: interim guidance, 23 april 2020. world health organization; 2020 spinelli a, pellino g. covid-19 pandemic: perspectives on an unfolding crisis. br j surg. 2020 mar 19;10. tian h, liu y, li y, wu ch, chen b, kraemer mu, li b, cai j, xu b, yang q, wang b. an investigation of transmission control measures during the first 50 days of the covid-19 epidemic in china. science. 2020 mar 31. ti lk, ang ls, foong tw, ng bs. what we do when a covid-19 patient needs an operation: operating room preparation and guidance. canadian journal of anesthesia/journal canadien d'anesthésie. 2020 mar 6:1-3. cook tm, el‐boghdadly k, mcguire b, mcnarry af, patel a, higgs a. consensus guidelines for managing the airway in patients with covid‐19: guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists. anaesthesia. 2020 mar 27. lie sa, wong sw, wong lt, wong tg, chong sy. practical considerations for performing regional anesthesia: lessons learned from the covid-19 pandemic. canadian journal of anesthesia/journal canadien d'anesthésie. 2020 mar 24:1-8. maier gw, newton jr jr, wolfe ja, tyson jr gs, olsen co, glower dd, spratt ja, davis jw, feneley mp, rankin js. the influence of manual chest compression rate on hemodynamic support during cardiac arrest: high-impulse cardiopulmonary resuscitation. circulation. 1986 dec 1; 74(6 pt 2):iv51-9. brewster dj, chrimes nc, do tb, fraser k, groombridge cj, higgs a, humar mj, leeuwenburg tj, mcgloughlin s, newman fg, nickson cp. consensus statement: safe airway society principles of airway management and tracheal intubation specific to the covid-19 adult patient group. med j aust. 2020 mar 16;16. shen c, wang z, zhao f, yang y, li j, yuan j, wang f, li d, yang m, xing l, wei j. treatment of 5 critically ill patients with covid-19 with convalescent plasma. jama. 2020 mar 27. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.136-145 136 community-based health education improve knowledge and attitudes of covid-19 prevention emdat suprayitno*, syaifurrahman hidayat, dian permatasari, elyk dwi mumpuningtias, yulia wardita universitas wiraraja, indonesia corresponding author: emdat@wiraraja.ac.id abstract background: corona virus disease-19 is becoming a pandemic. the easy-to-spread nature of the virus which requires good knowledge and good attitude in determining preventive measures to break covid-19 transmission. purpose: this study aimed to determine the effect of community-based health education on knowledge and attitudes of covid-19 prevention. methods: this is quantitative research with design of quasi-experimental. the sampling technique used was simple random sampling, the samples were 62 people divided into two groups. the intervention group that received the intervention of community-based health education and control group that received a covid-19 leaflet. results: the research result found that mann whitney u test score of knowledge between intervention and control group after the given intervention was p=0.004. independent t test score of attitudes between intervention and control group after intervention was p=0.003. the mann whitney u test score of knowledge differences (δ) between intervention group and the control group after intervention was p=0.002. mann whitney u test of attitudes differences (δ) between intervention group and the control group after intervention was p=0.000. conclusion: the research showed that respondents in the intervention group have better knowledge and better attitudes. the community-based health education method can be an alternative option to promote and prevent the spread of covid-19 infection. keywords: health education, knowledge, attitudes, covid-19. received august 12, 2021; revised august 21, 2021; accepted september 17, 2021 doi: https://doi.org/10.30994/jnp.v5i1.164 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. http://thejnp.org/ mailto:emdat@wiraraja.ac.id https://doi.org/10.30994/jnp.v5i1.164 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.136-145 137 background covid-19 is currently a serious world problem whereas the number of cases is keeps on increasing each day. the virus is infecting everyone regardless the age or gender. covid19 first originated in the wuhan city in hubei province, china in december 2019. since then it has spread in over 210 countries and areas (sohrabi et al., 2020). this is a virus disease that caused by a virus of severe acute respiratory syndrome coronavirus (sarscov-2). since the first infection of coronavirus disease 2019 (covid-19) happened in the wuhan, china, the infection is spreading fast across the world and becoming pandemic and global crisis (cucinotta & vanelli, 2020). the cumulative number of covid-19 total cases across the world is increasing exponentially. on the 3rd april 2020, there were almost a million cases of confirmed covid-19 across the globe, including 80,000 in china. covid-19 which caused by sars-cov2 is a respiratory disease that highly contagious, especially transmitted from droplet and direct contact (surgery et al., 2020). the phenomenon in the ground that was observed by researchers was there were many people in the murtajih village, such as in the market and other public spaces who did not exercise prevention measure by wearing mask. additional finding was proper handwash using soap was rarely observed. the result of prior study by jaji (2020), shown that there is difference between the score of knowledge about covid-19 prevention after given intervention of health education (jaji, 2020). the purpose of this research is to provide innovation of community-based health education on the knowledge and attitudes of covid-19 prevention. a person that diagnosed positive covid-19 shown a symptom of flu with dry cough, throat ache, high fever, and other respiratory problem. around 2.2 million people had been infected and more than 0.15 million people were dead death globally. usa is a country that affected the most with the number of patient’s infected around 0.7 million. although the measure taken was high, there is no cure for this disease. however, prevention and management is the best option (ali & alharbi, 2020). in madura, the first positive case of covid-19 occurred in pamekasan regency on march 30, 2020 with an additional one patient under monitoring and 128 people under monitoring, while in other districts in madura, namely bangkalan there is one patient under monitoring, and 196 people under monitoring. sampang regency has 87 people under monitoring and sumenep regency has 65 people under monitoring (sakti, 2020). since pamekasan regency is declared as red zone, it has caused some people to become worried and anxious. based on interviews with 6 pamekasan residents in pademawu village, they said that they still did not understand the protocol of transmission prevention and how covid-19 is transmitted the causes of covid-19 transmission are many factors, but research says one of them is the lack of public knowledge about covid-19 and its prevention. covid-19 can infect and be contagious if a person touches a surface contaminated with sars-cov-2 and then comes into direct contact with mucous membranes such as the eyes, nose or mouth (lotfi et al., 2020). it has been reported that the virus capable of infect human in the range of six foot (1.8 metres). the virus able to survive for two hours until a couple of days in the droplet from cough or sneeze that land in the ground. the infection can happen by touching things or surfaces that have been infected by the virus, even though this is not the main path of infection (jaimes et al., 2020). the common symptoms of infection are restlessness, muscle pain, sneeze, throat ache, dry cough, high fever, respiratory disorders, etc. the severe cases developing pneumonia, severe respiratory syndrome, kidney failure, and even death (huang et al., 2020). the transmission of human to human contributed greatly to the infection pandemic. the covid-19 infection transmitted by droplet, cough, contaminated hands/ surface. however the transmission prevention of human to human can be reduced by http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.136-145 138 frequent handwash with soap and water or disinfecting the hands using alcohol based cleaners as recommended by who (pradhan et al., 2020) preventive action is the key to implementation in health and community services. measures for prevention in the community are maintaining hand hygiene, using hand sanitizers or washing hands with soap and running water, avoiding touching parts of the face (such as eyes, nose and mouth), applying coughing and sneezing ethics, wearing masks and keeping a distance at least 1 meter) from other people (jaji, 2020). theoretically, the component of public behavior in covid-19 prevention action consist of knowledge, attitudes, and action. to render a habit into a behavior, starting from knowledge and attitudes should be good towards something that will become a behavior change (notoatmodjo, 2010). knowledge one of which received from health workers and health cadre by using various method and media such as community-based health education (suprayitno, purnomo, et al., 2020). prevention and treatment are paramount to control covid-19. therefore, collective efforts of the community and government are urgently needed (suprayitno, rahmawati, et al., 2020). the recommendation to minimize infection is to avoid sneezing and coughing in public, handwash using soap, cover mouth and nose with a mask when sneezing and coughing (jin et al., 2020). it is also advisable to stay at home if anyone has flu symptoms. it is also best not to go to school, work and public places, not to use public transportation (plane, train, metro, bus, taxi, etc.) (ali & alharbi, 2020). in the current pandemic, people must follow health care instructions and avoid close contact with other people, especially individuals with compromised immune systems. also, frequent hand washing and following strict personal hygiene measures are necessary to control transmission of the virus. (alahdal et al., 2020). objective the research purpose is to determine the effect of community-based health education on knowledge and attitudes of covid-19 prevention. methods this research was a quantitative research with a quasi-experimental design. the population in this study was the people in the east solo hamlet and north solo, murtajih village, pademawu sub-district. the sampling technique used was simple random sampling, the samples were 62 people divided into 2 groups, namely the control group and intervention group. the intervention group was given community-based health education intervention. the first health education was carried out by researchers by visiting each respondent's house with the pademawu village nurses. the materials were the covid-19 definitions, covid-19 modes of transmission, the procedure of wearing masks and handwash with the correct soap using poster as the media. on the second day, the health education continued at the house of the chief of the east solo hamlet by exercised health protocol, namely measuring body temperature, washing hands with soap, wearing masks and doing physical distancing for each person by 1.5 meters away. health education was carried out by health cadres involving the chief of murtajih village and with researchers by delivering the same material as on the first day. meanwhile the control group was only given leaflets about the prevention of covid-19 to each respondent's house. the results of the study were analyzed using the wilcoxeon test, mann whitney u test and the independent t test. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.136-145 139 results general data table 1 the respondent’s distribution according to age age total percentage 26-35 years 3 4,8 36-45 years 38 61,3 46-55 years 4 6,5 56-65 years 13 21 >65 years 4 6,5 total 62 100 table 1 shown that the age of respondents were majority 36-45 years as much as 38 people (61,3%). table 2 the respondent’s distribution according to education education total percentage unfinish elementary 5 8,1 elementary 10 16,1 junior high 14 22,6 senior high 21 33,9 higher education 12 19,4 total 62 100 table 2 shown the education of respondents were majority senior high as much as 21 people (33,9%). table 3 the respondent’s distribution according to gender gender total percentage male 28 45,2 female 34 54,8 total 62 100 table 3 shown the gender of respondents were majority male as much as 34 people (54,8%). table 4 the respondent’s distribution according to occupation occupation total percentage civil servant 4 6,5 farmer 27 43,5 entrepreneur 7 11,3 private employer 24 38,7 total 62 100 table 4 shown the occupation of respondents were majority farmer as much as 27 people (43,5%). specific data 2.1. the comparison between mean score of public knowledge and attitudes to wearing mask and hand washing in the prevention of covid-19 in the control group variable score mean sd p value knowledge pre 9,06 1,03 0,046 post 9,19 1,01 http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.136-145 140 attitude pre 30,67 3,20 0,096 post 30,83 3,14 based on table 2.1, the mean of the knowledge score of the control group before health education was 9.06 ± 1.03 and the mean of the knowledge after health education was 9.19 ± 1.01. the wilcoxon test result of knowledge score was p = 0.046, means that there is no significant difference in the knowledge score in the community-based health education group. while the mean of the attitudes score of the control group before health education was 30.67 ± 3.20 and the average attitude score after health education was 30.83 ± 3.14. the paired t test result of attitudes score was p = 0.096, means that there is no significant difference in attitude scores in the control group before and after community-based health education. the comparison between mean score public knowledge and attitudes to wearing mask and hand washing in the prevention of covid-19 in the intervention and control group before community-based health education treatment. variable group mean sd p value knowledge intervention 9,32 1,13 0,343 control 9,06 1,03 attitude intervention 31,25 3,58 0,927 control 30,67 3,20 based on table 2.2, the mean of the knowledge score of the intervention group before community-based health education was 9.32 ± 1.13 and the control group was 9.06 ± 1.03. the results of the mann whitney test of knowledge score was p = 0.343, means that there is no significant difference in knowledge scores in the intervention group and the control group before community-based health education. meanwhile, the mean of the attitudes score of the intervention group before community-based health education was 31.25 ± 3.58 and the control group was 30.67 ± 3.20. the results of the independent t test of attitude score was p = 0.927, means that there is no significant difference in attitude’s scores in the intervention group and the control group before community-based health education. the comparison between mean score of public knowledge and attitudes to wearing mask and hand-washing in the prevention of covid-19 in the intervention and control groups after community-based health education. variable group mean sd p value knowledge intervention 9,93 0,85 0,004 control 9,19 1,01 attitude intervention 33,06 2,30 0,003 control 30,83 3,14 based on table 2.4, the mean of the knowledge score of the intervention group after community-based health education was 9,93 ± 0,85 and the control group was 9,19 ± 1,01. the results of the mann whitney test of knowledge score was p = 0.004, means that there is a significant difference in the knowledge score in the intervention group and the control group after community-based health education is carried out. meanwhile the mean of the attitudes score of the intervention group after community-based health education was 33.06 ± 2,30 and the control group was 30,83 ± 3,14. the independent t test result of attitude score was p = 0.003, means that there is a significant difference of attitudes score in the intervention group and the control group after community-based health education. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.136-145 141 the comparison between the difference (δ) of the mean of public knowledge and attitudes, before and after community-based education in the intervention group and the control group. variable group mean sd p value knowledge intervention 0,61 0,71 0,002 control 0,12 0,06 attitude intervention 1,80 2,31 0,000 control 0,16 0,52 based on table 2.5, the difference (δ) of the mean of knowledge in the treatment group before and after community-based health education was 0.61 ± 0.71 and the control group was 0.12 ± 0.06. the mann whitney test results of knowledge score was p = 0.002, means that there is a significant difference in the δ of the mean of knowledge scores in the intervention group and the control group after community-based health education. meanwhile the difference (δ) of the mean score of attitude score of the intervention group before and after community-based health education was 1.80 ± 2.31 and the control group was 0.16 ± 0.52. the mann whitney test result of attitude score was p = 0.000, means that there is a significant difference in the δ of the mean of attitude scores in the intervention group and the control group after community-based health education discussion the effect of community-based health education on covid-19 prevention knowledge based on the results of the study, there were differences in knowledge scores in the control group and the intervention group which indicated that community-based health education interventions were effective in increasing knowledge of covid-19 prevention. the results of this study are in line with research which states that community-based education provided by the community for the community itself can increase knowledge (zeinomar & moslehi, 2013). the research results of jaji (2020) shows that there are differences in the score of knowledge about the prevention of the covid-19 virus after the health education intervention (jaji, 2020). analytical surveillance results from the who report show that improving hand hygiene practices can reduce the transmission of pathogens in healthcare by 50% (surgery et al., 2020). several studies shown that the use of face masks by the general public has the potential to be of high value in limiting the transmission of covid-19 (eikenberry et al., 2020). increased knowledge can occur due to interactions with other people and the social environment, making it possible through these interactions to gain understanding. the level of knowledge is divided into two, namely good and bad (prihanta et al., 2016). good and bad knowledge gives meaning to an assessment of one's obedience behavior (priyanto, 2018). in the implementation of community-based health education interventions carried out by researchers accompanied by nurses, village chiefs and health cadres, this can affect the acceptance of respondents' knowledge. community as partner by anderson & mcfarlane (2000) is a development of betty newman model, focusing to community as partner and nursing process as an approach. this model emphasizing public active participation to improve and prevent health problem. naturally, individual will form group in the community which slowly affect the community health in general (munir 2015). employed group as a target is the best moves in providing health education to them who have similar background (huriah, 2007). the results showed that health education could increase one's knowledge. the success of health education can also be supported by the existence of tools or media to help facilitate the delivery of messages or material to be conveyed. one of the health education media used by researchers is the poster media. posters are visual media used to convey http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.136-145 142 messages or materials through pictures, colors and writing (ulya et al., 2018). this can increase the reader's interest in reading the information contained therein. some respondents said that they were interested in reading posters because they were accompanied by colors and images, so they were curious and read them repeatedly. in addition, its simple form and easy to paste anywhere makes it easier for readers to read the poster without having to search for it first (daryanto, 2015), (ulya et al., 2018). poster is a medium that presents information in visual form and stimulates the sense of sight. most of human knowledge is obtained through the sense of sight and information is more often remembered if they can read the information independently. the use of poster media aims to present information in an attractive form, easy to understand, and can be used as a reminder (notoatmodjo, 2010). the effect of community-based health education on attitudes of covid-19 prevention based on the results of the study, it was found that the difference in attitude scores in the control group and the intervention group showed that community-based health education treatment were effective in improving attitudes to prevent covid-19. the results of this study are in line with research conducted by syarif et al. (2015) that health education using audio visual media can increase knowledge and behavior of clean and healthy lifestyle patterns in preventing tb transmission (hartiningsih, 2018). based on the research results, health education can improve the attitude of the intervention group. attitudes clearly show reactions to the suitability of stimuli in everyday life, attitudes are the willingness to act and not the implementation of actions, the higher the knowledge, the better attitude will be formed (azwar, 2013). according to the knowledge-attitude-behavior model theory, knowledge is an essential factor that can influence behavior change, and individuals can acquire knowledge and skills through the learning process (liu et al, 2016). health promotion is basically a process of communication and a process of behavior change through health education. health promotion activities can achieve maximum results if the methods and media get great attention and must be adjusted according to the target. the use of a combination of various health promotion methods and media will greatly assist in the process of delivering health information to the public (suprayitno, purnomo, et al., 2020). according to bloom's theory, individual or group after being given health education can improve 3 domains, namely cognitive, affective, and psychomotor so that their knowledge and attitudes will increase. individual or group after being given health education will go through the process of remembering the material that has been studied, then the individual will understand (comprehension), namely the ability to explain and interpret correctly, then exercise the material that has been studied, and analyze the results of the actions (notoatmodjo, 2010). the results of the study are also supported by the education of the respondents, most of whom have high school education, diploma / bachelor degree, where generally someone with higher education will have broader knowledge. if someone with a higher education is given a stimulus on health education, he will react to the stimulus that has been given, so that the attitude is in line with one's health knowledge, according to daniel tolossa (2014), a person's low knowledge of tb can affect health knowledge and attitudes. knowledge and attitudes can be seen how the understanding of the disease about symptoms, causes, ways of prevention. patients with pulmonary tuberculosis who receive health education will automatically increase their knowledge, so there will be a change in attitude for the better and will be followed by a change in behavior to comply with the treatment program (azwar, 2013), (hayati & musa, 2016). according to bloom's theory, individual or group after being given health education can improve 3 domains, namely cognitive, affective, and psychomotor so that their http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.136-145 143 knowledge and attitudes will increase. individual or group after being given health education will go through the process of remembering the material that has been studied, then the individual will understand (comprehension), namely the ability to explain and interpret correctly, then exercise the material that has been studied, and analyze the results of the actions (notoatmodjo, 2010). attitude can be considered as a predisposition to respond and act. predisposing factors for the occurrence of behavior in a person are knowledge and attitudes towards action. changes in individual knowledge and attitudes begin with the obedience stage, identification will then become internalization. at first, individuals obediently perform the of health workers recommendations or instructions without objection because of sanctions. then if they gets reward they will obey the recommendations but still temporary, meaning that the action is carried out while there is still supervision. at this point, it is necessary to continue the monitoring so that behavior change is permanent. changes in individual behavior can be optimal if these changes occur through a process of internalization, where new behaviors are considered positive for individuals which are then integrated with the values of individual’s life (azwar, 2013). the results of the study are also supported by the education of the respondents, most of whom have high school education and diploma/ bachelor degree, where generally someone with higher education will have broader knowledge. if someone with a higher education is given a stimulus on health education, he will react to the stimulus that has been given, so that the attitude is in line with one's health knowledge, according to daniel tolossa (2014), a person's low knowledge of tb can affect health knowledge and attitudes. knowledge and attitudes can be seen how the understanding of the disease about symptoms, causes, ways of prevention. patients with pulmonary tuberculosis who receive health education will automatically increase their knowledge, so there will be a change in attitude for the better and will be followed by a change in behavior to comply with the treatment program (azwar, 2013; hayati & musa, 2016). the results of this study are in line with the research that health education using audiovisual media can increase knowledge and behavior of hygiene and healthy living habits in preventing tb transmission (hartiningsih, 2018). the results of this study are also supported by the level of education in the control group 1, most of them have a minimum of senior high education, where one of the factors affecting knowledge and attitudes is the level of education. a higher level of education will increase a person's ability to understand faster than those with less education. the higher the level of education, the easier it is for the person to receive information (hayati & musa, 2016). according to hesti's research (2016), the higher the level of education, insight and knowledge will also be broader, including the knowledge of sufferers and their families (hayati & musa, 2016) conclusion based on the results of the research and discussion previously described, community-based health education affects the knowledge and attitudes of the community in preventing covid-19 through the habit of hand-washing with soap and wearing a mask. it is hoped that the public will take steps to prevent the transmission of covid-19 by complying with health protocols, namely by wearing masks and hand-washing regularly with soap. acknowledgments the authors would like to thank the participants of this study conflicts of interest there is no conflict of interest http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 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(2013). the effectiveness of a community-based breast cancer education intervention in the new york state capital region. journal of cancer education, 28(3), 466–473. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.2. april 2021. page.154-166 154 perceptions towards diagnosis of prostate cancer in tharaka nithi county, kenya timothy kinoti kirungia1, consolata kirigia2*, lucy gitonga3, silas kiruki3 1department of nursing, kenya medical training college, chuka, kenya. 2school of nursing, university of embu, embu, kenya 3chuka university, chuka, kenya corresponding author: consolatakirigia@gmail.com abstract background: cancers are leading cause of death in developed nations and the second leading cause of death in developing nations. one of the most frequently diagnosed cancers among men is prostate cancer (pca). purpose: this research study aimed at exploring the patient’s and family’s perceptions towards diagnosis of prostate cancer in tharaka nithi county, kenya. methods: the study population comprised of families and pca patients attending chogoria mission hospital, magutuni sub-county hospital, chuka county hospital and tharaka subcounty hospital which were selected purposefully, from which a sample of 70 patients and 65 family members was obtained. purposive sampling method was used to sample patients and families. data were collected using interview schedules and focus group discussions and summarized using descriptive statistics. statistical analysis for association between variables was done using chi-square tests. results: the study revealed that; men in the age group 60-70 were most prone to the development of prostate cancer. a high percentage of patients and families perceived that prostate cancer was caused by genetic factors and should be treated by medical personnel. over 50% of the patients and families had no idea of the symptoms of prostate cancer neither had they heard of it before the patient was diagnosed. the study also revealed that 50% of the patients suffered hypertension, 80% did not believe the diagnosis at first and over 50% perceived the diagnosis as a death sentence. pca patients showed the highest level of acceptance and lung cancer patients the poorest acceptance of illness. over 90% of the patients and families observed general health improvement after medication. over 78% of the patients and family‟s had embraced insurance as a way of meeting the medical expenses. conclusion: this study demonstrated that patients and families perceived the diagnosis of prostate cancer as a death sentence. they also had low level of knowledge about pca. a strong correlation was demonstrated between family history and increased risk of pca. however, it was demonstrated that family history of pca did not increase levels of knowledge on the causes of pca. keywords: perceptions, diagnosis, prostate cancer, outcomes, patients, family’s. received january, 23, 2021; revised february 28, 2021; accepted march 2, 2021 doi: https://doi.org/10.30994/jnp.v4i2.126 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. http://thejnp.org/ mailto:consolatakirigia@gmail.com https://doi.org/10.30994/jnp.v4i2.126 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.2. april 2021. page.154-166 155 background prostate cancer is the leading cancer in both occurrence and the number of deaths in africa though african men suffer disproportionately from prostate cancer as compared to men from other parts of the world (rebbeck et al, 2011). cancers are the leading cause of deaths in developed countries and the second leading cause of death in developing countries with the leading cause of death being cardiovascular diseases (calys-tagoe et al, 2014). in 2012, 14.1 million new cancer cases were recorded globally with 8.2 million deaths and 32.6 million still living with the disease (calys-tagoe et al., 2014). the ministry of health estimates that by 2030, out of the cancer cases reported globally, 70% will come from developing countries. breast cancer that predominantly affects women and lung cancer that is mostly diagnosed in males are the two commonly cancers that are diagnosed and the two are leading in causation of global cancer-related deaths (calys-tagoe et al., 2014). however, according to etawo et al (2012), the second most frequently diagnosed cancer among men is prostate cancer (pca). cancer of the prostate is a disease pathway whereby prostate gland cells proliferate abnormally, ignoring growth-regulating signals in the environment surrounding the cells (wolf, 2013). the burden of pca is projected to grow to approximately 1.7 million new cases by 2030 simply due to the growth and aging of the world‟s population (jemal et al, 2012). according to roth et al (2008) pca is the most prevalent type of cancer among males in the united states with an estimated 218,000 new cases of prostate cancer being diagnosed and 27,000 patients succumbing from the ailment every year. moreover, approximately one in every five american men is affected by the disease (roth et al., 2008). statement of the problem the burden of prostate cancer has significantly increased in the last two decades. the financial, social and emotional devastation that often accompanies a diagnosis of prostate cancer is in large part due to the perceptions surrounding the disease and these perceptions need to be urgently addressed. many individuals associate the diagnosis of any cancer with death, and they perceive cancer as a punishment from god. this study aimed at exploring the patient’s and family’s perceptions towards diagnosis of prostate cancer in the county of tharaka nithi. objective the main objective of this study was to determine the patient’s and family’s perceptions towards diagnosis of prostate cancer in tharaka nithi county, kenya. h0: history of prostate cancer in the family and the knowledge level on prostate cancer causes are independent. methods study area this study was conducted in tharaka nithi county. the county has three major hospitals (chuka level four hospital, magutuni sub-county hospital and tharaka subcounty hospital) and one referral mission hospital (chogoria mission hospital) where patients diagnosed with prostate are followed. the four hospitals acted as strata. chogoria mission hospital is located in mwimbi sub-county, approximately one kilometer from the nairobi meru highway. it has a bed capacity of 250 patients and it has a fully functional palliative clinic. chuka level four hospitals is located in chuka town and it has a bed capacity of approximately 100 patients. the hospital is the largest county hospital in tharaka nithi county. magutuni sub-county hospital is located in mwimbi sub-county and it has a bed capacity of 83 patients. tharaka subcounty hospital is located in tharaka south sub-county and it has a bed capacity of 70 patients. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.2. april 2021. page.154-166 156 design the study design was descriptive cross-sectional, which enabled the researcher to determine the patients and family’s perceptions towards diagnosis of prostate cancer. the design was suitable because of the qualitative nature of this study. moreover, this research study was a social science type of research and thereby study questions needed descriptive answers in order to be answered. population the target population comprised of patient’s diagnosed of prostate cancer within tharaka nithi county. also, one family member of all the prostate cancer patients within tharaka nithi county. a review of the records in the four purposively selected hospitals showed the accessible population was as follows; table 1: number of patients attended to in one month. hospital no. of pca patients attended to in one month pcea chogoria mission hospital 51 magutuni sub-county hospital 32 chuka county referral hospital 37 tharaka sub-county hospital 30 total 150 source: hospital records (2018) one family members of each prostate cancer patient, who were purposefully selected, comprised of the family‟s population. sampling on the other hand, sampling refers to the process used by the researcher to identify and select a group of observations or individuals for the research study in a way that the selected individuals represent the population from which they were selected. the sample size was determined using fisher‟s formula (fisher et al., 1998) as follows 𝑛 = 𝑍2(1 − 𝑝) 𝑑2 where n = represents the desired sample size (if the target population is greater than 10,000) z = represents a corresponding confidence level value (i.e. 1.96 for 95% confidence) d = is the margin error (i.e. 0.05=5% p is the value estimated for the proportion of a sample that has the condition of interest (no reasonable estimate a default of 50% or 0.5 is used). 1.9620.5(1 − 0.5) 𝑛 = 0.052 n =384.16 n= 384 http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.2. april 2021. page.154-166 157 since the target population is less than 10,000, the sample size was adjusted using the yamane formula, (1967) with a sample of 150 as seen on the monthly number. where, nf = desired sample n = calculated sample n = estimate of population of study hence nf = 107.8651685 nf = 108 sampling procedure the researcher used purposive sampling method. the researcher went to the four purposively selected hospitals (chogoria mission hospital, chuka level four hospital, magutuni sub-county hospital and tharaka sub-county hospital) and identified patients diagnosed with prostate cancer and interviewed them. this method was applicable in this study because of the sensitivity of the information required, the qualitative nature of the information and the fact that respondents are men whose problem is a very sensitive organ. for the families, the patient purposefully referred the researcher to the appropriate family member who was also interviewed. however, during data collection there were five patients who came to the hospital alone and therefore the number of patients exceeded that of families by five. eligibility criteria eligibility criteria depends on the characteristics that are mandatory to the repondentd in order to be included in the study research. patients included to the sample were prostate cancer patients aged 18 years and above, and those who were willing to participate. those excluded were patients diagnosed of prostate cancer but not willing to participate in the study. families‟ included in the study were families with a prostate cancer patient and those who were willing to participate. data collection procedure this is the step by step process of acquiring data on the variables of study in a coordinated manner to enable answering of research questions by the researcher. data collection was performed by the researcher and one research assistant for a period of two months in the months of march and april, 2019. during this period, the researcher and the research assistant spent one month in each hospital where the required number of patients and families were interviewed. data collection instruments data collection was carried out by the researcher and an assistant using interview schedules and focus group discussions. the interview schedules comprised of four sections. section a gathered social demographic data, section b gathered data on knowledge, section c gathered data on the outcome of prostate cancer diagnosis and section d gathered data on health seeking behaviour. there was an interview schedule for the patients and another one for the families. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.2. april 2021. page.154-166 158 pre-testing pre-testing was done and enabled the researcher determine practicability and feasibility of the selected research design. pre-testing is the process of trying out techniques for research and practically of methods to establish their applicability and if necessary, make appropriate adjustments. pre-testing was done at embu teaching and referral hospital in embu county where 10 prostate cancer patients attending the palliative clinic and ten families were interviewed. this ensured reliability and sustainability of the interview schedule. findings from the pre-test helped inform the final interview schedule. data analysis and presentation in order to explain and describe the information in terms that were meaningful, it was subjected to treatment statistically. the quantitative infromation was entered into computer and analyzed for significance at p<0.05 using statistical package for social sciences (spss) (version 23.0). frequencies, percentages and mean were used. chi-square test was used for significant association between variables. pie charts and tables was used for data presentations. ethical considerations the researcher sought permission to carry out this research study from national commission for science, technology and innovation (nacosti) through the chuka university ethics and research committee for review and approval. approval was also sought from director clinical services from chogoria mission hospital and tharaka nithi county director of medical services for magutuni subcounty hospital, chuka county hospital and tharaka sub-county hospital. respondents were informed to fill an informed consent form as a proof of their acceptance and availability to participate in this research study. after the consent was obtained, the researcher informed the respondents that participation was voluntary, they were free to express their dissatisfaction anytime and they could withdraw from the research study when felt to do so. this was done to ensure that the information obtained was credible. confidentiality of the participants was assured by asking them to maintain their anonymity by telling them not to write their name on the interview schedules results patients’ social demographic information this research study showed that patient’s social-demographic characteristics have a role in patients and families perceptions towards diagnosis of prostate cancer. results from this study revealed that age group of 60-70 years is most prone to prostate cancer (30) followed by 70-80 at (23) and 50-60 at (7). the age group of 80-90 had (6), above 90 had (3) and 30-40 had (1). the results in this study showed that the highest number of prostate cancer patients were the married people at (82.29%) followed by widowed (7.14%), single (4.29%) separated (2.86%) and those who were divorced at (1.43%) as shown in table two. the results show that majority (35.17%) of the patients had attained secondary education followed by primary (31.43%), tertiary (20%) and those of have never schooled (12.86%). the results show that all the prostate cancer patients in this study were christians (100%). this is because tharaka nithi county is predominantly inhabited by christians who practice christianity. majority (41.23%) of the patients were being taken care by their wives followed by those cared by their daughters (27.14%), sons (25.71%) and lastly by brothers (5.71%). this is shown in table two. more patients were in informal employment (74.29%) as compared to those in formal employment (25.71%) as shown in table two. most of the patients had no history of http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.2. april 2021. page.154-166 159 prostate cancer in the family (74.29%) as compared to those who had history of prostate cancer in the family (25.71%). (table 2) table 2: patients‟ social demographic information variable value frequency percentage marital status divorced 1 1.43 married 59 84.29 separated 2 2.86 single 3 4.29 widowed 5 7.14 occupation formal 18 25.71 informal 52 74.29 education none 9 12.86 primary 22 31.43 secondary 25 35.71 tertiary 14 20 religion christian 70 100 history of prostate cancer in the no 52 74.29 family yes 18 25.71 person who takes care of the brother 4 5.71 respondent daughter 19 27.14 son 18 25.71 wife 29 41.43 body mass index (bmi) the results revealed that majority of the prostate cancer patients in this study had a body mass index of between (20 – 25) kg/m2 at (40) followed by a bmi of 25-30 at (13), 15-20 (10), 10-15 (6) and 35-40 (1) co-morbidity the results show that majority of the patients suffered from hypertension (50%) followed by none (28.57%), diabetes mellitus (8.57%), others (7.14%) and hiv/aids (5.71%) as shown in the table 3. table 3: co-morbidity variable value frequency percentage other illness of the respondent diabetes mellitus 6 8.57 hiv/aids 4 5.71 hypertension 35 50 none 20 28.57 others 5 7.14 total 70 100 variable analysis the results show that the patients had an average number of 5 children and average weight, height and bmi of 63.3kg, 169.11cm and 22.29 respectively as shown in table 4. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.2. april 2021. page.154-166 160 table 4: variable analysis for prostate cancer patients variable mean standard deviatio n median lower (95% ci) upper(95 % ci) age 69.76 9.47 69.5 67.54 71.98 children 5.17 2.04 5 4.69 5.65 duration 2.79 1.86 2 2.35 3.22 weight 63.3 12.81 61 60.3 66.3 height 169.11 11.63 168 166.38 171.83 bmi 22.29 3.99 22.48 21.36 23.23 patients’ knowledge in regard to prostate cancer this study sought to investigate the patients‟ knowledge level towards prostate cancer because knowledge influences the perceptions. causes of prostate cancer majority of the patients responded that prostate cancer is caused by genetics (60%) followed by witchcraft (21.43%), curse (8.57%), others (7.14%) and demons (2.18%) as shown in the figure 4. curse demons genetic others witchcraft figure 4: patients‟ knowledge on the causes of prostate cancer people who should treat patients most of the patients responded that prostate cancer patients should be treated by medical personnel (75.71%) followed by religious people (21.43%), herbal practitioners (1.43%) and witchdoctors (1.43%) as shown in the figure 5 70 60 50 40 30 20 10 http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.2. april 2021. page.154-166 161 herbal practitioners medical personnel religious people witch doctors figure 5: people who should treat patients knowledge on prostate cancer symptoms the patients were asked if they knew the symptoms of prostate cancer and majority of them didn’t (55.7%). those who knew the symptoms were the minority at (44.3%). moreover, when asked to mention the symptoms, majority indicated difficult in urinate association between education level and knowledge on prostate cancer for the family’s education level versus knowledge on prostate cancer, the hypothesis tested was; h0: families education level and knowledge on prostate cancer are independent. h1: there is an association between family’s education level and knowledge on prostate cancer. from the analysis x2(3) = 28.539, 𝑝 value ≤ 0.001, (table 5). since p value was less than level of significance, the null hypothesis (that education level of a family and knowledge on prostate cancer were independent) was rejected. the test showed that there was an association between families education level and the much they knew about prostate cancer. for the patient’s education level versus knowledge on prostate cancer, the hypothesis tested was; h0: patient’s education level and knowledge on prostate cancer are independent. h1: there is an association between patient’s education and knowledge on prostate cancer. from the results, x2(3) = 10.469, 𝑝 value ≤ 0.001 (table 6). since p value was less than the level of significance, the null hypothesis (that education level of a prostate cancer patient and knowledge on prostate cancer were independent) was rejected. the test showed that there is association between education level of a prostate cancer patient and knowledge on prostate cancer. table 5: chi-square test for family‟s education level and knowledge on prostate cancer value df asymp. sig. (2-sided) pearson chi-square 28.539a 3 .000 likelihood ratio 31.464 3 .000 linear-by-linear 25.121 1 .000 association n of valid cases 65 70 60 50 40 30 20 10 http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.2. april 2021. page.154-166 162 table 6: chi-square test for patient‟s education level and knowledge on prostate cancer value df asymp. sig. (2-sided) pearson chi-square 10.469a 3 .015 likelihood ratio 10.698 3 .013 linear-by-linear 7.560 1 .006 association n of valid cases 70 families perceived outcome following prostate cancer diagnosis of a relative the results show that majority of the families did not believe the diagnosis (90.77%) and the minority did believe the results (9.23%) as show in table 11. table 11: believing of diagnosis results variable value frequency percentage believing of the yes 59 90.77 diagnosis no 6 9.23 total 65 100 meaning of prostate cancer diagnosis majority of the families responded that positive diagnosis of their relative meant disease burden (84.62%) followed by normal life (13.85%) and loss of work (1.54%) as shown in table 12. table 12: meaning of prostate cancer diagnosis variable frequency percentage meaning of prostate cancer diagnosis of the relative disease burden 55 84.62 loss of work 1 1.54 normal life 9 13.85 total 65 100 likert scale on families perceived outcome of prostate cancer diagnosis families tended to agree that they had accepted their relative’s prostate cancer diagnosis, they also felt that prostate cancer patients can live normally after treatment (table 13). on a five-point likert scale the means were 4.12, 3.43 respectively and a median of 4. relatives seemed to disagree with the statement that prostate cancer patients were doomed to die and also that persons with prostate cancer could have intimate relationships. they were also not sure if they were embarrassed of their prostate cancer relative, prostate cancer affected intimacy between couples, it was shameful to have a prostate cancer relative, prostate cancer patient could work effectively and whether prostate cancer is a serious disease (table 13). table 13: family‟s opinion on prostate cancer diagnosis statement sa a ns d sd med ave stdev mode family had accepted that a 29 relative had pca 23 5 8 1 4 4.12 1.01 5 family was embarrassed of pca 9 relative 16 18 10 12 3 3 1.31 3 prostate cancer affected 14 9 10 22 9 3 2.95 1.4 2 http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.2. april 2021. page.154-166 163 intimacy between couples it was shameful to have a pca 7 relative 8 19 15 16 3 2.62 1.28 3 persons with prostate cancer 4 could have intimate relationships 12 16 21 12 2 2.62 1.17 2 patients with pca could be 19 treated and recover fully 21 13 7 5 4 3.65 1.23 4 prostate cancer patients could 12 work effectively 16 19 13 5 3 3.26 1.2 3 prostate cancer was a serious 12 disease 18 20 11 4 3 3.35 1.15 3 prostate cancer patients could 13 live normally after treatment 25 9 13 5 4 3.43 1.24 4 prostate cancer patients were 4 8 6 18 29 2 2.08 1.27 1 discussion married patients had significantly longer median survival than those who were divorced, single, separated or widowed (konrad et al., 1996). konrad et al., (1996) further found out that in models that controlled for age, stage, race and treatment, married patients had a significantly lower risk of mortality than those who were divorced, single, separated or widowed. occupation was found to have no association with the risk of having prostate cancer in a study which investigated if occupation such as farming exposed individual to herbicides and pesticides had an effect on the risk of having prostate cancer (checkoway et al., 1986). the study by bennett et al., (1998) recommended that low-literacy educational materials may improve patient awareness of prostate cancer and improve the frequency of diagnosis of early-stage cancer. in a study that investigated whether religion had an effect on the prostate cancer patients, the results revealed that relationship with god was a significant factor in the prediction of role, emotional and social functioning for these men after controlling for age, reported severity of treatment reactions and nonreligious resources (gall, 2004). results from this study also revealed that age group of 60-70 is most prone to prostate cancer as compared to age groups below 50 years and age groups above 90 years. these results concur with a research by vickers et al., (2014) which revealed the age of 60 years as the one mostly prone to positive diagnosis of prostate cancer. further research has shown that age is the greatest predisposing factor to the cancer of prostate (loeb et al., 2006). the risk increases notably after fifty years in white populations and those with familial predisposition. the results show that the average age of prostate cancer patients is 69.76 years with a 95% confidence interval; had an average number of 5 children and average weight, height and bmi of 63.3kg, 169.11cm and 22.29 respectively. the majority of the prostate cancer patients in this study had a body mass index of between (20 – 25) kg/m2. the bmi indices are classified as; healthy (18.5–24.9), overweight (25–29.9) and obese (≥ 30) (macinnis et al, 2006). these findings show that majority of the patients were healthy though there was a significant number of them who were overweight and a very small percentage that was obese. lepore et al., (2003) found out that education increased knowledge on prostate cancer. further, it was found that individuals who scan or seek cancer information are those who acquire knowledge, adopt healthy lifestyle behaviours, and get screened for cancer (shim et al., 2006). a study on knowledge, attitudes, and perception of prostate cancer among male outpatients of a tertiary care hospital in southeast nigeria found out that there was a strong evidence of association between education and perception of prostate cancer (aluh et al., 2018). education was found to have an impact http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.2. april 2021. page.154-166 164 on knowledge since respondents with a middle school or lower and high school were less knowledgeable compared to those with a college degree or higher (morlando et al., 2017). a study by ago et al (2001) in usa revealed that knowledge about prostate cancer was negatively correlated with age, education and income. the study further recommended a culturally sensitive promotional campaigns to increase awareness of the racial disparities in the incidence of prostate cancer and mortality rates. the statistics in this study portray a good health seeking behaviour following the diagnosis of prostate cancer. in a study by pradhan et al., (2018), most of the study subjects were diagnosed at stage ii and iii. diagnosis of cancer at advanced stages was attributed to the fact that there was inadequate awareness and inappropriate health seeking behaviour among general population. most prostate cancer patients were observed to seek sexual medications (hyde et al., 2016). this was attributed to masculine beliefs which are highly salient. men who were more emotionally selfreliant and attributed greater importance to sex formed stronger help-seeking intentions (hyde et al., 2016). a study on health seeking behaviour among cancer patients attending ocean road cancer institute in tanzania showed that 68.2% of the patients presented themselves when pca was already at late stages of development (kombe et al., 2007). men were observed to have a poor health seeking behaviour after diagnosis with prostate cancer according to hyde et al., (2017). this is because they felt that their masculinity had been eroded after being diagnosed with prostate cancer. for that reason, they were unwilling to go and seek health care provider’s help since there is the traditional perception that men are never weak. the findings from this study contradict with the findings in a study in the united kingdom which found that patient’s and family’s were dissatisfied with the current follow-up care regimes and information they were receiving (lamers et al., 2016) conclusion in conclusion, prostate cancer affects male population over certain age with higher prevalence. since prostate cancer is a treatable disease if diagnosed early, individuals, and community should increase their levels of awareness, and knowledge. patients and families perceived the diagnosis of prostate cancer as a death sentence. they also had low level of knowledge about pca. a strong correlation was demonstrated between family history and increased risk of pca. however, it was demonstrated that family history of pca did not increase levels of knowledge on the causes of pca. the results in this study showed that the highest number of prostate cancer patients were the married people; more patients were in informal employment as compared to formal employment; most of the patients had attained both primary and secondary education; majority of the prostate cancer patients in this study were christians and the percentage of the number of patients who had no prostate cancer history in their families was higher than the percentage of the of patients who had the disease history in the family. a high percentage of the families who were the caretakers of the prostate cancer patients were their wives which agrees with the statistics that a bigger percentage of the patients were married. the social-demographics of a patient and family play a vital role in determining when they seek care, if they can afford that care, what the possible outcomes are and whether they will seek care at all. conflicts of interest the authors declare no conflict of interest regarding publication of this paper. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 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(2012). international variation in prostate cancer incidenc and mortalit rates. european urology, 61, 1079–1092. https://doi.org/10.1016/j.eururo.2012.02.054 kombe, d., yuma, s., mtiro, h., & mlawa, g. (2007). health seeking behavior among cancer patients attending ocean road cancer institute, tanzania. east african journal of public health, 4(1), 19-22. https://pubmed.ncbi.nlm.nih.gov/17907756/ konrad, a., lai, h., burke, m. a., goodkin, k., & lai, s. (1996). marriage and mortality in prostate cancer. the journal of urology, 156(5), 1696-1700. https://doi.org/10.1016/s0022-5347(01)65485-5 lamers, r. e., cuypers, m., & husson, o. (2016). patients are dissatisfied with information provision: perceived information provision and quality of life in prostate cancer patients. psychooncology 2016;25: 633–40. https://doi.org/10.1002/pon.3981. http://thejnp.org/ https://doi.org/10.7324/japs.2018.81109 https://doi.org/10.1200/jco.1998.16.9.3101 https://doi.org/10.1186/1756-0500-7-577 https://doi.org/10.1002/pros.2990100111 https://www.ajol.info/index.php/nhj/article/view/81256 https://doi.org/10.1023/b:qure.0000040789.49691.59 https://doi.org/10.1016/j.esxm.2015.12.004 https://doi.org/10.1016/j.eururo.2012.02.054 https://pubmed.ncbi.nlm.nih.gov/17907756/ https://doi.org/10.1016/s0022-5347(01)65485-5 https://doi.org/10.1002/pon.3981 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.4 no.2. april 2021. page.154-166 166 lepore, s. j., helgeson, v. s., eton, d. t., & schulz, r. (2003). improving quality of life in men with prostate cancer: a randomized controlled trial of group education interventions. health psychology: official journal of the division of health psychology, american psychological association, 22(5), 443–452. https://doi.org/10.1037/0278-6133.22.5.443 loeb, s., roehl, k. a., antenor, j. a. v., catalona, w. j., suarez, b. k., & nadler, r. b. (2006). baseline prostate-specific antigen compared with median prostate-specific antigen for age group as predictor of prostate cancer risk in men younger than 60 years old. urology, 67(2), 316-320. https://doi.org/10.1016/j.urology.2005.08.040 macinnis, r. j., & english, d. r. (2006). body size and composition and prostate cancer risk: systematic review and meta-regression analysis. cancer causes & control, 17(8), 989-1003. https://doi.org/10.1007/s10552-006-0049-z. morlando, m., pelullo, c. p., & di giuseppe, g. (2017). prostate cancer screening: knowledge, attitudes and practices in a sample of men in italy. a survey. plos one, 12(10), e0186332. 7 https://doi.org/10.1371/journal.pone.0186332 pradhan, s. k., gupta, s. a., shrivastava, n., verma, n., dixit, s., & panda, p. s. (2018). health seeking behaviour and factors affecting it among oral cancer patients seeking radiotherapy at a regional cancer centre: a retrospective study. international journal of community medicine and public health, 5(4), 16471652. https://doi.org/10.18203/2394-6040.ijcmph20181250 rebbeck, t. r., zeigler-johnson, c. m., heyns, c. f., & gueye, s. m. (2011). prostate cancer screening, detection and treatment practices among subshara african urologists. africa journal of urologist, 17(3), 55-91. https://doi.org/10.1007/s12301-011-0016-0 roth, a. j., weinberger, m. i., & nelson, c. j. (2008). prostate cancer: psychosocial implications and management. future oncology, 4(4), 561–568. https://doi.org/10.2217/14796694.4.4.561 shim, m., kelly, b., & hornik, r. (2006). cancer information scanning and seeking behavior is associated with knowledge, lifestyle choices, and screening. journal of health communication, 11(s1), 157-172. https://doi.org/10.1080/10810730600637475 vickers, a. j., ulmert, d., sjoberg, d. d., bennette, c. j., björk, t., gerdtsson, a., & scardino, p. t. (2013). strategy for detection of prostate cancer based on relation between prostate specific antigen at ag e 40-55 and long term risk of metastasis: case-control study. bmj, 346, f2023. https://doi.org/10.1136/bmj.f2023. wolf, a. m. d. (2013). prostate cancer treatment choices. annals of internal medicine. https://doi.org/10.7326/0003-4819-159-6-201309170-00018 http://thejnp.org/ https://doi.org/10.1037/0278-6133.22.5.443 https://doi.org/10.1016/j.urology.2005.08.040 https://doi.org/10.1007/s10552-006-0049-z https://doi.org/10.1371/journal.pone.0186332 https://doi.org/10.18203/2394-6040.ijcmph20181250 https://doi.org/10.1007/s12301-011-0016-0 https://doi.org/10.2217/14796694.4.4.561 https://doi.org/10.1080/10810730600637475 https://doi.org/10.1136/bmj.f2023 https://doi.org/10.7326/0003-4819-159-6-201309170-00018 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.108-119 108 using blended and virtual schwartz center rounds® to support maternity staff in ireland during the covid-19 pandemic jean doherty*, clara k devine, sarah cullen national maternity hospital, holles street, dublin 2, republic of ireland corresponding author: jean.doherty@nmh.ie abstract background: many staff supports, such as the internationally accredited schwartz center rounds were suspended worldwide during the covid-19 restrictions, at a time when they were most needed. schwartz rounds are multi-disciplinary forums where staff can discuss the emotional, social and ethical challenges of care in a confidential and safe environment, intending to improve staff well-being and patient care. in a bid to improve staff support after the suspension of full schwartz rounds, virtual, then blended (limited spaces for socially distanced in-person attendance and virtual access) rounds were initiated. purpose: this study aimed to evaluate schwartz rounds in a maternity setting in ireland and compare full-in person rounds with virtual and blended rounds. methods: standard schwartz rounds evaluation forms were completed by rounds attendees. data were analysed using spss (version 24). respondents were invited to include a comment at the end of the form, and these free-text comments were analysed thematically. results: six rounds were evaluated (2 full in-person rounds attended before the pandemic, 1 virtual, 3 blended) and a total of 115 evaluation forms were completed. the rounds were rated extremely high. some, but not all aspects of the rounds were rated more positively from the full in-person rounds. some technical difficulties were a barrier to fully experiencing the round when attending remotely. conclusion: schwartz rounds are attended by staff in over 560 healthcare organisations, internationally and have been reported to improve staff well-being and teamwork. the pandemic saw schwartz rounds being suspended in most organisations due to social distancing guidelines. virtual and blended rounds are recommended as an effective replacement for full schwartz rounds while social distancing and infection control measures are in place. however, in order to improve post-panellist discussion and gain the full schwartz round experience, recommencement of full, in-person rounds are recommended as soon as public health measures allow. keywords: schwartz rounds, staff support, virtual support, maternity staff, virtual schwartz rounds. received august 12, 2021; revised august 21, 2021; accepted september 17, 2021 doi: https://doi.org/10.30994/jnp.v5i1.160 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. http://thejnp.org/ mailto:jean.doherty@nmh.ie https://doi.org/10.30994/jnp.v5i1.160 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.108-119 109 background schwartz rounds are multi-disciplinary forums where staff (clinical and non-clinical) can discuss the emotional, social and ethical challenges of care in a confidential and safe environment, to improve staff well-being and patient care (flanagan et al., 2020; chadwick et al., 2016). the rounds do not focus on the technical aspects of care or problem-solving. instead, the rounds provide colleagues with an opportunity to discuss and reflect on a particular incident and how this experience made them feel (taylor et al., 2018). the schwartz centre for compassionate care was developed in the usa in 1995, whereby the rounds, which follow a particular format, commenced. at present, the rounds are run in over 650 healthcare organisations internationally. the first schwartz round in ireland took place in 2015. schwartz rounds were recommended in an action research study conducted at the research site, to aid in the reduction of burnout among midwives (doherty and o’brien, 2021). subsequently, in 2019, the research site, a busy urban maternity hospital, initiated the schwartz rounds (cullen, 2021) and was the first maternity unit in ireland to run them. the overall aim of schwartz rounds is to provide support to the care providers so that they can, in turn, provide exemplary care, directly or indirectly, to women and families. in each round, approximately three staff members who volunteer to be panellists (storytellers) share an experience under a specific theme assigned to that specific round. examples of themes used in the past are: ‘thrown in at the deep end’; ‘covidtastrophy’ and ‘a day to remember’. this is followed by a facilitated open and confidential group discussion between the attendees and the panellists. here, the audience shares their emotional or social reactions to what they heard or even share a similar experience of their own. all employees in the hospital are invited to attend by way of email, word of mouth and posters distributed by the schwarts steering committee around the hospital. attendance is voluntary, as is engagement in the conversation that follows the panellists' stories. attendees are welcome to sit, listen and reflect internally. internationally, schwartz rounds have been reported to improve working relationships with people in health settings through shared experiences and reflection (gleeson et al., 2020). burnout, stress and intention to leave are incredibly high among healthcare workers (hunter et al., 2018; hayes et al., 2017). burnout is associated with exhaustion and reduced efficacy, motivation and empathy (doherty and o’brien, 2021; schaufeli et al., 2009; maslach and leiter, 2008), ultimately reducing quality patient care. empathy, teamwork, and compassion within healthcare teams are essential in reducing burnout and compassion fatigue (doherty and o’brien, 2021; lamothe et al., 2014) and improving clinician-rated patient safety (welp et al., 2016). an evaluation of the schwartz rounds in the uk reported an increase in round attendees' psychological well-being compared to non-attendees (maben et al., 2018). the same study reported increased compassion and empathy for colleagues and patients. an irish evaluation of the rounds in a paediatric setting recommended this intervention to give staff space to feel listened to, thus improving working conditions (silke et al., 2019). furthermore, respondents from the irish schwartz rounds pilot evaluation found that attendees gained a greater insight into themselves and their colleagues, breaking down barriers and a levelling of hierarchical structure, improving teamwork and staff interactions (adamson et al., 2018). unfortunately, the restrictions brought on by the covid-19 pandemic caused the suspension of the rounds in the research site for several months. in a bid to provide staff support at this most crucial time, the rounds were restarted, initially in virtual form. blended rounds were subsequently offered, with socially distanced seating for in-person rounds and remote access also available. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.108-119 110 objective to evaluate the views of staff on their experiences of attending schwartz rounds in a maternity setting in ireland. the secondary aim was to compare standard in-person rounds (which included lunch beforehand) with virtual and blended rounds. methods ethical approval was granted by the research sites research ethics committee for this evaluation. standard schwartz rounds evaluation forms, developed by the point of care foundation, were completed by rounds attendees, and these were used in the data collection process. completion of feedback forms was voluntary and anonymous. forms included nine questions on a five-point likert scale, ranging from ‘strongly disagree’ to ‘completely agree’. data were also collected about the respondent's profession within the organisation, how many rounds they had previously attended and how they were informed about the rounds. data were analysed using spss (version 24). respondents were invited to include a comment at the end of the form, and these free-text comments were analysed thematically. results data were collected from feedback forms between december 2019 and may 2021. typically, a round would take place approximately every six weeks. however, due to the covid-19 pandemic, rounds were paused on two occasions – march november 2020 and december 2020 february 2021. initially, two standard in-person rounds were analysed that were held in a lecture theatre at the research site, with lunch provided beforehand. the third round evaluated was a virtual round. the last three rounds evaluated were blended, using a virtual platform and having limited spaces available in a large lecture theatre for people without computer access. panellists and facilitators were all present in the lecture theatre. in total, the six rounds were attended by 237 people, and 115 feedback forms were completed by attendees of the rounds a 55% response rate. table 1, below, presents the distribution of professions attending schwartz rounds. a wide range of departments/professions were included in this evaluation. the largest percentage of attendees were of midwifery management, including clinical midwife managers (cmm1-3) and the assistant directors and director of midwifery and nursing. table 2 and 3 present the evaluation questions and responses. overall, the feedback was highly positive. the questions that received the most positive responses connected with planning to attend a round again and recommend the rounds to colleagues, with 99.1% and 100% agreeing ‘somewhat’ or ‘completely’ to these comments, respectively. the question that received the lowest positive feedback connected with how the respondent feels about their work as a result of attending a round. a total of 8.7% ‘neither agreed nor disagreed’ with this comment. the other 92.3%, however, ‘agreed somewhat’ or ‘completely’. the schwartz rounds were rated ‘excellent’ or ‘exceptional’ by 94.2% of all respondents. an independent samples t-test was conducted to compare attendee’s experience of standard in-person rounds (n=55) with virtual or blended rounds (n=60). the breakdown of responses is also presented in tables 2 and 3 (statistical significance is presented underneath each result). generally, respondents rated the in-person round more favourably than the blended and virtual form. respondents in both groups would recommend the round to colleagues and reattend themselves. however, there was a statistically significant difference in responses for the comment stating that the group discussion was helpful, with 90.9% of people attending an in-person round ‘completely agreeing’ with this statement, compared to 68.3% of the respondents from a virtual/blended round. additionally, 68.3% of blended/virtual round attendees ‘completely agreed’ with the statement that the round http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.108-119 111 would help them work better with their colleagues, compared to 85.5% of the in-person attendees. the comment related to whether the respondent feels differently about their work as a result of attending a round also differed significantly, with 50% of the blended/virtual round respondents ‘completely agreeing’, compared to 76.4% of the in-person round attendees. the overall rating of the schwartz rounds was also statistically higher for inperson attendees. respondents were also invited to write comments related to their experience of attending the round and a half (50.4%) included a free-text comment. examples of these comments are presented in figure 1, under four themes: stories, sharing, gratitude and schwartz during covid-19. as with the multiple-choice questions, the comments were highly favourable and complimentary. several respondents described their emotional reaction to attending the schwartz round. they highlighted how the shared experiences of colleagues will help them to consider people's emotions in the future. the honesty of the discussions was perceived positively, and there was significant respect and gratitude to the panellists for sharing their emotions and experiences with their colleagues. some respondents commented on the difference between an in-person round and attending the round online. there were technical issues at the first virtual round, with inadequate speakers on computers in the hospital, and some had difficulty hearing the panellists. furthermore, having a round online was perceived to reduce the natural flow of the discussion compared to an in-person round. the panellists were provided separate surveys asking them for their feedback on the experience of sharing an emotional story with their colleagues. ten questions were asked on a 5-point likert scale ranging from 'strongly disagree' to 'strongly agree'. in total, 17 panellists told stories over the six rounds, and 12 feedback forms were completed and analysed. please see table 4 below for the results of the panellist feedback. almost all (91.7%) of the respondents would recommend being a panellist with 100% enjoying this role. firm agreements were made to the statements connected with the support they received from the facilitators and the help in preparation. one question received mixed responses. panellists were asked if they have noticed a positive change in their work since being a panellist. only 55.5% agreed or strongly agreed with this statement, and three panellists did not answer this question. two panellists commented that it was too soon to answer this question as the survey was completed immediately after the round. table 1: distribution of professions attending schwartz rounds obstetrics 9 (7.9%) midwifery management 18 (15.7%) midwifery/nursing 17 (14.8%) neonatology 2 (1.7%) professional development 10 (8.7%) physiotherapy 11 (9.6%) social work 2 (1.7%) perinatal mental health 3 (2.6%) administration 11 (9.6%) psychology 2 (1.7%) advanced practice/clinical specialist 8 (7.0%) radiology 1 (0.9%) pharmacy 2 (1.7%) medical science 4 (3.5%) other 8 (7.0%) http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.108-119 112 table 2: responses for each of the ten statements in the questionnaire and overall rating black = overall results (n=115) green = full in-person rounds (n=55) blue = virtual/blended rounds (n=60) black italic: statistical significance between groups, using independent samples t-test (p = <.05, two tailed) strongly disagree disagree somewhat neither agree nor disagree agree some what complet ely agree n (%) the stories presented by the panel were relevant to my daily work p= .328 (no statistically significant difference) 0 0 0 21 (18.3) 94 (81.7) 0 0 0 8 (14.5) 47 (85.5) 0 0 0 13 (21.7) 47 (78.3) i gained insights that will help me to meet the needs of patients p= .005 (statistically significant difference) 0 1 (0.9) 5 (4.3) 27 (23.5) 82 (71.3) 0 0 1 (1.8) 8 (14.5) 46 (83.6) 0 1 (1.7) 4 (6.7) 19 (31.7) 36 (60.0) today's round will help me work better with my colleagues p= .148 (no statistically significant difference) 0 1 (0.9) 3 (2.6) 23 (20) 88 (76.5) 0 1 (1.8) 1 (1.8) 6 (10.9) 47 (85.5) 0 0 2 (3.3) 17 (28.3) 14 (68.3) the group discussion was helpful to me p= .002 (statistically significant difference) 0 0 1 (0.9) 23 (20) 91 (79.1) 0 0 0 5 (9.1) 50 (90.9) 0 0 1 (1.7) 18 (30) 41 (68.3) i have a better understanding of how my colleagues feel about their work (n=114) (n=54) p= .03 (statistically significant difference) 0 0 1 (0.9) 21 (18.4) 92 (80.7) 0 0 0 6 (11.1) 48 (88.9) 0 0 1 (1.7) 15 (25) 44 (73.3) i have a better understanding of how i feel about my work p= .003 (statistically significant difference) 0 0 10 (8.7) 33 (28.7) 72 (62.6) 0 0 2 (3.6) 11 (20) 42 (76.4) 0 0 8 (13.3) 22 (36.7) 30 (50) i plan to attend schwartz rounds again p= .22 (no statistically significant difference) 0 0 1 (0.9) 3 (2.6) 111 (96.5) 0 0 1 (1.8) 2 (3.6) 52 (92.5) 0 0 0 4 (6.7) 56 (93.3) http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.108-119 113 i would recommend schwarts rounds to colleagues p= .47 (no statistically significant difference) 0 0 0 6 (5.2) 109 (94.8) 0 0 0 2 (3.6) 53 (96.4) 0 0 0 4 (6.7) 56 (93.3) table 3: overall rating of the schwartz round attended black = overall results (n=102) green = full in-person rounds (n=55) blue = virtual/blended rounds (n=60) black italic: statistical significance between groups, using independent samples t-test (p = <.05, two tailed) poor fair good excellent exceptional please rate today's round (n=46) (n=56) p= .009 (statistically significant difference) 0 1 (1.0) 5 (4.9) 43 (42.2) 53 (52) 0 1 (2.2) 0 14 (30.4) 31 (67.4) 0 0 5 (8.9) 29 (51.8) 22 (39.3) sharing “fantastic speakers – people’s hearts are so durable; nice to know we can all share experiences, to remember kindness always in our world” “gained some great insight into the experiences of my colleagues” “it is an act of generosity for our colleagues to share their experiences to the benefit of all of us” “thank you, it was very moving” “very powerful… shocked at my reaction at the end very tearful” “so brave of the speakers. a good opportunity to reflect on our work” sharing experiences shared emotions stories “excellent stories, made me stop and think” “1st time to sit and listen to experiences of colleagues, thought provoking; good to share experiences” “powerful stories. how do we mind ourselves and others more?” “the three presenters were very brave and honest. i admire them greatly for sharing their feelings with all of us. it will make all of us more conscious of other’s feelings” “honest, frank and heartfelt discussions” “thank you to the participants for their honesty, vulnerability and humanity” thought provoking honest http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.108-119 114 figure 1: free-text comment themes and associated comments table 4: schwartz panellist questions and responses (n=12) strongly disagree disagree neither agree nor disagree agree strongly agree n (%) i knew what to expect at the round 0 0 1 (8.3) 3 (25) 8 (66.7) i felt supported throughout the preparation process 0 0 0 1 (8.3%) 11 (91.7) i felt fully prepared to share my story at the round 0 0 0 1 (8.3%) 11 (91.7) i enjoyed being a schwartz panellist (n=11) 0 0 0 5 (45.5) 6 (54.5) i feel more connected to my colleagues by being a panellist 0 0 1 (8.3) 4 (33.3) 7 (58.3) it has given me time to reflect on my work role 0 0 1 (8.3) 4 (33.3) 7 (58.3) “very valuable support for all of us i really value this initiative” “super job again today. fantastic + important resource for staff” “excellent forum to discuss emotional events that impact our lives” “amazing speakers! so honoured” “thank you to the three speakers for their honesty, openness, bravery and vulnerability” “so brave of the speakers. a good opportunity to reflect on our work” gratitude schwartz initiative panellists schwartz during covid-19 “i thought both speakers did very well, but i can't help but think that they must have felt vulnerable not being able to see their audience” “well done, difficult in viral space” “it’s challenging (but worthwhile on-line) i think being in a real room together brings people together and that may impact on discussion after panellist speak” “video presence on screen more beneficial for all. my work computer didn't accommodate that but will rectify for future” “hard to hear at times, lots of background noise, microphone too far away from speakers” “excellent. sound quality remotely, though, a bit of an issue for me” virtual versus in-person technical issues http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.108-119 115 i have noticed a positive change in my work since being a panellist (n=9) 0 1 (8.3) 3 (33.3) 2 (22.2) 3 (33.3) i feel i have gained professionally from being a panellist (n=11) 0 0 3 (27.3) 5 (45.5) 3 (27.3) i feel i have gained personally from being part of the panel 0 0 1 (8.3) 4 (33.3) 7 (58.3) i would recommend being a schwartz panellist to colleagues 0 0 1 (8.3) 3 (25) 8 (66.7) discussion overall, the experience of staff attending schwartz rounds from a diverse range of disciplines was extremely positive in this study. the rounds were rated excellent or exceptional by over 94% of respondents, and all respondents would recommend the rounds to colleagues. these findings provide valuable evidence for the promotion and recommendation of schwartz rounds within the maternity setting in ireland. schwartz rounds were deemed by senior management an ideal intervention to assist in the reduction of work-related stress and burnout and promote the fostering of transparent, positive and open work cultures. supportive social-emotional cultures at all levels should be promoted and managed within all clinical work environments. studies evaluating schwartz rounds have provided empirical evidence for helping healthcare workers from a variety of healthcare settings to feel less isolated and provide more significant insights into psychological aspects of teamwork and care (chadwick et al., 2016; mboua et al., 2021). participants in a canadian qualitative study reported a renewed passion for their work, reduced stress, and a greater sense of community (adamson et al., 2018). the more rounds the participants attended, the more profound the change reported (adamson et al., 2018). respondents in the current study highlighted their increased compassion and openness to vulnerability due to the experiences shared during rounds. this sharing of emotions and experiences will allow for a more positive and supportive work culture. furthermore, being open to a person's own, and others, vulnerabilities allows for better recognition and management of stress (chadwick et al., 2016). due to limited numbers in this study, it was impossible to undertake a comparative analysis of overall ratings or experiences between different staff groups. however, the above qualitative study compared the experience of clinical and non-clinical staff (adamson et al., 2018). their study highlighted the benefits of schwartz rounds for non-clinical staff. the rounds helped non-clinical staff see that even though their contact with patients was minimal or non-existent, they are part of a hospital-wide bubble – a chain or cluster of activities that contribute to overall patient care. schwartz rounds using a virtual platform: the term ‘unprecedented times’ has been used continuously since the onset of the covid-19 pandemic. indeed, never in our history has there been such a rapid and severe change, or challenge, to health services worldwide. the immediate priority was the safety of patients, with numerous policy changes, operational and logistical challenges, supply and informational barriers and staff illness and stress (mboua et al., 2021; jakimowicz and maben, 2020). for the safety of the staff at the research site, the schwartz rounds were suspended as, at the time, social distancing was not possible, and the transmission of covidhttp://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.108-119 116 19 was unknown. the swift technical innovations brought on by the pandemic’s restrictions allowed for virtual group meetings, medical consultations and conferences. the schwartz team, eager to continue to provide staff support during this challenging time, introduced the first virtual round, then proceeded to commence blended rounds in order to cater for as many staff members as possible. although the first few in-person schwartz rounds were attended by many staff members, in-person attendance at the blended rounds was minimal. this could be due to staff members perception of safety in a group setting, or perhaps staff have become more accustomed to the virtual platform for meetings. this could also be because virtual rounds are more easily accessible. additionally, people not on shift are more likely to attend virtual rounds, whereas in-person rounds may only be attended by staff in the hospital on the day they are run. the results of the multiple-choice questions and the free-text comments provided were interesting with regard to the positive impact of in-person schwartz rounds compared to virtual ones. technical issues are a common feature of the virtual world. indeed, attendees commented on the technical issues they encountered, particularly in the first virtual round, but also, somewhat less, in the rounds that followed. further, the post-panel discussion, a key and essential element of schwartz rounds, had a significantly higher impact during the in-person rounds compared to the virtual rounds. this is not a surprising finding. previous research has highlighted the limitations of virtual platforms in recognising non-verbal cues, feelings and body language (schulze and krumm, 2017; munro and swartzman, 2013). a review of the literature on virtual team meetings identified many challenges, such as limitations in relationship building, trust, cohesion and overall team performance (schulze and krumm, 2017). furthermore, technology can cause communication breakdowns, with issues such as time lags, lack of familiarity with media platforms, the use of written chat elements of platforms, rather than speaking, and audio problems (schulze and krumm, 2017). for these reasons, munro and swartzman (munro and swartzman, 2013) advise against substituting conventional team meetings with virtual meetings, if possible. notwithstanding, the virtual/blended schwartz rounds still received extremely positive feedback. while awaiting the freedom to be able to hold full, in-person rounds in the clinical setting, the findings of this study support blended rounds as an alternative to in-person rounds, in order to cater for as many staff members as possible while following public health guidelines. the findings from this study, however, highlight the importance of utilising the lecture theatre to its current capacity as much as possible. in this fragmented time where people have limited opportunities to get together with colleagues face to face, enhancing the in-person element of the schwartz round would enhance discussion and improve attendees experience and outcome of attending a schwartz round. limitations: schwartz rounds and this evaluation study are not without their challenges. the rounds themselves require logistical and financial commitments. furthermore, panellist preparation and debriefing sessions require time from both the panellist and the facilitators. initially, a lack of understanding among staff as to the function of the round was a barrier. however, as more people attend rounds, their understanding increased, improving attendance, impact and interest. facilitator expertise is essential when it comes to sticking with the aims and function of the round and sensitively steering the conversation away from people's instinct to problem-solve (taylor et al., 2018). other challenges to the rounds include the availability of staff members to attend the rounds in a busy maternity environment. additionally, the interest of staff members to volunteer to be on the panel is an ongoing challenge. it is important to note that the schwartz rounds may not be for everyone some http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.108-119 117 people may find that discussing emotional topics in a group setting intimidating, some people feel that they could best spend their time on other tasks, and some are simply not interested. there is no ‘one size fits all’ intervention for the enhancement of staff well-being (taylor et al., 2018). a range of approaches, interventions and policies are necessary, and these all need to be evaluated and revised as necessary. however, organisation-wide interventions, such as the schwartz rounds, are key to tackling cultural/environmental factors which may impact staff well-being (taylor et al., 2018). this will help to improve cultural norms around the need for staff support and the importance of empathy and compassion for colleagues (taylor et al., 2018). the limitations of the evaluation study emanate from the small numbers for analysis and that the evaluation took place in one maternity unit in ireland. the evaluations are completed immediately after the round. this is done to enhance response rates and reduce recall bias. therefore, the long-term impact of attending, and indeed being a panellist, could not be deduced. furthermore, this type of evaluation does not include a control group for comparison. in order to capture the long-term outcome of attending schwartz rounds, one would require a robust evaluation, such as a realist evaluation, to determine the impact of the rounds, as opposed to other causes within the organisation. however, based on this evaluation, this staff intervention appears to be an acceptable approach in a maternity setting in ireland. schwartz rounds have proven an effective method to help improve working conditions for staff (silke et al., 2019; reeves et al., 2017). conclusion the schwartz rounds at a busy maternity hospital in ireland were evaluated, and conventional in-person rounds were compared with virtual/blended rounds, which included a virtual platform as well as the opportunity to attend in person. the schwartz rounds were evaluated extremely positively by staff members from several staff groups within the hospital. the sharing of experiences and emotions had a positive impact on staff members who attended the rounds through listening to panelist’s stories and during the discussion that followed. the in-person rounds received a more favourable response than the virtual and blended rounds. however, the blended rounds are a positive alternative to full, in-person rounds until such a time as social distancing can be reduced. declarations: acknowledgements we acknowledge and thank the point of care foundation and the quality improvement division of the hse (health services executive) for their support and training of our schwartz team and promotion of schwartz rounds, nation-wide. we thank the schwartz round attendees who took the time to participate and the panellists of each schwartz round for their honesty and vulnerability, without whom the rounds would not be possible. funding this study was funded by hse nursing and midwifery planning and development unit, south dublin, kildare & wicklow conflicts of interest/competing interests none declared http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.108-119 118 references adamson, k., sengsavang, s., myers-halbig, s. and searl, n. (2018) developing a compassionate culture within pediatric rehabilitation: does the schwartz roundstm support both clinical and nonclinical hospital workers in managing their work experiences? qualitative health research, 28(9) 1406–1420. chadwick, r.j., muncer, s.j., hannon, b.c., goodrich, j. and cornwell, j. (2016) support for compassionate care: quantitative and qualitative evaluation of schwartz center rounds in an acute general hospital. jrsm open, 7(7) 205427041664804. cullen, s. (2021) implementing schwartz rounds in an irish maternity hospital. irish journal of medical science (1971 -), 190(1) 205–208. doherty, j. and o’brien, d. (2021) a participatory action research study exploring midwives’ understandings of the concept of burnout in ireland. women and birth, s1871519221001037. flanagan, e., chadwick, r., goodrich, j., ford, c. and wickens, r. (2020) reflection for all healthcare staff: a national evaluation of schwartz rounds. journal of interprofessional care, 34(1) 140–142. gleeson, d., arwyn-jones, j., awan, m., white, i. and halse, o. (2020) medical student schwartz rounds: a powerful medium for medical student reflective practice. advances in medical education and practice, volume 11 775–780. hayes, b., walsh, g. and prihodova, l. (2017) national study of wellbeing of hospital doctors in ireland. 1. dublin: royal college of physicians in ireland. hunter, b., henley, j., fenwick, j., sidebotham, mary and pallant, j. (2018) work, health and emotional lives of midwives in the united kingdom: the uk whelm study. jakimowicz, s. and maben, j. (2020) ‘i can’t stop thinking about it’: schwartz rounds ® an intervention to support students and higher education staff with emotional, social and ethical experiences at work. journal of clinical nursing, 29(23–24) 4421–4424. lamothe, m., boujut, e., zenasni, f. and sultan, s. 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(2019) caring for caregivers: an evaluation of schwartz rounds in a paediatric setting. irish medical journal, 112(6) 951. taylor, c., xyrichis, a., leamy, m.c., reynolds, e. and maben, j. (2018) can schwartz center rounds support healthcare staff with emotional challenges at work, and how do they compare with other interventions aimed at providing similar support? a systematic review and scoping reviews. bmj open, 8(10) e024254. welp, a., meier, l.l. and manser, t. (2016) the interplay between teamwork, clinicians’ emotional exhaustion, and clinician-rated patient safety: a longitudinal study. critical care, 20(1) 110. http://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.210-223 210 detection of asymptomatic cases of covid-19 pregnant women: a systematic review prima soultoni akbar1*, santy irene putri2, astri yunita3 1program studi perekam medis dan informasi kesehatan, politeknik kesehatan kemenkes malang, malang, indonesia 2program studi kebidanan, universitas tribhuwana tunggadewi, malang, indonesia 3program studi kebidanan, stikes bhakti mulia pare, kediri, indonesia *corresponding author: primasoultoniakbar@gmail.com abstract background: there have been many cases of the covid-19 coronavirus detected in pregnant women. data posted by the centers for disease control and prevention (cdc) shows that around 55% of pregnant women who are confirmed covid-19 and hospitalized are asymptomatic. purpose: the purpose of this study is to systematically review the detection of asymptomatic covid-19 cases in pregnant women. the articles were selected from worldcat, proquest, ebsco, and pubmed database journals published from january to april 2020. "covid-19" or "coronavirus" or “coronaviruses” or "2019-ncov" or "sars-cov" or "mers-cov" and “asymptomatic” and “pregnant women” were the keywords included for this review. articles in english or indonesian language that were published or in press articles about covid-19, focusing on the detection of asymptomatic covid-19 cases of pregnant women, and the type of study is cohort were inclusion criteria. methods: the articles using language rather than english or indonesian were excluded. articles for which no abstract and no provided any significant information were in the exclusion criteria. results: a total of 628 articles achieve from the databases, the authors identified that 12 articles were analyzed. conclusion: based on the results of a review of several articles it can be concluded that pregnant women who do not have symptoms of covid-19 show a large enough percentage and have a greater risk of receiving intensive care compared to women who are not pregnant. keywords: asymptomatic, corona, covid-19, pregnant women received march 10, 2022; revised april 1, 2022; accepted april 29, 2022 doi: https://doi.org/10.30994/jnp.v5i2.201 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:primasoultoniakbar@gmail.com https://doi.org/10.30994/jnp.v5i2.201 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.210-223 211 background pregnant women are considered vulnerable because of the adaptive physiological changes during the covid-19 pandemic, so they may be more inclined to covid-19 than the general population. due to the rapid development of the covid-19 pandemic, the care of pregnant women and the safety of the fetus are of utmost concern. however, there is little evidence on the evaluation and treatment of pregnant women infected with covid-19, and the possible dangers of spreading the infection from mother to fetus are still puzzling (yu et al., 2020). obstetric patients have multiple links to health care agencies and the majority are admitted to health care services during childbirth, so they have unique challenges during the covid-19 pandemic (city et al., 2020). now is currently known about the proper management of pregnant women during the covid-19 pandemic. primarily based on an extensive literature review, the worldwide society of infectious illnesses in obstetrics and gynecology (isidog) presented advice to provide steering for health care professionals who treat pregnant sufferers and which turned into applied in writing in countrywide health policies. although pregnant women do not have conceded immunity, the immunological adjustments of pregnancy can lead to a kingdom of extended susceptibility to positive intracellular pathogens, specifically viruses, microorganisms, and intracellular parasites (jamieson et al., 2006). measles, number one varicella, influenza, variola (smallpox), lassa fever, ebola, and sars are examples of viral infections, in which pregnant women are greater liable to infection and expand an extra intense disease trouble and better mortality fee (journal et al., 2003; lam et al., 2004). as for covid-19, the reproduction rate, or in other words the average number of people transmitted by people infected with the virus during the peak of the epidemic was between two and three times (range 2.5 to 2.9), somewhat higher than for influenza (peng et al., 2020). it has lengthy been recognized that pregnant women are not always more liable to viral illnesses, however, changes in their immune devices during pregnancy can be related to more intense signs. sars-cov and mers-cov are recognized to reason intense headaches through being pregnant. however, there may be currently no proof that pregnant women are greater susceptible to covid-19 contamination or that those with covid-19 are greater liable to excessive pneumonia. consequently, covid-19 all through being pregnant may boom the risk of maternal venous thromboembolism (vte). up to now no vertical transmission, teratogenicity or early miscarriage has been stated in the literature. pregnant women with covid-19 infection may experience more severe symptoms than women who are not pregnant. limited data report rapid deterioration in women who are asymptomatic at the time of health care and are later diagnosed with severe covid-19. in some, but not all, pregnant women, maternal comorbidities were found during examination (hypertension, diabetes, cholestasis of pregnancy) (breslin et al., 2020). early literature on covid-19 in pregnant women centered on symptomatic patients who later tested high excellent for the virus (bauer et al., 2020). but, several recent courses suggest the threat of non-symptomatic contamination amongst pregnant and childbirth women. the said prevalence of non-symptomatic covid-19 contamination among pregnant women is specifically outstanding, as signs and symptoms and signs of past-due pregnancy and even uninvolved delivery may overlap with signs of covid-19 contamination. curiously, the excessive percentage of asymptomatic infections amongst delivery mothers (breslin et al., 2020; city et al., 2020) recommend that nonspecific signs in pregnant sufferers may be associated more regularly with being pregnant than with covid-19 signs and symptoms. this https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.210-223 212 supports a low threshold for testing pregnant women with effective instances of covid-19, even though they present with signs that occur in a normal being pregnant; this is specifically important in groups with excessive covid-19 contamination charges. current reviews of asymptomatic covid-19 infections raise issues about the accuracy of current checks. in non-pregnant women, fake bad covid-19 rt-pcr outcomes had been stated in up to 18% of radiologically shown cases (long et al., 2020). when adjusted for data presented by sutton and colleagues (city et al., 2020), where nearly 90% of women giving birth are non-symptomatic, this error rate implies a large number of undetected infections among obstetric sufferers, due to a combination of symptom-primarily based checking out and trying out mistakes. ordinary, the available records advocate that a big wide variety of pregnant and transported women with covid-19 may be non-symptomatic or may additionally have signs but the signs are related to everyday being pregnant. furthermore, those ladies might also have false bad rt-pcr outcomes. as part of the consideration of obstetric care, and especially in communities and establishments with a high burden of covid-19 contamination, regulations are needed to mechanically compare women giving delivery as being at excessive risk for covid-19iinfection and to inspire conservative regulate that make sure surest patient care, and readiness of fitness carrier companies. it isn't yet recognized what's the pleasant method for handling covid-19 all through pregnancy and childbirth. it was far pretty clear that we want to recall no longer simplest epidemiological and scientific elements, but also organizational, social, and political troubles. assessments were performed universally on all treated pregnant ladies are an awesome opportunity to determine the incidence of most of the population. based on this rationalization, researchers are interested in systematically reviewing the detection of covid19 in pregnant women with asymptomatic cases. objective the objective of this systematic review was to detect asymptomatic covid-19 cases in pregnant women. methods study design this study evaluation is based totally on the reporting items for the prisma systematic overview and guidelines. a literature search was carried out from september to october 2020. article for systematic reviews was obtained from worldcat, proquest, ebsco, and pubmed. keywords to search for this article included: "covid-19" or "coronavirus" or “coronaviruses” or "2019-ncov" or "sars-cov" or "mers-cov" and “asymptomatic” and “pregnant women”. inclusion and exclusion criteria the inclusion criteria for articles are articles in english or indonesian and published articles about covid-19, with a focus on detecting asymptomatic cases of covid-19 in pregnant women, and the type of research is a cohort. exclusion criteria in this study include articles that use languages other than english or indonesian, and articles that do not display abstracts and do not provide complete information. data extraction articles from worldcat, proquest, ebsco, and pubmed using the mendeley program were collected and the author obtained a total of 628 articles. articles were selected https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.210-223 213 using featured reporting items for systematic review and the prisma method. a total of 12 selected articles were included for analysis in this study. data analysis study articles are systematically reviewed and qualitatively analyzed. results from 628 articles collected through preliminary searches on worldcat, proquest, ebsco, and pubmed. the authors included 12 articles on detecting asymptomatic covid-19 cases in pregnant women in 2019 to 2020. the selection process in detail is illustrated in figure 1. most of the articles explained that pregnant women who came to health care facilities did not show any symptoms of covid-19. however, when laboratory tests were carried out, the number of positive confirmed covid-19 was quite high. most of these pregnant women have mild symptoms even like the symptoms of pregnant people in general. several studies have not found any symptoms of covid-19 such as coughing, fever, or difficulty breathing. figure 1. prisma flow diagram id e n ti fi c a ti o n s c re e n in g e li g ib il it y articles assessed for eligibility (n = 37) duplicate articles removed (n = 384) articles identified from worldcat, proquest, ebsco, and pubmed databases (n = 628) records after duplicate articles were removed (n = 244) articles included (n=12) articles excluded (n = 207) the title is not suitable for the topic not available in full text the usage of language aside from english and indonesia articles excluded (n = 25) -abstract is not available -not provided any significant information in c lu d e d https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.210-223 214 table 1. evidence table no author (year) purpose study design sample results 1. viktoriya london, rodney mclaren jr., fouad atallah, catherine cepeda, sandra mccala, neli fisher, janet l. stein, shoshana haberman, howard minkof (2020) this study aims to compare symptomatic and asymptomatic pregnant women with covid-19 retrospective cohort pregnant mother positive for covid-19 eighty-one patients tested positive (symptomatic [n = 60] preexposure only [n = 21]) and 75 patients were tested (all nonsymptomatic). in total, there were 46 symptomatic and 22 asymptomatic pregnant women (tested on exposure alone [n = 12] or as part of universal screening [n = 10]) with positive covid-19. of the symptomatic pregnant women (n = 46), 27.3% had experienced premature birth and 26.1% needed respiratory support while those who were not asymptomatic (n = 22) had preterm labor or needed respiratory support (p = 0.007 and p = 0.01) (london et al., 2020) 2. noelle breslin, caitlin baptiste, cynthia gyamfibannerman, russell miller, rebecca martinez, kyra bernnstein, laurencee ring, ruth landau, stephannie purisch, alexander m. friedman, karin fuchs, desmondn sutton, maria andrikopoulo u, devonn rupley, jeanju sheen, janiceeaubey , noelia zork, leslie moroz, mirela mourrad, ronald. presenting experience with positive covid-19 during pregnancy in hospital of newyork city more than 2 the week between march 13, 2020, and 27 march 2020 cohort 43 pregnant women confirmed covid-19 it was found that pregnant women with covid-19 came with the usual complaints of pregnancy or that most of the referred patients were asymptomatic (breslin et al., 2020) https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.210-223 215 wapner, lynn. l. simpson, mary e. d’alton, dena goffmann (2020) 3. atakan tanacana, seyit ahmet erola, batuhan turgaya, alii taner anuka, ellcin islekk secena, gulin feykann yegina, sebnnem ozyera, fisun kircad, beediandin, serpil unlue, elif gul yappar eyia, huseyin levennt keskina, dilekksahina, aziz ahimett surelf, ozlemn moraloglu tekin (2020) investigated rates of sars-cov-2 positive in hospitalized asymptomatic pregnant women prospective cohort 206 asymptomati c pregnant women three of the 206 pregnant ladies who participated in the have a look at had an advantageous rt-pcr check (1.4%) and all fantastic instances have been in the excessive-danger being pregnant group. while one of the instances within the excessive-threat being pregnant group had proven very suspicious symptoms for covid-19, two repeated rtpcr assessments have been bad (tanacan et al., 2020) 4. muratt yassa, cihangirr yirmibes, g cavusoglu, hazaal eksi, cevdett dogu, cannberk usta, memis alli. mutlu, pinarr birol, cagri gulumser & niyazi tug. (2020) presents the overall prevalence of sars-cov-2 infection rates and hospitalized asymptomatic pregnant women, and assesses the diagnostic accuracy of maternal symptoms and pulmonary ultrasound (lus) findings in detecting infection prospective cohort women who are confirmed to be pregnant the one-month universal trial of sars-cov-2 infection by rt-pcr in hospitalized pregnant women showed an overall diagnosis of infection and asymptomatic rates of 7.77% and 4%, respectively (yassa et al., 2020) https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.210-223 216 5. asma ansari, farhat karim, rabiyaaakbar , uzma urooj, hafsa khalil, nighat shafiq (2020) determine the incidence of sars cov-2 (covid-19) infection among hospitalized women and their severity prospective cohort pregnant mother primarily based on pcr testing of 525 moms who gave beginning in the course of the study period, 43 (8.1%) had been nice for covid-19. of the total patients screened, 484 (92%) were symptomatic and forty-one (7.8%) have been displayed screen superb. 20 (48.7%) were additionally pcr high-quality. in step with disorder severity, 28 (65%) patients were asymptomatic 10 (23%) had moderate, 4 (9.3%) mild, and excessive (1%). covid-19 categories for highquality and bad screening patients have been compared and statistically extensive for advantageous screened patients (p < 0.0001) (ansari et al., 2020) 6. mnprabhu, k caginno, k c mathews, r l friedllander, s m glyn, j m.kubiak, y j yang, z zhao, r n baergen, j i diipace, a s razavi, d wnskupski, jn r snnyder, h k singh, r b kalish, c m oxford, l.e rilley (2020) describe the distinction in outcomes between pregnant girls with and without covid-19 prospective cohort pregnant women with gestational age > 20 weeks of the 675 treated women, 10.4% were positive for sarscov-2, 78.6% of them were asymptomatic (prabhu et al., 2020) 7. e.ferazi, l frigerio, v savasi, p vergani, f prefumo, s baresi, s bianchi, e. cirielo, f fachinetti, m t gervassi, e iurlaro, a kustermann, g.mangili, f mosca, l patanè, d spazzini, a spinillo, g trojano, m report the mode of delivery and the delivery of the baby to women infected with covid-19 retrospective cohort a pregnant woman who is confirmed positive for covid-19 this is constant with the truth that this syndrome is commonly slight or moderate in pregnancy and it's miles very probably that many inflamed pregnant women are asymptomatic or with symptoms (ferrazzi et al., 2020) https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.210-223 217 vignalli, a villa, g v zuccotti, f parazzini, i cetin (2020) 8. whitney r. bender, sindhu srinivas, paulina coutifaris, alexandra acker, adi hirshberg (2020) describe the mental reviews of asymptomatic obstetric sufferers in inpatient and early postpartum tested for breathing syndromecoronavirus-2 (sars-cov2) acute/extreme as part of a everyday trying out application and document on the effect of this software on labor and transport fitness care people cohort asymptomati c pregnant women undergoing testing for sars-cov2 318 non-symptomatic women trying out for sars-cov-2 over a 2-week length. seventyfive percent who tested effective reported negative. among 310 women who examined negative, 34.4% of multiparous mentioned multiplied postpartum tension in comparison to previous deliveries due to issues approximately exposure to infectious marketers inside the hospital and lack of social help (bender et al., 2020) 9. mariann. knight, kathrynn bunch, nicolla voussden, edwardd morris, nigel. simpson, chris gale, patrick o’brien, maria quiglley, peter brocklehurst, jennifer j. kurinczuk (2020) describes a national cohort of pregnant women who hospitalized with severe acute respiratory syndrome (sars-cov2), identify factors associated with infection, and explain the results, along with transmission infection, for mother and baby prospective cohort 427 pregnant women were hospitalized with confirmation of sarscov-2 infection between march 1st 2020 and april 14, 2020 in the context of the ongoing covid-19 pandemic, the collection of data on the outcome of infection during pregnancy becomes very important. however, unanswered questions regarding the extent and effect of asymptomatic or mild infection (knight et al., 2020) 10. giovanni nazzaro, evaluate the strength of the cohort pregnant woman with the mean gestational age at diagnosis was 30.6 ± 9.5 weeks, https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.210-223 218 mariavittoriaa locci, maurizio. guidda, attilio di spiezio sardo, pierluigi beneddetti panici, vincenzo berghella, maria elenna flacco, lamberto manzoli, giusepe bifulco, giovannii scambia, fulvio zulo and francesco d’antonio (2020) relationship between characteristics of the mother and pregnancy and the risks to adverse perinatal outcome in pregnancy with confirmed covid-19 confirmation covid-19 with 8.0% of women diagnosed in the first case, 22.2% in the second, and 69.8% in the third trimester of pregnancy. asymptomatic cases by 24.2% (di mascio et al., 2020) 11. ignacio heraiz, dolores folgueira, cecilia vilalaín, laura forcén, rafael. delgado and alberto galindo (2020) evaluate universal performance screning for sars-cov-2 using quantitative reverse transcrption polymerasechain-reaction (qrt-pcr) assay retrospective cohort pregnant women who are about to give birth and have given birth between april 8 and may 2 2020 at big maternity in madrid there had been 212 deliveries. 9 cases with an analysis of covid-19 previous to admission. 203 ladies were referred with covid-19 signs and symptoms however simplest one had a tremendous qrt-pcr. among 194 nonsymptomatic women, the most effective case (0.5%) changed into wonderful (herraiz et al., 2020) 12. stefano cosma, fulvio borela, andrea caroso, andrea sciarone, jessica cusato bsc, silvia corcione, giulio mengozzi, mario preti, dionysios katsaros, giovanni. di perri, chiara benedeto (2020) evaluate cumulative incidents sars-cov-2 infection during the first trimester of pregnancy cohort pregnant woman the cumulative prevalence of covid-19 all through the first trimester turned to 10.1% with a high incidence of nonsymptomatic sufferers (42.8%). just like the direction of disorder in nonpregnant adults, 80 to 90% of non-severe infection signs were suggested to be four instances higher in covid-19 positive sufferers (57%) than in terrible people (thirteen%) (p < 0.001), this suggests that direct self-trying out should be open covid-19 confirmatory testing (cosma et al., 2020) https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.210-223 219 discussion from the several articles above, it is known that most pregnant women suffer from covid-19 without symptoms (asymptomatic). one study stated that the majority of respondents (97%) were asymptomatic patients or had mild symptoms such as fever or cough so they did not require oxygen therapy (harishchandra et al., 2020). at the time of the primary said a case of a pregnant lady with asymptomatic covid-19 contamination and asymptomatic covid-19 pregnant women with precise records have been rarely saying. there has been no fever, cough, or dyspnea, and everyday blood check confirmed an everyday white blood mobile don't forget and an everyday lymphocyte remember. the affected character confirmed asymptomatic infection before gift procedure surgery, considering that there are no precise antiviral pills for covid-19 contamination and antiviral pills, this may have a chance to the protection of the fetus because the simplest conventional remedy consists of inhaled oxygen and oral iron administration may be carried out. after a surgical procedure, mothers in labor are advised no longer to breastfeed their babies, consequently, an antiviral remedy is given (lu et al., 2020). caring for pregnant women all through the sars-cov-2 pandemic is a scientific challenge due to the fact no longer best are they more liable to infectious outbreaks because of physiological changes, however, there is additionally a vital want to hold the health of the fetus. obstetric patients, unlike other clinically susceptible groups, still need to get the right of entry to fitness offerings on a regular foundation and are probable to require unique permission for a referral. obstetric instances permit the early identity of asymptomatic through the examiner. this proves that it's far important to use suitable ppe and effective control of maternity services to facilitate fine patients so that they can be remoted. in a single study, thirteen pregnant women confirmed mild or asymptomatic covid-19 nice, together with 15.4% (2/13) had a prenatal fever and 61.6% (8/13) had a postpartum fever, and 15.4% with cough, and none had myalgia or fatigue, hemoptysis, headache, palpitations, diarrhea or dyspnea (yang et al., 2020). a high probability of asymptomatic presentation indicating fewer pregnant women and young pregnant women with covid-19 manifest symptoms than non-pregnant women. this may be due to the universal screening strategy for covid-19 in pregnancy and the low threshold for screening non-pregnant patients. despite the possible strategies above for detecting pregnant women with mild disease, investigators have observed increased admittance to intensive care units and the need for invasive ventilation compared to non-pregnant women with covid-19 (allotey et al., 2020). pregnant women without symptoms are at risk of receiving intensive care because it can delay diagnosis and make the virus more able to spread the disease silently (dashraath et al., 2020). mentioned asymptomatic being pregnant charges range from 43 percent to 89%, with an estimate of 4 to 9 undetected instances in keeping with every symptom. this helps general screening as a feasible method. in the look at there was a high charge of bias in reporting (sufferers had been asymptomatic but have been detected as advantageous cases whilst an indepth record changed into carried out) of nearly 70%. due to the wide variety of signs of covid-19 overlaps with the physiological adjustments at some stage in pregnancy. the above focus on the priority of symptom evaluation according to traditional running procedures, the want for proper patient schooling about signs and signs and symptoms, and the capability https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.210-223 220 boundaries of diagnostic strategies based on patient symptom reviews, almost 50% of whom are asymptomatic. universal screening of people who are not included in the screening group at delivery, should be examined in endemic areas that provide a good estimate of the prevalence of covid-19 infection at the general population level, allow for adequate health team protection, appropriate patient isolation, neonatal diagnosis immediately after birth and what follow-up should be done (pilar et al., 2020). conclusion based on the results of a review of several kinds of literature, it can be concluded that pregnant women who do not show covid-19 symptoms show a large percentage and have a greater risk of receiving intensive care compared to women who are not pregnant. in several articles reviewed, it was stated that during the study pregnant women tended to not show any symptoms including fever. this is different from what happened in non-pregnant patients where covid-19 symptoms such as stones, fever, and difficulty breathing were experienced by these patients. references alfirevic, a., bustamante, s., hargrave, j., & marciniak, d. 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(2020). the rate of sars-cov-2 positivity in asymptomatic pregnant women admitted to hospital for delivery: experience of a pandemic center in turkey. european journal of obstetrics and gynecology and reproductive biology, 253, 31– 34. https://doi.org/10.1016/j.ejogrb.2020.07.051. yang, h., sun, g., tang, f., peng, m., gao, y., peng, j., xie, h., zhao, y., & jin, z. (2020). clinical features and outcomes of pregnant women suspected of coronavirus disease 2019. the journal of infection, 81(1), e40–e44. https://doi.org/10.1016/j.jinf.2020.04.003. yassa, m., yirmibes, c., cavusoglu, g., eksi, h., dogu, c., usta, c., mutlu, m., birol, p., gulumser, c., & tug, n. (2020). outcomes of universal sars-cov-2 testing program in pregnant women admitted to hospital and the adjuvant role of lung ultrasound in screening: a prospective cohort study. journal of maternal-fetal and neonatal medicine, 33(22), 3820–3826. https://doi.org/10.1080/14767058.2020.1798398. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.210-223 223 yu, n., li, w., kang, q., xiong, z., wang, s., lin, x., liu, y., xiao, j., liu, h., deng, d., chen, s., zeng, w., feng, l., & wu, j. (2020). clinical features and obstetric and neonatal outcomes of pregnant patients with covid-19 in wuhan, china: a retrospective, single-centre, descriptive study. the lancet. infectious diseases, 20(5), 559–564. https://doi.org/10.1016/s1473-3099(20)30176-6. https://thejnp.org/ journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 47 52 47 analysis of the effect telephone counseling by nurses on the compliance of the control of dots poly tuberculosis patients at dungus madiun lung hospital agus winarto 1 , tjahja bintoro 2 1 rs paru dungus, madiun, east java, indonesia 2 ppni madiun, east java, indonesia) corresponding author : aguswinarto2015@gmail.com abstract background: adherence to treatment is the behavior of tb patients to come control in accordance with control schedule in dots poly dungus madiun lung hospital. telephone counseling is a communication performed by nurse dots poly dungus madiun lung hospital to the tb patient or his family using a telephone, with the intention of asking about the state of his illness, current complaints, motivate regularly taking medication, answer patient questions and complaints, and reminded drug taking schedule. purpose : the purpose of this study is to prove the influence of the provision of telephone counseling by nurses to the compliance of tb dots patient control in dungus madiun lung hospital. methods : research design preexperiment with a one-shot case study design. the population is tb patients treated in poly dots from january 2017 to march 2017 with a sample of 15 respondents by purposive sampling. data collection using a checklist of telephone counseling and checklist the observation of the arrival of the control on time after given counseling via telephone,checklist data was analyzed with binomial test. result : research result, after counseling via telephone almost all respondents came to the control on time 13 respondents (87%) and there is the effect of telephone counseling by nurses on the compliance of the control of dots poly tuberculosis patients at dungus madiun lung hospital. (binomial with sig = 0.007 <α = 0.05 then h0 is rejected). conclusion : provision of counseling is necessary to improve patient compliance in treatment until completion. with telephone counseling from tb dots poly nurse to patient, in addition to more effective communication awakening, as well as motivating patients to adhere to tb treatment programs. keywords : telephone counseling, compliance control, tbc patients received: february 03, 2018; revised february 24, 2018; accepted march 10, 2018 how to cite: winarto, a., & bintoro, t. (2018). analysis of the effect telephone counseling by nurses on the compliance of the control of dots poly tuberculosis patients at dungus madiun lung hospital. journal of nursing practice. 1(2). 47-52 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 47 52 48 background tuberculosis is a disease of global concern. with all the control measures undertaken, incidences and deaths from tuberculosis have declined, but tuberculosis is estimated to still strike 9.6 million people and cause 1.2 million deaths by 2014. by 2015 the national treatment success rate is 85.0% (data as of june 2016). who set the standard of treatment success rate of 85%. from east java provincial health office data obtained data that the discovery and cohort analysis on the treatment data conducted in 2011 showed that the success rate of the provincial scale is good enough. if the treatment outcome is sorted according to fashankes, then the results are as follows: puskesmas is still the fasyankes with the best treatment success rate of 91%, private practice doctor 88%, general hospital 71%, lung hospitals and bp4 63%. treatment drop out rates as a result of medication noncompliance is one of the important indicators of treatment performance and affect the quality of treatment. the higher the drop out rate in a region / fasyankes, there is a tendency to increase the rate of finding new cases or even increasing cases of mdr in the region. public hospitals, lung hospitals / bp4 are fasyankes who have a risk for high drug drop out rate with a medication drop out rate of 19% when compared with puskesnas with 2% dropout rate. dropout rates at dungus madiun hospital 2016 by 10% while the maximum number of patients with treatment drop by 5%. tb patients in dots dungus madiun hospital were found that there were 862 patients from january to december 2016, there were 86 treatment drop out rate (9.98%), mostly at the advanced treatment stage between month the 5th to the 6th treatment was 95%, and 5% of the treatment drops occurred during the initial treatment period, precisely at month 2. =, but after fieldwork that out of the 86 patients recorded in the dorp out patient, after the search was found 30 patients moved to residence without notice, 7 patients died, and 49 stopped treatment. this shows the lack of communication caused the difference in the data information recorded. objective the purpose of this study is to prove the influence of the provision of telephone counseling by nurses to the compliance of tb dots patient control in dungus madiun lung hospital. methods this research is a quantitative research, with research design using pre-experiment method, and the research design used is one-shot case design study with randomized sample, used to see the effect of treatment (counseling via telephone) to the compliance of poly dots tb patient control dungus madiun lung hospital. the population is tb patients treated in dots poly from january 2017 to march 2017. samples are tb patients who are in the control category of irregular / non-compliance control scheduled control in may 2017, with sampling purposive sampling technique, 15 respondents. independent variable in the form of giving counseling via telephone by dots policeman. and the dependent variable is the compliance of the control of poly tuberculosis patient dots at dungus madiun lung hospital. samples were obtained in dots poly according to schedule control list in accordance with inclusion and exclusion criteria. next we concerned the sample as a prospective respondent and included in the table of prospective respondents. and when the respondent journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 47 52 49 comes for treatment and meets first with the researcher, the researcher explains the purpose and objectives of the research on the respondent and gives informed consent to the respondent to be signed when approve. explain to the responder that between h-7 and h-2 of the next control schedule will receive a call from the researcher. if telephone counseling has been done by the researcher to the respondent, then the researcher will give the sign (√) in the counseling check box via telephone. furthermore, when the schedule of subsequent control respondents, researchers make observations and attendance attendance attendance control. if the respondent comes timely control on schedule or before, then the compliance observation checklist is marked 1 in the compliance control column. if the respondent does not arrive on the day as scheduled or arrives late from schedule, then the number 0 is in the compliance control column. data from counseling check list via telephone and checklist of observation control, then data characteristic of respondent shown in pie and narration diagram. to know the effect of giving counseling via telephone to compliance of control carried out statistical test non parametric binomial. results the respondents in this study were some of the tb patients who were recorded in the non-compliant control or irregular control scheduled controls in may 2017, as many as 15 respondents. characteristics of respondents are declared by domicile, sex, age, result of bta examination, and treatment stage, as follows the following: 1. most of the respondents came from madiun regency with 10 people or 67%. 2. most of the respondents are male with the number of 9 people or 60%. 3. almost half of respondents are aged 61 years and over with the number of 6 people or 40%. 4. most of the respondents were patients with tb of bta negatif with number of 11 people or 73%. 5. almost all respondents in the treatment period continued with the number of 13 people or 87%. characteristics of the variable as follows: 1. independent variable in the form of giving telephone counseling by nurses was done to all respondents who experienced control delay that is 15 respondents. 2. dependent variables in the form of compliance control, after giving counseling via telephone, indicate that almost all respondents obedient control on time, with the number of 13 people or 87%. table 1. binomial statistic test results using spps as follows binomial test category n observed prop. test prop. exact sig. (2-tailed) kepatuhan group 1 compliant 13 .87 .50 .007 group 2 non-compliant 2 .13 total 15 1.00 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 47 52 50 from the output obtained that the category is obedient = 13 and the uncompliance category = 2, proportion 1.0, exact value sig = 0.007, level of significance α = 0.05 value sig = 0.007 <α = 0.05 conclusion: since the value of sig = 0.007 <α = 0.05 then h0 is rejected which means that there is the effect of giving telephone counseling on patient control compliance in dots rs dungus madiun. discussion identification of tb dots patient's control compliance after being counseled via telephone by nurse at dungus madiun dung hospital. the results showed that after giving counseling via telephone, almost all patients who had been late to control to be obedient control on time, with the number of 13 respondents or 87%. there are still a small number of patients who have not adhered to timely control, ie as many as 2 respondents or 13%. when connected with the respondent characteristic data obtained identification of control compliance observation result after given counseling via phone on h-7 to h-2 from schedule control it is as follows: 1. based on the respondent's domicile (regency), the respondents obtained from ponorogo, magetan, nganjuk 100% obedient after given counseling via telephone, while respondents from madiun regency as many as 8 (80%) respondents obedient and 2 (20%) respondents did not obey. 2. based on respondent's gender, male respondent 7 (100%) respondents submitted after giving counseling via telephone, while female respondents were 6 respondents (75%) obedient and 2 respondents (25%) did not obey. 3. based on the age group of respondents, obtained respondents age group 1-20 years, 2140 years and 61 years and over 100% obedient respondents abide after given counseling via telephone. while respondents age group 41-60 years as many as 2 respondents (50%) obedient and as much as 2 respondents (50%) are not obedient. 4. based on the results of bta examination of respondents, obtained respondents with the results of bta negative examination of 11 people, 91% obedient and 9% not obedient. while respondents with positive bta examination results as many as 4 people, 75% obedient and 25% disobeyed after being given counseling via telephone. 5. based on the treatment period of the respondents, the respondents obtained the intensive treatment period as much as 2 respondents, 50% obedient and 50% tidal obedient. while respondents with treatment period continued as many as 13 respondents, 92% obedient and 8% disobedient. analysis of the effect of telephone counseling by nurses on the compliance of the control of dots poly tuberculosis patients at dungus madiun dung hospital the results showed that there was influence of telephone counseling on patient compliance control. this is evidenced by the results of binomial analysis performed with spss, which states the value of exact sig = 0.007 smaller than the level of significance α = 0.05. the results also showed that after counseling via telephone, there was an increase in the percentage of control compliance rates when compared with control compliance rates before being given counseling via telephone. the compliance rate before counseling via telephone was 39 compared to 54 = 72%, whereas the rate of compliance after counseling via telephone was 13 compared to 15 = 82%. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 47 52 51 counseling is a process of giving help done by an expert (called counselor / counselor) to an individual experiencing a problem (called counselee) which leads to the problem faced by the client. counseling is one form of communication that has a purpose to change the current situation to a better state. prayitno (2004). the researcher's opinion, in the group of respondents who are a group of tb sufferers who need a long period of time, at least 6 months for the duration of treatment, it is necessary to get counseling in addition to increase the motivation of undergoing treatment, also provide solution solutions when there are obstacles during the treatment. advantages or advantages of counseling counseling services over the phone, among others in addition to the client more willing to open talk about the problem because he does not communicate face to face, so he can be more ready and open, can also reduce the difficulty of the schedule of activities and distance (wikipedia.org). the idea of using telephone media to provide counseling from researchers is a new step in the continuation of counseling that has been routinely given when patients come for treatment and meet both physicians and nurses in poly dots, on the grounds that there are still high levels of control delay also because each each individual already has a telephone tool. in a study conducted by i made bagiada and ni luh putri primasari in 2010 on factors that influence the degree of non-compliance of tuberculosis patients in the dots clinic at sanglah denpasar hospital, it is found that one of the factors is the patient's own problem, such as the lack of knowledge about tb , lack of costs, lazy treatment, and feel healed. from the results of i made bagiada research, researchers can conclude that many factors that can affect the non-compliance of tuberculosis patients to be able to seek treatment regularly and on time and complete in term. the treatment program of tuberculosis patients takes a relatively long time between 6 months to 9 months. to minimize the factors that affect the non-adherence of tuberculosis patients, researchers try to provide a treatment to monitor and increase motivation in patients and their families in the form of counseling via telephone. in the counseling will be obtained information on the current condition of the patient, the complaints experienced, the obstacles experienced so that patients do not take their own decisions that can harm. researchers can provide solutions to the problems that are being experienced by patients and can remind the next control schedule. the degree of patient disobedience can be influenced by the communication between patient and physician, for example, information with poor supervision, dissatisfaction with aspects of emotional connection with physicians, dissatisfaction with treatment (given, 2004). telephone counseling is a treatment to improve the quality of communication from health workers with patients. improving the quality of communication is expected to increase compliance rates. increasing compliance rate of respondent control after counseling via telephone shows that by improving communication between patient and health officer will influence patient's disobedience level, from the medical journal made by rina loriana, ridwan m.thaha, iwan m. ramdan mulawarman university of samarinda (2012) stated that "that there is a significant difference of knowledge about the adherence of patients receiving pulmonary tb treatment before and after getting counseling, there is a significant difference in attitude about the treatment of patients with tb lung before and after getting counseling and there are significant differences in the level of treatment compliance in patients with pulmonary tb before and after getting counseling. it can be concluded that the effect of counseling on knowledge, attitudes and compliance to treatment of pulmonary tb patients in the working area of the health service of samarinda city. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 47 52 52 conclusion after the research can be concluded that after being given telephone counseling by the nurse, almost all tb poly dots patients who have been late to control become obedient control on time. the influence of giving counseling via telephone to the compliance of treatment of pulmonary tuberculosis patients in poli dots lung hospital dungus madiun.pengaruh giving counseling via telephone to tb patients who once late control in particular, in addition to improve the quality of communication can also motivate tb patients in the program treatment. references ariesubowo, (2008). “komunikasi-dengan-pelanggan” ( https://wordpress.com). diakses tanggal 20 januari 2017 dinkes kab. madiun. (2013). profil kabupaten madiun. (http://www.depkes.go.id/resources/download/profil/profil_kab_kota_2013/ 3519_jatim_kab_madiun_2013.pdf). diakses tanggal 20 januari 2017. dinkes kab. madiun. (2015). profil kabupaten jawatimur. (http://dinkes.jatimprov.go.id/userfile/dokumen/profil%20kes_2015.pdf). diakses tanggal 20 januari 2017. mulyana, deddy. (2010). ilmu komunikasi. bandung: remaja rosdakarya. niven, neil. 2004. psikologi kesehatan keperawatan pengantar untuk perawat dan profesional kesehatan lain. jakarta: egc. ri, depkes. (2007). pedoman pengelolaan program tb nasional, jakarta: depkes ri, depkes. (2011). pedoman pengelolaan program tb nasional, jakarta: depkes ri, depkes. (2014). pedoman pengelolaan program tb nasional, jakarta: depkes siswanto, susilo, dan suyanto, (2015). methodologi penelitian kesehatan dan kedokteran. jogjakarta : bursa ilmu soepritjahjono,(2013).“pengertian-komunikasi-teleponl”https://wordpress.com). diakses tanggal 20 januari 2017. sugiono. (2003). methodologi penelitian admistrasi. bandung: cv alfabeta wiki, (https://id.wikipedia.org/wiki/telepon). di akses tanggal 19 maret 2017. wiki, (https://id.wikipedia.org/wiki/konseling). diakses tanggal 19 maret 2017 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.176-182 176 the effect of music therapy on anxiety in pre-anesthesia in the operation room of genteng hospital banyuwangi katmini*, suryanto institut ilmu kesehatan strada indonesia, kediri, indonesia *corresponding author: katminitini@gmail.com abstract background: pre-anesthesia preparation is very important to minimize risks during surgery. this is because the outcome of surgery depends on the assessment of the patient's condition and the preoperative preparation performed on the pre-anesthetized patient. music has many benefits for human health and can provide good mental strength for listeners. purpose: analyzing anxiety before and after music therapy intervention in pre-anesthesia in the operating room and health education with music therapy for anxiety in pre-anesthesia in the operating room. methods: the research design was quasi-experimental with a pre and post-approach. the population of all patients who underwent surgery under spinal anesthesia. the samples taken in this study were 15 samples of patients who underwent surgery under spinal anesthesia. the independent variable is music therapy. the independent variable is music therapy. the dependent variable is anxiety. the analysis used is univariate and bivariate. results: based on the results of data collection conducted by researchers, there are six subject that represent the results of the study, age, gender , marital status, last education, profession, type of surgery. conclusion: this study concludes that music therapy can reduce the patient's level of anxiety so that it will divert attention to anxiety (distraction) and provide a sense of relaxation before the patient undergoes spinal anesthesia. keywords: education, good mental, operating received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.339 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:katminitini@gmail.com https://doi.org/10.30994/jnp.v6i2.300 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.176-182 177 background pre-anesthesia is a further step from the results of the pre-operative evaluation, especially anesthesia to prepare the patient, both psychologically and physically so that the patient is ready and optimally to undergo anesthetic and diagnostic procedures or the planned surgery (erhan & aryan, 2020). pre-anesthesia care begins when the patient is in the treatment room or can also begin when the patient is handed over to the operating room and ends when the patient is transferred to the operating table (majid et.al. 2011). pre-anesthesia preparation is very important to minimize risks during surgery. this is because the outcome of surgery depends on the assessment of the patient's condition and the preoperative preparation performed on the pre-anesthetized patient. music and sounds are amazingly stimulating. music is a harmonic air vibration, the nerves in the ear catch it, transmitted to the central nervous system in the brain, giving rise to a certain impression on a person. musical harmony that is equivalent to the body's internal rhythm will give a pleasant impression on a person. in addition, music also greatly affects the human physique, as long as the right vibration and harmony are used, the listener will feel comfortable and relaxed (mehtap et, al. 2019). the advantages of using music therapy are that music is not harmful, inexpensive, safe, has no negative side effects, can lower blood pressure, pulse and respiration. the disadvantage is that you have to use media so you can't do it anytime and anywhere (dana et, al. 2021). lack of preparation in pre-anesthesia can cause a threat to the body, integrity, and soul of a person so the patient becomes anxious pre-anesthesia. anxiety experienced can be sourced from fear of pain, physical changes, disability, surgical equipment, operating personnel, unconscious after being sedated, and' surgery failure (artini, 2015). surgery or surgery is a stressor for the patient which can evoke stress reactions both physiologically and psychologically. preoperative anxiety generally occurs in patients who will undergo elective anesthesia and surgery procedures(juan et, al. 2019). anxiety that arises before the anesthetic action will interfere with the operation process. music has many benefits for human health and can provide good mental strength for listeners. people who listen to music will have a strong mentality, calm emotions, live more comfortably and relaxed and make their lives more confident by developing intellectual knowledge for them. music can also affect depression reduction (andriyani, 2019). music therapy in its application can increase the production of the four positive hormones in the human body, namely endorphins, dopamine, serotonin, and oxytocin. the function of the four positive hormones can make the body more relaxed, reduce anxiety or stress, increase happiness, increase intelligence, and increase self-confidence (situmorang, 2017). music therapy is a nursing intervention, where music is used as a medium for therapeutic activities to maintain, improve, and develop mental health, physical health, and emotional health (padila et, al 2020). the growing evidence-based nursing practice shows progress in helping patients reduce anxiety, namely through music therapy (quanman, et. al 2019). based on this description, researchers are interested in researching "the effect of giving music therapy to anxiety in pre anesthesia in the operating room of genteng hospital banyuwangi". methods the population in this study were all patients who underwent surgery under spinal anesthesia. the sample in this study amounted to 15 people who underwent surgery with spinal anesthesia in the operating room of the genteng banyuwangi general hospital. 15 people who underwent surgery under spinal anesthesia were treated with music therapy. the sample has https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.176-182 178 inclusion criteria in the form of adolescent and adult patients aged 17-45 years; patients undergoing surgery for the first time; patients who underwent surgery under spinal anesthesia (sab); patients with compliments consciousness; no hearing loss and exclusion criteria: patients with cito/emergency surgery. this sampling technique uses incidental sampling. the independent variable in this study was music therapy. the dependent variable in this study is the level of anxiety. this research was conducted at the genteng general hospital in banyuwangi in august 2022. the type of research is that observations were carried out twice before the experiment and after the experiment. observations made before experiment (0) are called pre-test and observations after the experiment (01) are called post-tests. the difference between 0 and 01, namely 01 0 is assumed to be the effect of treatment or experiment. in this study, the measuring instrument used was a questionnaire. the data collection procedure was carried out by covering several stages, including explanation and confirmation of the respondent's willingness; pre-test; providing health education through music therapy; post-test. processing of research data includes editing; coding; scoring; tabulating. the research data that has been collected were analyzed by univariate test to see the characteristics of respondents using frequency distribution and descriptive statistical results which include mean, median, standard deviation, minimum and maximum values , and bivariate test to prove the research hypothesis. the criteria set are as follows: 1) if the p-value is 0.05 then h1 is accepted or h0 is rejected, meaning the effect of music therapy on reducing anxiety in pre-anesthesia in the operating room of the genteng banyuwangi general hospital. 2) if the p-value > 0.05 then ho is accepted and h1 is rejected, meaning that there is no effect of music therapy on reducing anxiety in pre-anesthesia in the operating room of the genteng banyuwangi general hospital. results the results of data collection regarding the characteristics of respondents based on music therapy intervention group: table 4.1 characteristics of research subjects based on age, gender, marital status, last education, profession, type of surgery characteristics music therapy n % age 18-25 6 40,0 26-35 6 40,0 36-45 3 20,0 gender male 7 46,7 female 8 53,3 marital status not married yet 5 33,3 married 10 66,7 last education elementary school 0 0 junior high school 3 20,0 senior high school 6 40,0 diploma degree 2 13,3 https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.176-182 179 characteristics music therapy n % bachelor degree 4 26,7 master degree 0 0 profession student 1 6,7 housewife 5 33,3 government employees 0 0 entrepreneur 9 60,0 laborer 0 0 type of surgery urology 3 20,0 general surgery 6 40,0 ob-gyn 6 40,0 source: primary data, 2021 table 4.1 shows the results of the characteristics of research subjects based on age, sex, status, last education, occupation, and type of surgery. the age category of respondents showed that most of the respondents were aged 26-35 years (early adults), namely 8 respondents (53.3%). the gender of the respondents showed that most of the respondents were female, namely 8 respondents (53.3%). the marital status variable is mostly high school respondents, namely 10 respondents (66.7%). in the last education category, it was found that almost half of the sma respondents were 6 respondents (40.0%). the job variable found that most of the respondents were in the self-employed category, namely 9 respondents (60.0%). almost half of the respondents fall into the category of general surgery ob-gyn, namely 6 respondents (40.0%). specific data contains the characteristics of the findings of the focus of research on the effect of music therapy on reducing anxiety in pre-anesthesia in the operating room of the genteng banyuwangi general hospital, as follows: table 4.2 characteristics of specific data for research subjects characteristics music therapy n % pre anxiety no anxiety 0 0 mild anxiety 1 6,7 moderate anxiety 3 20,0 severe anxiety 11 73,3 panic 0 0 post anxiety no anxiety 10 66,7 mild anxiety 5 33,3 moderate anxiety 0 0 severe anxiety 0 0 panic 0 0 source: primary data, 2021 table 4.2 shows the results of the characteristics of the research variables based on preanxiety. the pre-anxiety variable obtained results that most of the respondents were in the category of severe anxiety, namely 11 respondents (73.3%). post-anxiety variables showed that most of the respondents were included in the not anxious category, namely 10 respondents (66.7%). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.176-182 180 analysis of anxiety reduction before and after music therapy intervention in preanesthesia in the operating room of the genteng banyuwangi general hospital. table 4.3 paired t-test for reducing anxiety before and after music therapy interventions on reducing anxiety in pre-anesthesia in the operating room of the banyuwangi genteng general hospital pre dan post anxiety n mean sig (2-tailed) pre 15 291,67 0,000 post 15 136,67 source: primary data, 2022 the results of the analysis showed that the mean value of the pre-test (291.67) for anxiety was higher than the post-test score (136.67) for anxiety. the p-value obtained was p = 0.000 (p < 0.05), which indicates that there is a decrease in anxiety before and after music therapy intervention in pre-anesthesia in the operating room of the genteng banyuwangi general hospital. the results of the post-anxiety research showed that most of the respondents were in the non-anxious category, namely 10 respondents (66.7%). the results of the analysis showed that the mean value of the pre-test (291.67) for anxiety was higher than the post-test score (136.67) for anxiety. the p-value obtained was p = 0.000 (p < 0.05), which indicates that there is a decrease in anxiety before and after music therapy intervention in pre-anesthesia in the operating room of the genteng banyuwangi general hospital. discussion the decrease in anxiety levels in the intervention group can occur because of the music therapy intervention. music therapy can help express feelings and have a positive influence on a person's mood and emotional state (guangli, 2021). music therapy can provide a calming effect for respondents, can reduce anxiety, make feelings become relaxed, relaxed, and can stabilize them emotionally. according dave (2011) things that must be considered in giving music therapy are choosing the type of music that is not too fast and loud. beat 60-80/minute that has a regular and steady tone, the patient chooses music with the direction of a therapist, a maximum volume of 60db, harmonious harmonization, and is supported by a comfortable, quiet room, and away from the noise so that one can concentrate on the music which is given. under the conditions in the field when the research was conducted, the patient was faced with the same situation, which was to undergo surgery (astuti, 2019). this has been proven in a 1996 study, the journal of the american medical association reports on the results of a music therapy study in austin, texas which found that half of the pregnant women who listened to music during the birth of their child did not need anesthesia. musical stimulation increases the release of endorphins and this reduces the need for medication. the release also provides a distraction from pain and can reduce anxiety (fillipo, et. al, 2020). sedative music is not the only distraction effect in inhibiting the perception of anxiety (siti, et. al, 2021). music is believed to increase the release of endorphins (siti, et. al, 2021). endorphins are ejectors of the sense of relaxation and calm that arise, the midbrain secretes gama amino butyric acid (gaba) which functions to inhibit the conduction of electrical impulses from one neuron to another by neurotransmitters in the synapse. the midbrain https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.176-182 181 secretes enkephalins and beta-endorphins and these substances can cause a relaxing effect which ultimately eliminates anxiety neurotransmitters in the somatic sensory perception and interpretation center in the brain so that the effect that can appear is reduced anxiety (john, 2020). the researcher concluded that the conclusion in this study was that music therapy could reduce the patient's level of anxiety so that it would divert attention to anxiety (distraction) and provide a sense of relaxation before the patient underwent spinal anesthesia. conclusion the conclusion of this research are the results of the analysis showed that there was a decrease in anxiety before and after music therapy intervention in pre-anesthesia in the operating room of the genteng banyuwangi general hospital. the results of the study on preanxiety showed that most of the respondents were in the category of severe anxiety. the results of the post-anxiety study showed that most of the respondents were in the category of not being anxious. with the results of research on the effectiveness of spinal anesthesia video education and music therapy, it can add knowledge or input and consideration in research related to this further. it is suggested that the anesthesiologist can be used as a reference to reduce preanesthesia anxiety, namely non-pharmacological (psychological). references andaryani, e. t. 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(2020). the effects of music therapy in patients undergoing septorhinoplasty surgery under general anesthesia. braz. journal otorhinolaryngol, 86, pp. 419–426. https:// doi: 10.1016/j.bjorl.2019.01.008. fillipo, g., barbara, z., francesco, d.l., chiara, l., flavia, e., nicola, b., and nicola, n. (2020). the influence of music therapy on preoperative anxiety in pediatric oncology patients undergoing invasive procedures. the arts in phychotherapy. 68 (101649). https://doi.org/10.1016/j.aip.2020.101649. guaangli, l., ruying, j., dandan, l., jingfen, y., zhen, w., and charoan, c. (2021). effects of music therapy on anxiety: a meta-analysis of randomized controlled trials. journal of psychiatry res., 304, 114137, 2021. https://doi.org/10.1016/j.psychres.2021.114137. john h. (2020). guyton & hall physiology review e-book. elsevier health sciences. juan, l., chuyan, g., yajuan, y ., and haiqin y. (2019). the implication of music therapy on the anxiety of patients undergoing day surgery with non-general anaesthesia,. ambul. https://thejnp.org/ https://doi.org/10.1093/jmt/48.3.264 https://doi.org/10.1016/j.bjorl.2019.01.008 https://doi.org/10.1016/j.aip.2020.101649 https://doi.org/10.1016/j.psychres.2021.114137 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.176-182 182 surg. 25 (1), 26–27. majid, a., jodha, m., and istianah, u. (2011). keperawatan perioperatif. yogyakarta: gosyem publishing. mehtap, k., nuray .d., and mehtap t, (2019). effect of music therapy on sleep quality. journal of altern ther heal. med. http:// pmid: 31221932. novita, d. (2021). pengaruh terapi musik terhadap nyeri post operasi open reduction and internal fixation (orif) di rsud dr. h. abdul moeloek propinsi lampung. j. ilm. kesehat. keperawatan. padila, p., setiawati,s., iin, i., , henny, s. m., and chatarina, s. (2020). emosi dan hubungan antar sebaya pada anak tunalaras usia sekolah antara terapi musik klasik (mozart) dan murrotal (surah ar-rahman). j. keperawatan silampari, 3 (2), 752–763. quanman, l., yudong, m., xin,. z., clifford w., cuping w., and jian, w. (2020). prevalence and factors for anxiety during the coronavirus disease 2019 (covid-19) epidemic among the teachers in china. j. affect. disord., 277, 153–158. https://doi.org/10.1016/j.jad.2020.08.017. siti, s. s., prasanti, a., and rahmaya n. h. (2021). perbedaan kecemasan intraoperasi pasien sectio caesarea (sc) sebelum dan sesudah diberikan terapi musik di ruang instalasi bedah sentral (ibs) rsud ajibarang. seminar nasional penelitian dan pengabdian kepada masyarakat, 208–215. situmorang, d. d. b. (2017). efektivitas pemberian layanan intervensi music therapy untuk mereduksi academic anxiety mahasiswa terhadap skripsi. jbki (jurnal bimbing. konseling indones.,2 (1), 4. https://thejnp.org/ https://doi.org/10.1016/j.jad.2020.08.017 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 53 59 53 the effectiveness of baby massages using audiovisual approach for improving interactions between mother and infant in kradenan, srimulyo, piyungan, bantul rahmah widyaningrum undergraduate program of nursing, stikes madani yogyakarta corresponding author : rachma.ninov@yahoo.co.id abstract background: the golden period of time (0-12 months) is a critical period for infant that require good stimulation to reach normal physiological development. baby massage is one stimulation method that was given by parents to enhance the bonding between mothers and their babies. audio-visual technique is one of the best method to deliver information for mother to perform self-baby massage at home, further increasing attachment between them. purpose: to evaluatethe effectiveness of baby massages using audiovisual approach for improving interactions between mother and infant in kradenan, srimulyo, piyungan, bantul. methods: this was a quasi experimental design with pretest-posttest. study was conducted from august to september 2017 using total subjects of 20 pairs of mothers and babies. the inclusion criteria were normal birthweight, 38-42 weeks gestation age, apgar score>7, breastfed, and didn’t have contraindication with massage procedure. sample was divided into two groups; treatment group (audio-visual delivery) and control group (leaflet delivery). ten subjects for treatment group were purposively recruited from posyandu pantang mundur, kradenan whereas the others were similarly recruited from posyandu monggang. data was presented as frequency distribution and analyzed using independent sample t-test. results: there was no difference between maternal and infant interactions at the beginning of the study (p = 0.16). after two weeks treatment, there is no significance difference between treatment and control group (p=0.42).mother and infant bonding scorewas increased in treatment group although not significantly different (p=0.21). conclusion: baby massage can improve bonding between mother and baby. further study is required to asses the effectiveness of baby massage on attachment between mother and baby. keywords: audio-visual method, baby massage, maternal and baby interactions received: february 03, 2018; revised february 24, 2018; accepted march 10, 2018 how to cite: widyaningrum, r. (2018). the effectiveness of baby massages using audiovisual approach for improving interactions between mother and infant in kradenan, srimulyo, piyungan, bantul. journal of nursing practice. 1(2). 53-59 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 53 59 54 background bonding is a feeling that arises and grows in the parents of the baby. bonding will appear when the baby is given touch, caress, and massage with the affection of his parents. heath and bainbridge (2006) stated that infant massage is togetherness and physical as well emotional touching between mothers and their infants. mothers can learn to pay attention to the reactions of their babies when touched, knowing their natural instinct and preference, which makes it easier for mothers to understand and sometimes become more patient when they are unable to calm their babies. as the mother notices and recognizes her baby's reaction and responds, the baby will react and establish a positive relationship between them. the affectionate, loving massage provided by the mother will add a strong bonding connection between mother that will support the growth of the baby mentally and emotionally. several studies have reported beneficial effect of infant massage. studyfrom 48 infants at term conducted by field et al (2005), showed an increase in body weight and length after a month of massage by a baby's parents. similar results were found in groups of premature infants who were massaged 3 times a day for 5 days, which can furhter reduce hospital time and save the cost of care for us$ 10,000 per baby (dieter et al., 2003). treatment of 15 minutes massage in premature babies for 3 times a day for 10 days (when in incubator) can increase body weight by 47% compared to control group. in general, baby massage is a massage technique that flows from head to toe of baby. the massage technique must be done smooth and softstarting from the head, face, shoulders, arms, legs, back, chest and ends in the abdomen (mcgrath et al., 2007). furthermore, there are several techniques that mother must know for individually apply the massage to infant. these techniques were based on infant age, the pressure power, massage area, frequency, and position, which can be categorized into three technique groups (roesli, 2001; field et al., 2004). objective this study was to measure to evaluate the effectiveness of baby massages using audiovisual approach for improving interactions between mother and infant in kradenan, srimulyo, piyungan, bantul. methods research design this was a quasi experimental design with pretest-posttest. study was conducted from august to september 2017 using total subjects of 20 pairs of mothers and babies. sample was divided into two groups; treatment group (audio-visual delivery) and control group (leaflet delivery). ten subjects for treatment group were purposively recruited from posyandu pantang mundur, kradenan whereas the others were similarly recruited from posyandu monggang. setting and samples the use of audiovisual media of infant massage is one form of maternal recognition of the benefits, goals, and guidance of movement in performing infant selfmassage by mothers for their babies. the inclusion criteria were normal birthweight (2500 grams 4000 grams), 38-42 weeks gestation age, apgar score>7, breastfed, and didn’t have contraindication with massage procedure. samples totaling 20 pairs of infants taken purposively sampling were divided into intervention groups (given infant massage video journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 53 59 55 and performed infant massage independently) and control group (given infant massage leaflet). data collection and instrument baby mother interactions were measured before being given baby massage video and 2 weeks after mother's baby massage practice to their respective baby. baby massage is a real action in the form of baby massage performed by the mother of the baby independently, with the help of video provided by the researchers. baby massage is done daily 2x per session 15 minutes, for 14 days. the baby massage step is divided into 3 parts: the first 5 minutes the baby is given a gentle massage in the prone position (on the head, shoulders, back, legs and arms). the second five minutes followed by flexion and extension on the arms and legs, then ended the same movement in the first session. the instrument used is the observation sheet is a checklist of baby massage execution, made in the form of 2x / day table for 2 weeks. implementation of baby massage is written with a check mark (√) on the observation sheet. while maternal and infant interactions between mother-infants were measured using maternal attachment inventory (mai) (muller, 1994). the questionnaire consists of 26 items of questions to the respondent to assess: 1) how the mother feels and feels in general about the proximity of his interaction with the baby; 2) perceived by the mother; and 3) the situation experienced by mother and baby. answers were scored between 1 (never) to 4 (always / often) total score ranges between 26 to 104. the validity score is 0.76 and the reliability score 0.90. data analysis data analysis result of research done quantitatively according to research purpose, data analysis used in this research using descriptive analysis (univariat). demographic characteristics are calculated on a percentage and mean basis. while bivariate analysis using paired sample t-test to compare the measurement in each (one) group. while independent paired sample t test was used to compare between groups (intervention and control), the difference between the two groups of pretest and posttest mean values. furthermore, the discussion of the research results obtained. ethical considerations ethical considerationstest of this research is obtained from the ethics committee poltekeskemenkesyogyakarta. informed consent was obtained from each respondent either verbally or in writing filled by the mother regarding her approval in participating in this research. the mother of the infant receives information about the benefits of following this research and has the right to accept, reject or discontinue the study. no sponsorship of any product, researcher uses video of personal work. results subjects characteristics this research was conducted on august september 2017 at posyandupantang mundur,kradenan (treatment group) and posyandubalitamonggang (control group). the samples were purposive sampling with 20 mothers and babies, 10 mothers each for treatment group and control group. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 53 59 56 table 1. characteristics of respondents in posyandupantang mundur kradenan, srimulyo, piyunganbantul (n = 20) characteristics intervension group control group mothers characteristic n (%) n (%) 1. age <20 years old 20 – 29 years old 30 – 39 years old >40 years old 2. education level smp elementary sma high school university 3. occupation house wife civil servant private sectors 4. income <1.125.000 1.125.000-3.000.000 >3.000.000 0 3 6 1 2 7 1 9 0 1 2 7 1 0 30 60 10 20 70 10 90 0 10 20 70 10 0 4 6 0 1 4 5 9 1 0 1 9 0 0 40 60 00 10 40 50 90 10 0 10 90 0 babies characteristic n (%) n (%) 1. age 0-6 months 7-12 months 13-18 months 2. gender of baby female male 3. z score <-2 sd -2 sd +2 sd >+2 sd 5 1 4 3 7 0 10 0 50 10 40 30 70 0 100 0 5 3 2 4 6 0 10 0 50 30 20 40 60 0 100 0 source: primary data, 2017 based on table 1 on mothers characteristic shows that the majority of maternal age range 30-39 years is 6 (60%), whereas the last education of mother of majority is sma (7) (70%) with job almost entirely as housewife (irt) a total of 9 people (90%), and the income of most mothers range 1,125,000 to 3,000,000 a total of 7 people (70%). the babies characteristic indicate that the majority of children in the category of infants are between 0-6 months and 5 people (50%), with the majority sex is 7 men (70%), and all children have tb / bb with z-score calculation between -2 to +2 sd number of 10 people (100%). interactions between mother and infant the results of statistical analysis showed that was no difference between maternal and infant interactions at the beginning of the study (p = 0.16). after two weeks treatment, there is no significance difference between treatment and control group (p=0.42). mother journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 53 59 57 and infant bonding score was increased in treatment group although not significantly different (p=0.21).this suggests that intervention in the form of interaction video delivery is not effective in improving the interaction between mother and baby. table 2. statistical analysis of research results no information control group treatment group significancy (p) # 1 pre-test 3,85±0,11 3,75±0,16 0,16 2 post-test 3,78±0,16 3,83±0,11 0,42 signifikansi (p) $ 0,11 0,21 # independent sample t-test statistical analysis $ paired sample t-teststatistical analysis based on data analysis, there was an increase of adherence level between mother and infant in the treatment group. the results of this study are consistent with research conducted by lee (2006) and gurol and polat (2012), which reported that an increase in the level of adhesions between mothers and infants in a group of mothers who were given the ability or skill to do infant massage. psychological touch of mother will increase the interaction between mother and baby which will indirectly affect health status and baby response to mother's voice and touch (onozawa et al., 2001; moore and anderson, 2007). studies have also shown that infant massage can reducing maternal stress levels such as in mothers with low socioeconomic levels (glover et al., 2002, chiu and anderson, 2009). discussion baby massage is one of the traditional activities performed in several countries such as africa and asia. a study conducted by darmstadt and saha (2002) reported that 96% of nurses in bangladesh’s hospitalhas practice infant massage 1-3 times a day using mustard oil (brassicaceae). the practice of infants massage has been reported to have several benefits such as increasing infant weight, improving sleep quality, increasing essential fatty acids in the body and preventing hypothermia (kulkarni et al., 2010). another study showed that infant massage with oil smear was able to reduce deaths because of nosocomial infections by 41% (darmstadt et al., 2008). in addition, infant massage is also useful for improving the level of adherence between mother and baby (lee, 2006; gurol and polat, 2012). although this study finds improvement, there are some disadvantages. first, the study did not look at maternal compliance rates in the treatment group in performing home massage practices. this leads to an insignificant increase in scores or values between mother and infant closeness. according to kusbiantoro (2014), mother's behavior in practicing baby massage was influenced by mother's knowledge factor and family support. this study did not measure maternal knowledge of infant massage or family support, so control of these two variables needs to be done in subsequent research. the second factor is the duration of intervention. this study was conducted in just 2 weeks, where the provision of this intervention is still not able to increase mother awareness. studies show that the health interventions used to change behavior and give effect at least 3 months to 12 months of intervention (jepson et al., 2010). therefore, studies with a long duration and controlled need to be done to determine the effectiveness of infant massage in improving the interaction between mother and baby. audio-visual aids are those instructional devices which are used in the classroom to encourage learning and make it easier and interesting. the material like charts, map, journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 53 59 58 models, film strip, projectors radio, television etc called instructional aids (rather, 2004). audio-visual aids are devices present unit of knowledge through auditory of visual. stimuli both with a view to help learning (singh, 2005). audio-visual aids are valuable tools in education more so, in the field of health education as these have a long-lasting impression on the target population. video enhances, dramatizes, and brings a sense of realism, which can have a great impact on the population (naseem shah et al, 2016). conclusion the conclusion of this study was the intervention of baby massage can improve the closeness between mother and baby. further studies with better and controlled designs still need to be done to see the effectiveness of infant massage intervention with regard to confounding or external variables. acknowledgments researchers are grateful to all mothers who participated in this study. this study was funded by private higher education coordinator, region v, yogyakarta province. references chiu sh dan anderson gc. 2009. effect of early skin-to-skin contact on mother-preterm infant interaction through 18 months: randomized controlled trial. nternational journal of nursing studies; 46:1168-1180. darmstadt gl, saha sk, ahmed as, ahmed s, chowdhury ma, law pa, rosenberg re, black re, santosham m. 2008. effect of skin barrier therapy on neonatal mortality rates in preterm infants in bangladesh: a randomized, controlled, clinical trial. pediatrics; 121(3): 522-9. doi: 10.1542/peds.2007-0213. darmstadt, g.l. dan saha s.k. 2002. traditional practice of oil massage of neonates in bangladesh. j health popul nutr.; 20(2):184-8. dieter, j.n.i., field, t.m, hernandez-reif, m., emory, e.k & redzepi, m. 2003. stable preterm infants gain more weight and sleep less after five days of massage therapy. j pediatr psychol, 28(6):403-411. field, t m. 2003. stimulation of preterm infants. pediatr rev;24:4-11. field, t.m, diego, m. & hernandez-reif, m. 2005. massage therapy research. dev rev, 27(1):75-89 glover v, onozawa k, hodgkinson a. 2002. benefits of infant massage for mothers with postnatal depression. seminars in neonatology; 7: 495-500. gurol, a dan polat s. 2012. the effects of baby massage on attachment between mother and their infants. asian nursing research; 6(1): 35-41. heath, a. & bainbridge, n. 2006. baby massage kekuatan menenangkan dari sentuhan. jakarta: dian rakyat. jepson rg, harris fm, platt s, tannahil c. 2010. the effectiveness of interventions to change six health behaviours: a review of reviews. bmc public health; 10:538. kulkarni a, kaushik js, gupta p, sharma h, agrawal rk. 2010. massage and touch therapy in neonates: the current evidence. indian pediatrics; 47: 771-776. lee, h.k. 2006. the effects of infant massage on weight, height, and mother-infant interaction. journal of korean academy of nursing; 36: 1331-39. mcgrath, j.m, thillet, m. & cleave, l.v. 2007. parent delivered infant massage: are we truly ready for implementation? newborn infant nurs rev, 7(1):39-46 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 53 59 59 naseem shah, vijay prakash mathur, tanupriya gupta. effectiveness of an educational video in improving oral health knowledge in a hospital setting. indian j dent. 2016 apr-jun; 7 (2): 70-75. onozawa k, glover v, adams d, modi n, kumar rc. 2001. infant massage improves mother–infant interaction for mothers with postnatal depression. journal of affective disorders; 63: 201-207. rasul, s., bukhsh, q., batool, s. 2011. a study to analyze the effectiveness of audiovisual aids in teaching learning process at university level. journal of procedia, social and behavioral sciences 28 (2011) 78-81. rather, ar. 2004. essentials intructional technology, published by darya gaj new delhi. roesli, u. 2001. pedoman pijat bayi prematur dan bayi usia 0 – 3 bulan. jakarta: trubus agriwidya singh, y. 2005. instructional technology in education, published by darya gaj new delhi. journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.106-112 106 determinants of community on covid-19 vaccine participation in rt 01 rw 05, ngadiluwih village kediri district lingga kusuma wardani1*, alfi aqliana nur fahma2, dhita kurnia sari3, nur yeny hidajaturrokhmah4, dedi saifulah5, retno palupi yonni siwi6 1,2,3,4,5 department of nursing, institut ilmu kesehatan strada indonesia, kediri, indonesia 6 department of midwifery, institut ilmu kesehatan strada indonesia, kediri, indonesia *corresponding author: linggakusumawardani@gmail.com abstract background: coronavirus disease 2019 (covid 19) is an infectious disease that is becoming a global pandemic. the purpose of this study was to analyze the effect of social support and trust on the participation of the covid-19 vaccine in the community in rt 01 rw 05 ngadiluwih village, kediri regency. purpose: the design of this study is an observational quantitative study with a cross sectional approach with the focus of the research directed at analyzing the effect of social support and trust on the participation of the covid-19 vaccine in the community in rt 01 rw 05 ngadiluwih village, kediri regency. the total population is 62 respondents and a sample of 54 respondents is taken by using simple random sampling technique. methods: the findings showed that almost half of the respondents had sufficient social support category as many as 22 respondents (40.74%). almost half of the respondents have confidence in the medium category as many as 25 respondents (46.30%). most of the respondents participated in vaccination in the complete category as many as 30 respondents (55.56%). results: based on the results of the logistics regression analysis showing that the p-value of 0.001 it was concluded that there was an effect of social support on the participation of the covid-19 vaccine in the community in rt 01 rw 05 ngadiluwih village, kediri regency. and the p-value of 0.004 <0.05, h1 is accepted, so it can be concluded that there is an influence of trust on the participation of the covid-19 vaccine in the community in rt 01 rw 05 ngadiluwih village, kediri regency. conclusion: it is hoped that the community can carry out a complete covid-19 vaccination, both vaccine 1 and vaccine 2, and even attempt to participate in conducting booster vaccines to stop the spread of covid-19. keywords: covid-19, participation & trust, social support received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.365 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:linggakusumawardani@gmail.com https://doi.org/10.30994/jnp.v6i2.365 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.106-112 107 background corona virus disease 2019 (covid 19) is an infectious disease that is becoming a global pandemic. by 2020, millions of people will fall ill and die from this disease every day. among the confirmed cases, the death rate of covid-19 is around 2.67%. the mode of transmission is mainly through respiratory droplets and contact. everyone is usually susceptible to this virus (deng and peng, 2020). at this time covid 19 is a serious problem worldwide, and the number of cases is increasing every day. attacking everyone, regardless of age or gender, is considered a global pandemic. the global covid-19 pandemic was first announced on march 11, 2020, indicating that the virus has infected many people in various countries (world health organization, 2020). indonesia is one of the countries where covid-19 has been confirmed. on march 2, 2020, indonesia reported 2 confirmed cases of covid-19. starting from this case, the number of cases of indonesian people infected with the corona virus is increasing every day. as of july 13 2021, covid-19 cases in indonesia have reached 2,615,529 confirmed cases with the number of deaths from covid-19 amounting to 68,219 cases (2.6%). indonesia is a country with the highest confirmed case rate in southeast asia (ri ministry of health, 2020). then on july 13 2021 in south sumatra there were 33,207 confirmed cases with 1,628 deaths (4.90%) and the highest number of deaths was in ogan komering ilir district. this condition has a direct impact on millions and even the entire world community, as a result of the implementation of health protocols that must be stipulated in all aspects of activity, ranging from social restrictions to total lockdowns that hinder all community activities. if the spread of the virus is not controlled effectively, the sequelae of covid-19 can become a major challenge for the world's health system and have a major impact on the global economy (rachman and pramana, 2020). based on the results of a preliminary study conducted by researchers on may 17, 2022, 20 people in ngadiluwih village, kediri regency, found that a total of 6 respondents (30%) did the complete covid 19 vaccine, both vaccines 1 and 2, besides that, a number of 12 respondents (60%) did the covid-19 vaccine was not complete, namely only 1 vaccine, while a number of 2 respondents (10%) had never done a covid-19 vaccine. based on the information stated by all respondents, it was found that the majority of respondents felt that the covid-19 vaccine was not necessary if it was to anticipate being exposed to the covid-19 virus where this was due to the large number of cases of people who had been vaccinated, but many were exposed to the covid-19 virus, so that people thought that by being vaccinated instead it puts you at risk of being exposed to covid 19, and besides that most people do vaccines because of administrative needs such as obligations when going to school, working and even going to certain places that require you to have had the vaccine. this vaccination solution again caused controversy for some people. first, because there are doubts about vaccine development, because the vaccine development time is quite short, about one year. this is different from other vaccines which may take years. this then raises public concern about the side effects or impact of vaccines on vaccine providers (pranita, 2020). so that people's perceptions and attitudes become a benchmark for people's awareness. promotive and preventive efforts must be carried out by health workers and the community. the development of the internet and the latest convenience of information provide support for the amount of information. the spread of misinformation will influence people's perceptions of the covid-19 vaccine and thereby influence people's behavior. decisions and choices made are based more on information from the internet, especially social media (moudy and syakurah, 2020). social, emotional support, real action and information are urgently needed, especially during the covid-19 outbreak. many parties disseminate information related to covid-19, https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.106-112 108 so that the public can know well. this support is expected to be able to encourage (reinforcing) the formation of covid-19 prevention behavior in everyone. uchino (2020) explains that social support refers to the comfort, care, appreciation, or assistance provided by individuals or other groups to individuals. this support can come from a spouse, family, friends, health workers or the community. research shows that increased social support is significantly associated with lower psychological distress. the survey showed that more than 70% of the public was aware of the government's discourse on carrying out national vaccinations in an effort to reduce the rate of covid-19 cases. the majority of people (around 65%) are willing to accept the covid-19 vaccine if it is provided by the government, while around 27% are hesitant and a small number (8%) refuse. aceh and west sumatra are the provinces with the lowest revenue (below 50%). meanwhile, the regions with the highest receipts were west papua with 74% and the nusa tenggara islands with 70% (ministry of health ri, 2021). based on the conditions above, the authors are interested in researching the determinants of the participation of the covid-19 vaccine in the community at rt 01 rw 05 ngadiluwih village, kediri regency. methods in this study, researchers used a quantitative analytic design with a cross-sectional approach, namely a study to study the dynamics of the correlation between risk factors and effects, by way of approach, observation or data collection at one time (point time approach), that is, each subject the study was only observed once and measurements were made of the character status or subject variables at the time of examination. this does not mean that all research subjects are observed at the same time (soekidjo, 2017). this study will analyze the effect of social support and trust on the participation of the covid-19 vaccine in the community in rt 01 rw 05 ngadiluwih village, kediri regency with a population of 62 respondents and a sample of 54 respondents who were taken using the simple random sampling technic. results social support table 1 distribution of the frequency of respondents based on the social support of the respondents in rt 01 rw 05 ngadiluwih village, kediri regency which was held on 13-25 september 2022 with a total of 54 respondents kriteria frekuensi persen (%) good 15 27,78% sufficient 22 40,74% deficient 17 31,48% total 54 100,00% based on table 1 above, it is known that almost half of the respondents have social support in the sufficient category, as many as 22 respondents (40.74%). trust table 2 distribution of the frequency of respondents based on the beliefs of the respondents in rt 01 rw 05 ngadiluwih village, kediri regency which was held on 13-25 september 2022 with a total of 54 respondents https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.106-112 109 kriteria frekuensi persen (%) high 11 20,37% moderate 25 46,30% low 18 33,33% total 54 100,00% based on table 2 above, it is known that almost half of the respondents have confidence in the medium category of 25 respondents (46.30%). participation table 3 distribution of the frequency of respondents based on the participation of respondents in rt 01 rw 05 ngadiluwih village, kediri regency which was held on 13-25 september 2022 with a total of 54 respondents kriteria frekuensi persen (%) complete 30 55,56% incomplete 24 44,44% total 54 100,00% based on table 3 above, it is known that the majority of respondents participated in carrying out vaccinations in the complete category, as many as 30 respondents (55.56%). statistical test results table 4. results of logistic regression analysis on the determinants of the participation of the covid-19 vaccine in the community at rt 01 rw 05 ngadiluwih village, kediri regency which was held on 13-25 september 2022 with a total of 54 respondents the effect of social support on participation based on the results of the logistic regression analysis, it shows that the p-value is 0.001 <0.05, so h1 is accepted, so it is concluded that there is an effect of social support on the participation of the covid-19 vaccine in the community in rt 01 rw 05 ngadiluwih village, kediri regency. the effect of trust on participation based on the results of the logistic regression analysis, it shows that the p-value is 0.004 <0.05, so h1 is accepted, so it is concluded that there is an influence of trust on the participation of the covid-19 vaccine in the community in rt 01 rw 05 ngadiluwih village, kediri regency. discussion social support to the community in rt 01 rw 05 ngadiluwih village, kediri regency the results showed that almost half of the respondents had adequate social support, 22 respondents (40.74%). in addition, a number of 17 respondents (31.48%) had less social support. meanwhile, 15 respondents (27.78%) had good social support. social support can come from a spouse or partner, family members, friends, social and community contacts, a group of friends, church or mosque congregation, and co-workers or your boss at work. (taylor, et al., 2009). meanwhile, according to tarmidi & kambe (2010) social support can be applied to the family environment, namely parents. so parental social support is the support given by parents to their children either emotionally, appreciation, information or groups. parental support is associated with academic success, positive selfimage, self-esteem, self-confidence, motivation and mental health. parents' social support can be divided into two things, namely positive support and negative support. positive support is positive behavior shown by parents, negative support is behavior that is considered negative which can lead to negative behavior in children. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.106-112 110 trust in the covid-19 vaccine in the community in rt 01 rw 05 ngadiluwih village, kediri regency the results showed that almost half of the respondents had confidence in the medium category, as many as 25 respondents (46.30%). in addition, a number of 18 respondents (33.33%) have confidence in the low category. while a number of 11 respondents (20.37%) have confidence in the high category. according to researchers, trust is a hope held by an individual when words, promises, oral or written statements from an individual or other group can be realized. where the things that are said by health workers can be trusted by the community or patients and believe in all their recommendations to do. based on the results of the study, it was found that many people have low level of trust in vaccines, which is due to their lack of knowledge of the benefits of vaccines and also due to poor perceptions of health workers. community participation in covid-19 vaccination in rt 01 rw 05 ngadiluwih village, kediri regency the results of the study showed that the majority of respondents participated in the complete category of vaccination with 30 respondents (55.56%). meanwhile, 24 respondents (44.44%) participated in the incomplete category of vaccination. the effect of social support on the participation of the covid-19 vaccine in the community in rt 01 rw 05 ngadiluwih village, kediri regency based on the results of the logistic regression analysis, it shows that the p-value is 0.001 <0.05, so h1 is accepted, so it is concluded that there is an effect of social support on the participation of the covid-19 vaccine in the community in rt 01 rw 05 ngadiluwih village, kediri regency. social support can be effective in dealing with psychological distress during difficult and stressful times. for example, social support helps students deal with stressors in campus life. social support also helps strengthen immune function, reduce physiological responses to stress, and strengthen function to respond to chronic disease. (taylor, et al., 2009). the effect of trust on the participation of the covid-19 vaccine in the community at rt 01 rw 05 ngadiluwih village, kediri regency based on the results of the logistic regression analysis, it shows that the p-value is 0.004 <0.05, so h1 is accepted, so it is concluded that there is an influence of trust on the participation of the covid-19 vaccine in the community in rt 01 rw 05 ngadiluwih village, kediri regency. based on the information stated by all respondents, it was found that the majority of respondents felt that the covid-19 vaccine was not necessary if it was to anticipate being exposed to the covid-19 virus, which was due to the large number of cases of people who had been vaccinated, but many were exposed to the covid-19 virus, so that people thought that by being vaccinated instead it puts you at risk of being exposed to covid 19, and besides that most people do vaccines because of administrative needs such as obligations when going to school, working and even going to certain places that require you to have had the vaccine. conclusion 1. nearly half of the respondents had adequate social support, 22 respondents (40.74%). 2. nearly half of the respondents have confidence in the medium category as many as 25 respondents (46.30%). 3. most of the respondents had participated in the vaccination in the complete category of 30 respondents (55.56%). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.106-112 111 4. there is an effect of social support on the participation of the covid-19 vaccine in the community in rt 01 rw 05 ngadiluwih village, kediri regency. 5. there is an influence of trust in the participation of the covid-19 vaccine in the community in rt 01 rw 05 ngadiluwih village, kediri regency. references aditama, tjandra yoga. 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(2020). corona virus diseases (covid-19): sebuah tinjauan literatur. wellness and healthy magazine. https://thejnp.org/ journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 60 65 60 effect of nursing compliance in washing hand to phlebitis physical events in graha room hita husada dr iskak tulungagung hospital aprin rusmawati 1 , dedi eko subekti 2 , heri saputro 3 1,3 stikes surya mitra husada kediri 2 rsud dr iskak tulungagung corresponding author : akbaraprin@gmail.com abstract bacground: compliance of nurses in implementing a fixed procedure of nursing actions, including hand washing procedures, became one of the determinants of the success of prevention of nosocomial infections. noncompliance of nurses in hand washing may lead to an increase in the incidence of phlebitis. purpose: the influence of nurse compliance in hand washing of phlebitis incidence rate in graha hita husada room dr iskak tulungagung hospital. method: the design of this study was observational with cross-sectional design with population all the nurses in graha hita room dr. iskak tulungagung hospital number of 54 nurses. the sample is part of population that is 48 respondents with sampling technique by simple random sampling. the data that have been collected is processed by linear regression statistic test with significance α = 0,05. result: the results showed that most of the respondents had compliance with handwashing compliance, ie 38 respondents (79.2%) and most of the respondents did not experience phlebitis incidence, ie 34 respondents (70.8%). result of analysis of linear regression test got value p-value = 0,000 (<0,05) with value of r square 0,639 which means reject h0 and accept h1 so that there is relation of nurse compliance in hand washing with number of phlebitis incident in graha hita husada room dr iskak tulungagung hospital. conclusion: from the results of this study prove the compliance of nurses in hand washing by applying six steps of hand washing and five moments hand washing correctly and accurately able to prevent the incidence of phlebitis. keywords: compliance, hand washing, phlebitis received: february 03, 2018; revised february 24, 2018; accepted march 10, 2018 how to cite: rusmawati, a., subekti, d.e., & saputro, h. (2018). effect of nursing compliance in washing hand to phlebitis physical events in graha room hita husada dr iskak tulungagung hospital. journal of nursing practice. 1(2). 60-65 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 60 65 61 background hospitals efforts to improve the quality of health services, including services provided by nurses. the nurse is a 24-hour medical assistant along with the hospitalized patient. the role of the nurse is very large in the process of healing the patient. nurses are required to have the knowledge, skills and good attitude during caring for the patient. compliance of nurses in implementing a fixed procedure of nursing actions, including hand washing procedures, became one of the determinants of the success of prevention of nosocomial infections. the level of nurse compliance in handwashing in the united states is still around 50%, in australia still around 65%. similarly, handwashing program since 2008 is proclaimed at cipto mangunkusumo hospital (rscm) but nurse compliance is only about 60%. it was serious challenge for hospital infection control teams to promote handwashing programs.2 nosocomial infections cause 1.4 million deaths every day worldwide.3 the incidence of nosocomial infections has been one of the benchmarks for hospital service quality. the results of handoyo's research, et al (2006) phlebitis incidence in hospital surgery wards prof.dr. margono soekardjo purwokerto at 31.7%. each day found an average of 2-4 patients with phlebitis. treating phlebitis becomes very important because if not treated it can lead to sepsis. the incidence of infection in indonesia associated with health care type or type of hospital is very diverse. a study conducted by the ministry of health of the republic of indonesia in 2007 obtained data on the proportion of infections related to health services in government hospitals with 55.1%, while for private hospitals with 35.7%. abri hospital with 9.1%. from the data of the ppi committee in dr. iskak tulungagung hospital in september 2016 the incidence of hais of 0.3 ‰. based on preliminary studies conducted by researchers on december 31, 2016, known phlebitis incidence rate in graha hita room reached 13.9%. this shows that the phlebitis incidence rate in graha hita room is still very high. microorganisms have several ways of transmission to help facilitate the transfer of an agent from a reservoir to a vulnerable host. mechanism of transmission of infection through direct, indirect, and airborne transmission. during medical care, the hands of healthcare workers often come into contact with patients. thus, the hands of the clinician are the most common means for transmission of infection. transmission through this route is more common than vector, congenital or direct and indirect contacts. hand washing is the most important action and the only way to prevent the onset of disease. hand washing is a process that mechanically removes dirt and debris from the skin of the hands using ordinary soap and water. hand washing can also be done by using antiseptic or antimicrobial agents. a frequently used antiseptic agent is an antiseptic handrub or alcohol-based handrub. the use of an antiseptic handrub for clean hands is more effective at killing resident flora and transient flora than washing hands with antiseptic soap or plain soap and water. complete hand washing with adequate amounts of water and soap can remove up to 90% of the temporary flora. disinfection with alcohol is used to kill microorganisms and contaminants.6 increase patient resistance to infection, including nutritional status and susceptibility to infection in an effort to suppress infection transmission. failure in hand washing is triggered by limited handwashing facilities, such as sinks, paper towels, hand dryers and antiseptic liquids. however, when there are facilities, the next obstacle is the lack of awareness of the health worker (nurse) to perform journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 60 65 62 handwashing procedures so that the nurse does not wash hands thoroughly. who complies with the principles of six-step handwashing and five handwashing moments noncompliance of nurses in hand washing may lead to an increase in the incidence of phlebitis. phlebitis is a complication at the time of fluid therapy. the occurrence of phlebitis can be caused by bacterial (infectious), mechanical and chemical non-infectious phlebitis. infection due to iv therapy is an infection caused by contamination by germs in the cannula and stab wound to enter the cannula, and contamination of germs in infusion fluid. canal-related infections can occur with or without fever and bacteremia, and may include purulent thromboplebitis, cellulitis and local infection. infection is usually preceded or accompanied by phlebitis (usually warm and reddish skin over a soft or hard veins). although it can be caused by infection, phlebitis is usually caused by mechanical or chemical irritation of the cannula or intravenous fluids. the occurrence of infection rates will cause many losses, among others, causing death, either directly or indirectly and make the patient in hospital for longer and more expensive.8 infection-related health services can occur to patients, health workers, as well as everyone who comes to the hospital. this infection can be transmitted or acquired through health workers, sick people, and visitors with a career or hospital status. the solution to be made is that hospitals need to develop infection prevention and control programs. implementation of infection prevention and control programme (ipcp), is one form of patient safety program. the purpose of ipcp is to improve the quality of hospital services and other health facilities through infection prevention and control, to protect human health and public health from dangerous infectious diseases, and to reduce the rate of phlebitis. given the high risk of occurrence health care associated infection (hais) especially phlebitis, an action should be taken to prevent increased spread of infection. prevention can be done by evaluation of phlebitis events and also evaluation of nurse compliance in hand washing objective this study was to influence of nurse compliance in hand washing of phlebitis incidence rate in graha hita husada room dr iskak tulungagung hospital. methods this research was an observational analytic study with the population of all nurses in graha hita room dr. iskak tulungagung hospital number of 54 nurses. a sample of 48 respondents with simple random sampling and using observational list. independent variable used in this research is nurse compliance in hand washing, while the dependent variable used is phlebitis incidence. results handwashing compliance most of the respondents had compliance with handwashing compliance 38 respondents (79.2%). phlebitis incidence most of the respondents did not experience phlebitis incidence, is 34 respondents (70.8%). cross tabulation results showed 34 respondents (70.8%) who had compliance level of handwashing compliance and also did not experience phlebitis. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 60 65 63 statistical test results by using linear regression test: model sum of squares df mean square f sig. 1 regression 6.338 1 6.338 81.458 .000 a residual 3.579 46 .078 total 9.917 47 a. predictors: (constant), handwashing compliance b. dependent variable phlebitis incidence based on the above table it is known that p-value = 0,000 (<0.05) which means reject h0 and accept h1 so that there is influence of nurse compliance in hand washing with phlebitis incidence in graha hita husada room dr iskak tulungagung hospital. discussion nursing compliance in hand washing in graha hita husada room dr. iskak tulungagung hospital based on the results of research that has been done is known from 48 respondents, most of the respondents have compliance handwashing obedient, that is 38 respondents (79.2%). this is supported by cross-tabulation data of respondent's characteristic with handwashing compliance variable, in which obedient handwashing compliance experienced by respondents aged 31-40 years and age 41-50 years ie 15 respondents (31.2%), female 21 respondents (43,8%), have nursing diii education that is 23 respondents (47,9%) and have worked for 6-10 year that is 20 respondent (41,7%). menurut smet (1994) yang dikutip oleh emaliyawati (2013), obedience is the degree to which a person performs a way or behaves according to what is suggested or charged to it. compliance is part of the individual's behavior to obey or obey something. obedience is obedient, obedient, obedient to command, rule, discipline. factors affecting the implementation of nurse hand hygiene include age, education level, level of knowledge, length of service, availability of hand washing facilities, patient condition and hospital policy. 11 the results showed that most nurses were adherent in hand washing based on 5 handwashing moments prior to contact with the patient, prior to aseptic procedure, after exposure to body fluids, after contact with the patient and after contact with the patient's environment. this is certainly supported by the characteristics of respondents, where most respondents aged 31-40 years and age 41-50 years, female sex, educated diii nursing and have a working period of 6-10 years. in this study found the respondents who are not obedient in doing hand washing with disobeying the five moments of hand washing. this is due to lack of awareness of the nurse who causes less compliance nurse to wash hands. nurses working in hospitals have different characters and vary greatly both level of education, age, employment, and level of knowledge. differences of these characteristics will certainly affect the mastery of science, skills, and professional attitude of a nurse in performing its role. some experts as stated by smet, said that compliance is influenced by internal factors and external factors. internal factors that influence compliance can be none other than the characteristics of the nurse itself. this is why there are still nurses who do not obey the implementation of hand washing. phlebitis incidents in graha hita husada room dr. iskak tulungagung hospital journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 60 65 64 based on the results of research that has been done is known from 48 respondents, most of the respondents did not experience phlebitis, ie 34 respondents (70.8%). this is supported by cross-tabulation data of respondent's characteristic with phlebitis incidence variable, where the result of non phlebitis research is experienced by respondents aged 3140 years, ie 15 respondents (31.2%), female sex is 19 respondents (39.6% ), educated by diii that is 21 respondents (43,8%) and has worked for 6-10 year 17 respondents (35,4%). plebitis is defined as venous inflammation caused by both mechanical, chemical, and bacterial irritation. plebitis is characterized by the presence of red and warm areas around intravenous or venous fitting, pain and swelling plebitis is caused by mechanical factors, chemical factors and bacterial factors including poor handwashing techniques, failure to inspect damaged equipment, leaky or torn wrapping invites bacteria, poor aseptic techniques, poor cannula-mounting techniques, cannula installed too long and places injection rarely in visual inspection. 11 based on the results of the study, it is known that most of the respondents did not experience phlebitis incidence. this is because in the installation of infusion, the nurse has done the installation of infusion in accordance with the procedure (sop) that has been established, including hand washing procedures with six steps five moments. based on the results of this study known phlebitis incidence rate in graha hita husada room is 29.2%. this suggests that there is still phlebitis occurrence in the chamber although most patients do not experience phlebitis. this can be caused by the existence of nurses who are less adhere to hand wash with six steps and five moments of hand washing so that there is transmission of microorganisms to the intravenous needle piercing area. other causes of phlebitis can also be caused by mechanical factors and chemical factors not examined in this study but may affect the results of this study so that it can cause phlebitis. influence of nurses compliance in handwashing with phlebitis incidents in graha hita husada room dr. iskak tulungagung hospital based on the cross-tabulation between the variables, it was found that there were 34 respondents (70.8%) who had compliance level of handwashing and did not experience phlebitis. in addition there are also 4 respondents (8.3%) who wash their hands obediently but still experienced phlebitis, 10 respondents (20.8%) respondents who did not obey hand washing and also experienced phlebitis. based on the result of statistic test of linear regression with significance level α = 0.05, has p-value = 0,000 (<0,05) with r square 0,639 which means reject h0 and accept h1 so that there is influence of nurse compliance in hand washing with phlebitis at graha hita husada dr iskak tulungagung hospital. compliance is the basic capital a person behaves. according to kelmen and emaliyawati (2010) explained that changes in attitudes and behavior of individuals starting with the process of compliance, identification, and the last stage of internalization. at the beginning the individual obeys the advice / instruction without willingness to perform such acts and often because he wants to avoid punishment if he is disobedient, or to get the reward promised if he obeys the advice. this stage is called compliance stage. usually the changes that occur at this stage is temporary, meaning that the action was done dive there is still supervision. intravenous therapy can not be separated from complications. complications that can be obtained from intravenous therapy are systemic complications and local complications. systemic complications are less common but often more serious than local complications such as circulatory overload, air embolism and infection. local journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 60 65 65 complications of intravenous therapy include infiltration, phlebitis, thrombophlebitis, hematoma, and extravasation. phlebitis is inflammation of the veins caused by catheters or chemical irritants of additives and drugs administered intravenously. 7 the results showed that there was a significant effect of handwashing compliance with phlebitis occurrence, and this was consistent with existing theories that with proper handwashing corresponding to six-step and five handwashing moments could prevent phlebitis in patients. the existence of this effect is also reinforced by the results of research that can be seen on cross tabulation between hand compliance compliance variable with phlebitis incidence. in this study, it was found that nurse compliance in applying six step five handwashing moment was directly proportional to phlebitis occurrence so that most of the respondents did not have phlebitis, and in disobedient nurses in applying six step five handwashing moment will result in phlebitis incidence. references menteri kesehatan republik indonesia. 2011. permenkes no 1691/ menkes/per.viii.. tentang keselamatan pasien rumah sakit. susiati. 2013. panduan praktik keperawatan nosokomial cetakan ke i. yogyakarta : citra aji parama who. 2012. world alliance of patient safety and who guidelines on hand hygiene in health care anvanced draft. from; www.who. int/patient safety. diakses tanggal 2o desember 2016. brunner and suddarth. 2012. keperawatan medikal bedah edisi 8 volume 2. jakarta : egc. depkes ri. 2013. cuci tangan pakai sabun dapat mencegah berbagai penyakit. from http://www. depkes.go.id. diakses tanggal 1 januari 2017. pruss, et al. 2015. infection control in the hospital second edition. potter & perry. 2013. buku saku ketrampilan dan prosedur dasar. jakarta : egc. darmadi. 2013. infeksi nosokomial, problematika dan pengendaliannya. jakarta : salemba medika. cdc. 2012. clean your hands: a simple way to prevent infection. bersumber : : digilib.ampl.or.id/detail/detail.php?row=2&tp=artikel&ktg=sanitasi&kd_linl=kode =257-16. (diakses tanggal 24 desember 2016). kemenkes. 2014. pedoman teknis penilaian kinerja individu direktur utama rumah sakit dan kepala balai. jakarta : direj bina upaya kesehatan. sax, h, et al. 2012. infusion nursing standart of practice. http://www.who/ http://www/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.207-213 207 the effect of electronic tindak lanjut tensiku (e-titenku) model to knowledge of coronary heart disease prevention sidik awaludin1*, galih noor alivian1, aprilia kartikasari1, dwi novitasari2 1 department of health sciences, jenderal soedirman university, indonesia 2 department of health sciences, university of harapan bangsa, indonesia *corresponding author: abifayza@yahoo.co.id abstract background: cardiovascular disease is still a major global health problem. hypertension is the most risk factor for the incidence of cardiovascular disease and increases the risk of death. primary and secondary prevention efforts are needed by increasing patient awareness of identifying risk factors and carrying out preventive management. “electronic-tindak lanjut tensiku”, known as e-titenku, is a web and smartphone-based application designed to manage coronary heart disease prevention in patients with hypertension. purpose: the purpose of this study was to determine the effect of the e-titenku intervention model on knowledge of coronary heart disease prevention. methods: this research design is true experiment pre and post control group design. the sample size is 120 respondents with primary hypertension in banyumas regency, indonesia. the sampling technique used is simple random sampling. the inclusion criteria included respondents with primary hypertension, adults aged 40-65 years, cooperative and willing to be respondents, while the exclusion criteria were respondents experienced complications of other diseases due to hypertension. results: the results of the study were that the mean score of pre-intervention knowledge in the treatment group was 3.65, while in the control group was 3.43. while the mean score of knowledge after the intervention was 7.98 and the score of knowledge on the second measurement in the control group was 3.53. conclusion: the e-titenku intervention model was able to increase the knowledge score of coronary heart disease prevention. this model can be used by nurses in hospital and community services. keywords: blood pressure, coronary heart disease, intervention model, knowledge, smartphone received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.380 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:abifayza@yahoo.co.id https://doi.org/10.30994/jnp.v6i2.300 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.207-213 208 background cardiovascular disease is still a major global health problem. hypertension is the most risk factor for the incidence of heart disease and increases the risk of death from cardiovascular disease (james et al., 2014; shrout et al., 2017; utami & azam, 2019). the incidence of hypertension in indonesia is quite high. the results of the 2018 basic health research (riskesdas) show that most cases of hypertension in the community have not been diagnosed. the prevalence of hypertension at the age of 18 years and over in indonesia is 34.11%, which routinely measures blood pressure is only 12%, the incidence of hypertension will increase with increasing age (kemenkes ri, 2018). hypertension is a cardiovascular disorder characterized by systolic blood pressure of more than 140 mmhg and diastolic blood pressure of more than 90 mmhg (an et al., 2021; shrout et al., 2017). patients with hypertension often do not experience symptoms, they will feel symptoms if they have experienced complications in other organ systems, for example to the heart and cause coronary heart disease, which can be life threatening. the majority of hypertensive patients find that they have hypertension accidentally, that is, when they experience severe complaints and complications and blood pressure checks, it turns out that their blood pressure is very high, this incident causes a more complex management (awaludin et al., 2020). seeing this phenomenon, high blood pressure experienced by sufferers needs to be carried out in primary and secondary prevention efforts by increasing patient awareness of identifying risk factors and carrying out preventive management of coronary heart disease events (febriani & fitri, 2019; indrawati, 2015). efforts can be made in the form of discontinuing the known blood pressure. the first effort is through increasing knowledge and making immediate efforts to follow up on high blood pressure experienced in accordance with high blood pressure management guidelines, such as quitting smoking, low-salt diet, exercising regularly, reducing psychological stress, regularly taking antihypertensive drugs given, and monitor blood pressure regularly (mullie & clarys, 2011; nuraeni et al., 2016; su et al., 2021). increased follow-up can be pursued through a medium that is currently easily accessible, namely mobile health (m-health). m-health is a rapidly evolving health information delivery methodology with high potential in health care and health outcomes. in particular, m-health has the potential to enhance primary and secondary disease prevention and deliver personalized, adaptive and sustainable interventions, improve patient communication, access to treatment services, healthcare, and patient engagement and provide real-time medication monitoring and adherence support. the use of m-health can use applications on smartphones (hamilton et al., 2018; neubeck et al., 2015). nowadays almost every family already has a smartphone device. e-titenku is a web-based and smartphone-based application designed to manage coronary heart disease prevention in patients with hypertension. this application contains the interpretation of the results of independent blood pressure checks and intervention guidelines that must be carried out by people with hypertension after knowing their blood pressure. the guidelines in the smartphone application can provide information related to efforts to prevent heart disease through controlling blood pressure that will be carried out by people with hypertension. the purpose of this study was to determine the effect of the e-titenku model on knowledge of coronary heart disease prevention. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.207-213 209 methods this study used true experimental pre and post control group design. the sample size was 120 respondents, 60 intervention groups and 60 control groups. the sampling technique used is simple random sampling. the inclusion criteria included respondents with primary hypertension, adults aged 40-65 years, cooperative and willing to become respondents, while the exclusion criteria were respondents experienced complications of other diseases due to hypertension. data was collected by creating two groups of patients, namely the intervention group which was given model intervention and the control group was given standard intervention. the measurement of knowledge scores was carried out using an observation sheet. the knowledge score measurement in the intervention group was carried out 2 times, before being given therapy and immediately after the intervention model. this research has passed the ethical test of the ethics committee of jenderal soedirman university no: 771/ec/kepk/iv/2022. results characteristics of the respondents table 1. frequency distribution of respondents by age, systolic and diastolic blood pressure (n=120) characteristics intervention group (n=60) control group (n=60) mean sd mean sd age 64,91 4,06 65,98 3,08 blood pressure systolic diastolic 169 97 11,34 9,67 172 93 16,42 6,94 characteristics of respondents according to age, gender, and systolic and diastolic blood pressure tabel 2. frequency distribution of respondents by gender (n=120) characteristics of respondents intervention group (n=60) frequency percentage (%) control group (n=60) frequency percentage (%) gender man woman 31 29 51,7 48,3 37 23 61,7 38,3 tables 1 and 2 show the characteristics of the respondents in the intervention group, namely the mean age of 64.91 years, systolic blood pressure of 169 mmhg and diastolic blood pressure of 97 mmhg, most of which were male in the intervention group (51.7%) and the control group (61.7%). characteristics of respondents in the control group, namely the average age of 65.98, the mean systolic blood pressure of 172 mmhg and diastolic of 93 mmhg. knowledge score description table 3. description of knowledge score average (n=120) variable intervention group (n=60) mean control group (n=60) mean knowledge score pre-intervention post-intervention 3,65 7,98 3,43 3,53 https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.207-213 210 table 3 shows the categories of the mean pre-intervention knowledge score in the intervention group 3.65, while in the control group 3.43. while the mean score of knowledge after the intervention was 7.98 and the score of knowledge on the second measurement in the control group was 3.53. bivariate analysis in this study was carried out after the data normality test and homogeneity test were carried out. the results of the data normality test on the knowledge variable for the treatment and control groups used the kolmogorov-smirnov test which showed that all variables had a p-value <0.05 so that the data distribution was not normal, so the different test used was the non-parametric test, namely the wilcoxon test and mann-whitney test. test results differences in pre and post-intervention knowledge scores the results of the preand post-intervention differences test according to knowledge scores in the treatment group and control group are presented in the following table: tabel 4. test results differences in knowledge scores between pre and post-intervention (n=120) variable score intervention (n=60) p-value score control (n=60) p-value knowledge score pre–post intervention 3.65-7.98 <0,001a 3.43-3.53 0,421a a= wilcoxon test table 5 shows that the results of the difference in knowledge scores in the treatment group showed a significant difference (p-value <0.05), while in the control group there was no significant difference (p-value>0.05). the result of the difference in the mean knowledge score between the post-intervention groups. the results of the difference in intervention scores after being given the e-titenku model between the intervention group and the control group are presented in the following table: tabel 5. test results differences in mean knowledge scores of respondents between postintervention groups (n=120) variable intervention group (mean) control group (mean) p-value knowledge score 7.98 3.53 <0,001* *= p-value < 0,05 table 5 shows that the post-intervention knowledge score data of the e-titenku model showed a significant difference (p-value <0.05). these results support the research hypothesis (alternative hypothesis) that the e-titenku model influences the knowledge score of coronary heart disease prevention. discussion this chapter describes the discussion of the research results that have been carried out. this discussion consists of interpretation and discussion of the results as well as the relationship between the results of the study with a review of the theory and the results of previous studies. this chapter also describes the limitations of the study and the implications of research in nursing. the full discussion is explained as follows: table 1 shows the characteristics of the respondents in this study, it was found that the average age of the research respondents was 65-66 years or included in the elderly category. physiologically the elderly have begun to experience a decline in all organ functions so that they are at risk of experiencing degenerative diseases such as physical, cognitive, emotional, https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.207-213 211 social, and sexual changes (agustina & sari, 2014). physically, the elderly are at high risk for hypertension, heart disease, stroke, and kidney failure. this study is in accordance with the results of research conducted by agustina (2014) that the average age of respondents with hypertension is 60-70 years. table 2 also shows that the average blood pressure of respondents in the intervention and control groups is in the range of 169-172 which according to who is in the category of moderate and severe hypertension. high blood pressure is in line with the increase in a person's age, this is because with increasing age there is a change in the lumen of the blood vessels to become narrower and stiffer or known as atherosclerosis, so it will increase blood pressure. with increasing age, there will be an increase in systolic and diastolic blood. this is in line with his research. ningsih and indri (2017) who got the results of age related to the incidence of hypertension (p = 0.000), odds ratio (or = 15,706, 95% ci 3.615-68.230), meaning that the older a person is, the 15.7 times the chance of experiencing severe hypertension (ningsih & indriani, 2017). the results of adam's research (2019) that the determinants with the strongest correlation to hypertension in the elderly are age and smoking (adam, 2019). the results of the intervention research of the e-titenku model on the knowledge score of coronary heart disease prevention showed that there was a significant effect of giving the intervention of the e-titenku model on the knowledge score (tables 5 and 6). health education using appropriate media and based on nursing information technology with smartphones through applications is an innovation to facilitate and optimize one's knowledge, understanding. smartphone health (m-health) as a medical and public health practice supported by mobile phones and other wireless devices has presented new opportunities to improve patient care. different from telemonitoring stations and personal computer-based systems, the m-health application is inexpensive, ubiquitous, intuitive, and flexible for a variety of lifestyles. currently a large number of m-health applications have been developed for diabetes, but evidence of efficacy is still limited, for m-health applications with communication and intervention from services. available from apple app store and google play. applications fall into different categories, such as logbooks and diaries (chatrati et al., 2022; mufidah et al., 2020). the score of respondents' knowledge about the prevention of coronary heart disease using the e-titenku model can increase significantly. through this model, respondents can know whether their blood pressure is in the category of hypertension or not. in addition, respondents are able to follow up on existing blood pressure based on the recommendations in the e-titenku application program, so that the final result of coronary heart disease prevention can be carried out by each respondent personally in their respective homes. conclusion the e-titenku model can increase knowledge of coronary heart disease prevention in the community. references adam, l. (2019). determinan hipertensi pada lanjut usia. jambura health and sport journal, 1(2), 82–89. agustina, s., & sari, s. m. (2014). faktor-faktor yang berhubungan dengan hipertensi pada lansia di atas umur 65 tahun. jurnal kesehatan komunitas, 2(4), 180–186. an, j., zhou, h., luong, t. q., wei, r., mefford, m. t., harrison, t. n., lee, m.-s., sim, j. j., brettler, j. w., martin, j. p., ong-su, a. l., & reynolds, k. (2021). risk of https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.207-213 212 hospitalization and mortality associated with uncontrolled blood pressure in patients with hypertension and covid-19. international journal of cardiology cardiovascular risk and prevention, 11, 200–215. https://doi.org/https://doi.org/10.1016/j.ijcrp.2021.200117. awaludin, s., sumeru, a., alivian, g. n., & novitasari, d. (2020). the effect of sikkomodo (combination of music, humor, and prayer) formulation toward blood pressure of hypertension patient on the elderly group in banyumas regency. shs web of conferences, 86, 1002. chatrati, s. p., hossain, g., goyal, a., bhan, a., bhattacharya, s., gaurav, d., & tiwari, s. m. (2022). smart home health monitoring system for predicting type 2 diabetes and hypertension. journal of king saud university-computer and information sciences, 34(3), 862–870. febriani, r., & fitri, m. (2019). analisis kejadian hipertensi pada lansia dengan diabetes melitus. jurnal aisyiyah medika, 4. hamilton, s. j., mills, b., birch, e. m., & thompson, s. c. (2018). smartphones in the secondary prevention of cardiovascular disease: a systematic review. bmc cardiovascular disorders, 18(1), 1–23. indrawati, l. (2015). hubungan antara pengetahuan, sikap, persepsi, motivasi, dukungan keluarga dan sumber informasi pasien penyakit jantung koroner dengan tindakan pencegahan sekunder faktor risiko (studi kasus di rspad gatot soebroto jakarta). jurnal ilmiah widya, 1(1). james, p. a., oparil, s., carter, b. l., cushman, w. c., dennison-himmelfarb, c., handler, j., lackland, d. t., lefevre, m. l., mackenzie, t. d., ogedegbe, o., jr, s. c. s., svetkey, l. p., taler, s. j., townsend, r. r., jr, j. t. w., narva, a. s., & ortiz, e. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the eighth joint national committee (jnc 8). jama, 311(5), 507–520. kemenkes ri. (2018). riskesdas 2018. in a. suprapto, j. irianto, d. h. tjandrarini, & b. a. bowo (eds.), laporan nasional riskesdas 2018 (vol. 44, issue 8). sekretariat badan litbang kesehatan, kementerian kesehatan ri. mufidah, a., kurniawati, n. d., & widyawati, i. y. (2020). smartphone sebagai media edukasi pada pasien diabetes mellitus: a systematic review. jurnal penelitian kesehatan" suara forikes"(journal of health research" forikes voice"), 12(1), 89–92. mullie, p., & clarys, p. (2011). association between cardiovascular disease risk factor knowledge and lifestyle. food and nutrition sciences, 2011. neubeck, l., lowres, n., benjamin, e. j., freedman, s. ben, coorey, g., & redfern, j. (2015). the mobile revolution—using smartphone apps to prevent cardiovascular disease. nature reviews cardiology, 12(6), 350–360. ningsih, d. l. r., & indriani, i. (2017). faktor-faktor yang berhubungan dengan kejadian hipertensi pada pekerja sektor informal di pasar beringharjo kota yogyakarta. universitas’ aisyiyah yogyakarta. nuraeni, a., mirwanti, r., anna, a., & prawesti, a. (2016). faktor yang memengaruhi kualitas hidup pasien dengan penyakit jantung koroner. jurnal keperawatan padjadjaran, 4(2). shrout, t., rudy, d. w., & piascik, m. t. (2017). hypertension update, jnc8 and beyond. current opinion in pharmacology, 33, 41–46. su, x., chen, x., & wang, b. (2021). pathology of metabolically-related dyslipidemia. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.207-213 213 clinica chimica acta, 521, 107–115. https://doi.org/https://doi.org/10.1016/j.cca.2021.06.029. utami, n. l., & azam, m. (2019). kejadian penyakit jantung koroner pada penderita diabetes mellitus. higeia (journal of public health research and development), 3(2), 311–323. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.168-175 168 team work, openness of communication and working period for reporting patient safety events at the regional general hospital dr. iskak tulungagung dara benedicta antoninda1*, indasah2 1 universitas airlangga, indonesia 2 institut ilmu kesehatan strada indonesia, kediri, indonesia *corresponding author: daraantoninda@gmail.com abstract background: in 2021 rsud dr. iskak tulungagung again adopted a patient safety culture measure that was implemented for all hospital staff from several sources as the first step in a good patient safety program. nurses are a component of human resources (hr) in the hospital health care system, who work directly on the front lines and have more time to deal with patients. purpose: the purpose of this study is to analyze the influence of team work, communication openness and tenure on patient safety incident reporting at dr. isk tulungagung. methods: the type of research conducted in this activity is an observational study with a crosssectional design and using logistic regression statistical tests. the sample in this study were 406 respondents. results: based on the characteristics of the respondents, it showed that there were 304 female nurses and 102 male nurses. the longest working period was 6-10 years, namely 196 people. the results of the descriptive analysis show that the value of team work is 85%, the value of open communication is 83% and the cultural value of reporting patient safety incidents is 94%. meanwhile, based on the statistical test results, the p-value is 0.001 <0.05; p-value 0.001 <0.05; and a p-value of 0.000 <0.05. conclusion: thus showing that there isthe influence of team work, open communication and working period on reporting of patient safety incidents at the regional general hospital dr. isk tulungagung. keywords: incident reporting, nurses, patient safety received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.364 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:daraantoninda@gmail.com https://doi.org/10.30994/jnp.v6i2.300 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.168-175 169 background according to the regulation of the minister of health of the republic of indonesia number 1691/menkes/per/viii/2011 "hospital patient safety is a system where hospitals make patient care safer which includes risk assessment, identification and management of matters related to patient risk, reporting and analysis incidents, the ability to learn from incidents and their follow-up and implementation of solutions to minimize risks and prevent injuries caused by mistakes resulting from carrying out an action or not taking the action that should have been taken”. the hospital is a primary health care facility. thus the hospital must be able to provide integrated health services to patients as service users. building a patient safety movement in hospitals is a top priority in hospital services. will benefit various parties, both hospitals and patients as users of health services (kkprs, 2015) data on patient safety in the world still shows problems in the world of health. the institute of medicine (iom) in 2008 reported the number of unexpected events (ktd) in hospitals in the united states, namely 1.5 million patients were injured per year from medication errors, and 7000 of them were reported to have died (webair et al., 2015). in addition, based on the results of research in arab countries 2. considerable data is also shown by world health institutions where there are a large proportion of medical errors and problems in patient care (aspend, 2017). data in america shows that 1.5 million people are injured each year and the average patient who is hospitalized has one error every day. experience estimating that an average of 10% of all inpatient visits creates some form of unwanted harm, reports from developing countries also show a 77% rate in cases of adverse events (aspend, 2017) the safety culture system contained within the organization can be positive by there is open communication based on organizational values and beliefs as well as perceptions that are supported by members of the organization or individuals within an organization (hammer et al., 2011). the institute of medicine (iom) states that the biggest challenge is in building a work safety culture where a mistake is seen as an opportunity to improve service quality and prevent patient safety incidents (doweri, 2015). the motivation for reporting patient safety incidents that is carried out with full honesty and without a culture of blame (blame free culture) is a form of patient safety culture (mark, 2011). a reporting system that prioritizes learning from mistakes and improving service systems is the basis of a safety culture (reason, 1997). the most dominant dimension of improving patient safety culture is organizational learning/continuous improvement (abood & el-magd, 2018). based on the results of a preliminary study at dr. iskak tulungagung is known in the period 2018-2020 there were several reports of incidents that occurred. from patient safety incident reporting data and data from patient safety culture survey results in the previous year, in 2021 rsud dr. iskak tulungagung again adopted a patient safety culture measure that was implemented for all hospital staff from several sources as the first step in a good patient safety program. nurses as a component of human resources (hr) in the hospital health care system, who work directly on the front line and have more time dealing with patients, without neglecting the role of other workers. nurse performance is influenced by 3 variables, namely individual variables, organizational variables and psychological variables. individual variables, consisting of abilities, skills, knowledge, demographics and family background, psychological variables consisting of perceptions, attitudes, motivation, personality and learning. meanwhile, organizational variables consist of resources, rewards, workload, structure, supervision and leadership (rahmatia, 2020). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.168-175 170 thus the implementation of patient safety incident reporting in hospitals is to design jobs with due regard to human factors. this means that in the arrangement, taking into account length of work, team work and openness of communication. methods the type of research conducted in this activity is observational research, namely observational research (survey) that tries to find a description of the variables without intervening in the research target. the design used is cross-sectional, that is, the researcher only makes observations and measures variables at a certain time. measurements of unlimited variables must be at the same time, but have the meaning that each subject is only subjected to one measurement, without follow-up or repeated measurements (saryono & anggraeni, 2012). samples were taken by simple random sampling technique. the number of samples in this study were 406 respondents. statistical test using logistic regression,according to ghozali (2018) logistic regression analysis is a regression that tests whether there is a probability of occurrence of the dependent variable that can be predicted by the independent variable. results 1. characteristics of respondents table 1. characteristics of nurses based on gender no characteristics f % 1. gender a. woman 304 75% b. man 102 25% total 406 100% based on the table above, it shows that the majority of nurses are female, with 304 respondents (75%), while male nurses are 102 respondents (25%). 2. characteristics of respondents a. characteristics of team work variables table 2. characteristics of variables based on team work no characteristics f % 1. team work a. enough 345 85% b. not enough 61 15% based on the table above, it shows that the majority of nurses have adequate team work with a percentage of 85%. b. characteristics of communication openness variables table 3. variable characteristics based on open communication no characteristics f % 1. communication openness https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.168-175 171 a. enough 337 83% b. not enough 69 17% based on the table above, it shows that the majority of nurses have sufficient openness of communication with a percentage of 83%. c. characteristics of patient safety event reporting variables table 4. characteristics of patient safety event reporting variables no characteristics f % 1. patient safety incident reporting a. positive 382 94% b. negative 24 6% based on the table above, it shows that the majority of nurses have a positive patient safety incident reporting culture with a percentage of 94%. d. characteristics of variables based on working period at dr.iskak hospital table 5. characteristics of nurses based on years of service at dr.iskak hospital no characteristics f % 1. years of service a. 1-5 years 150 37% b. 6-10 years 196 48.3% c. >11 years 60 14.7% total 406 100% based on the table above, it shows that the majority of nurses have worked for 6-10 years with 196 respondents (48.3%), while working for 1-5 years with 150 respondents (37%) and with working experience >11 years with 60 respondents (14, 7%). 3. statistic test model df sig exp(b) team work 1 001 5,291 communication openness 1 001 3,200 years of service 1 .000 1,666 a. analysis of the influence of team work on reporting of patient safety incidents based on the results of the logistic regression analysis, it shows that the p-value is 0.001 <0.05, so h1 is accepted, so it is concluded that there is an influencethe influence of team work on reporting of patient safety events at dr.iskak hospital tulungagung https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.168-175 172 b. analysis of the effect of openness of communication on reporting of patient safety incidents based on the results of the logistic regression analysis, it shows that the p-value is 0.001 <0.05, so h1 is accepted, so it is concluded that there is an influencethe effect of openness of communication on reporting of patient safety incidents at dr.iskak hospital tulungagung c. analysis of the effect of working period on reporting of patient safety events based on the results of the logistic regression analysis, it shows that the p-value is 0.000 <0.05, then h1 is accepted, so it is concluded that there is an influencethe influence of working period on reporting of patient safety incidents at dr.iskak tulungagung general hospital discussion a. identifying team work, communication openness and working period according to (zulkifli, 2019) team work is the foundation of the success of an organization, with the same vision and mission, a team work will have high loyalty at work. if there is no team work in a team, it will be fatal to the work being done. based on the results of the study, it was shown that the majority of nurses at dr. iskak tulungagung general hospital had adequate team work with a percentage of 85%, with good team work it was hoped that all members in the team would have a sense of helping each other in work and a commitment to achieving a common goal is a characteristics of effective team work. according to research by research (dewi anggraeni, 2016) individual openness to incident reporting is one of the indicators of patient safety culture that is incorporated into individual behavior. an attitude that does not support accident reporting to staff, especially nurses, hinders the creation of safe services, because the lack of accident reporting has an impact on hospitals that do not know the potential risks that can lead to errors. based on the results of the study showed that the majority of nurses have sufficient openness of communication with a percentage of 83%. thus it can be said that nurses at dr. iskak tulungagung general hospital point to high communication openness. tenure of work is seen from how long the nurse has worked which is categorized into 3 categories namely 1-5 years, 6-10 years and more than 11 years. based on the research, it showed that the majority of nurses at dr.iskak tulungagung general hospital had a working period of 6-10 years with 196 respondents (48.3%), while a working period of 1-5 years was 150 respondents (37%) and a working period of >11 years was 60 respondents (14.7%). based on research by (zulkifli, 2019) which states thatwork experience plays a very important role in providing nursing care for nurses whose new working period must be obedient in providing nursing care, for senior nurses these nurses are used to and are calmer with the threats they get during their treatment period in health services. b. identify patient safety incident reporting patient safety culture a patient safety culture is said to be successful if all elements within the hospital apply a patient safety culture in their daily work (reiling, 2009). whereas beginta (2012) said that the effort that can be made to improve safety culture is to encourage everyone to be responsible for safety for themselves, co-workers, patients and visitors, prioritizing safety and profit over profits and organizational goals. patient safety culture is a major step in improving patient safety. according to pmk number 1691 of 2011 it explains that building awareness of patient safety values, leading and supporting staff in implementing patient safety is an important part https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.168-175 173 of creating a patient safety culture. one of the points in patient safety culture is reporting the number of incidents in real time to correct them so that the same mistakes will not be repeated.this is supported by research conducted by (jeffs, law, & gr, 2007) reporting is an important element of patient safety. adequate information in reporting will be used as material by the organization in future learning. organizations learn from previous experiences and have the ability to identify risk factors for incidents to occur so as to reduce or prevent incidents from occurring. based on the results of the study showed that the majority of nurses had a positive patient safety incident reporting culture with a percentage of 94%, thus it can be concluded that nurses at dr.iskak hospital have a good patient safety incident reporting culture. c. analyzing the effect of team work, open communication and working period on reporting patient safety events at the regional general hospital dr. isk tulungagung according to (top & tekingunduz, 2014) aspects of cooperation in a team can be an indication of a positive patient safety culture. the results of this study are in line with the results of research by najjar, nafouri, vanhaecht and euwema (2015) at the palestine hospital showing that patient safety culture on the dimension of nurse work teams between uni within the hospital is in the positive category of 73%. according to researchers, teamwork that has been formed in an organization cannot be separated from the support from the organization and the systems contained in an organization. hospital management has an important role in developing a solid team in providing nursing services. based on the results of the study, it showed that the p-value was 0.001 <0.05, so h1 was accepted, so it was concluded that there was an influence of team work on patient safety incident reporting at dr. iskak tulungagung general hospital. a positive patient safety culture has the characteristics that there is communication built with a sense of mutual openness, transparency by all employees and reflects patient safety. in addition, open communication is a component of patient safety culture.based on the results of the study, it showed that the p-value was 0.001 <0.05, so h1 was accepted, so it was concluded that there was an effect of openness of communication on the reporting of patient safety incidents at dr. iskak tulungagung hospital. thus it can be said that openness of communication is an important element of patient safety. without open communication, it will be fatal to patient safety. based on the results of the study, it showed that the p-value was 0.000 <0.05, so h1 was accepted, so it was concluded that there was an effect of working period on reporting of patient safety incidents at dr.iskak hospital, tulungagung. this is supported by research (zulkifli, 2019) which states thatwork experience plays a very important role in providing nursing care for nurses whose new working period must be obedient in providing nursing care, for senior nurses these nurses are used to and are calmer with the threats they get during their treatment period in health services. this is in accordance with the opinion (astriana, 2018) which states that the longer a person's working period, the competence, skills, expertise and experience gained will increase. thus the competence for the work done will be better because there is support from the period of work itself. so it can be concluded that the longer the working period, the more it will determine the quality of the work performed. conclusion a. the results of the descriptive analysis show that the value of team work is 85%, the value of communication openness is 83% and the longest working period is 6-10 years, namely https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.168-175 174 196 people (48.3%). b. the results of the descriptive analysis show that the cultural value of reporting patient safety incidents at dr.iskak hospital is 94%. c. based on the results of statistical tests showed a p-value of 0.001 <0.05; p-value 0.001 <0.05; and a p-value of 0.000 <0.05. thus it shows that there is an influence of team work, communication openness and tenure on patient safety incident reporting at the regional general hospital dr. isk tulungagung. references amarapathy, m., sridharan, s., perera, r., & handa, y. (2013). factors affecting patient safety culture in a tertiary care hospital in sri lanka. 2(3), 173±179. anwar, z. (2018). mentoring as an innovation in improving performance. journal of education and instruction, 1(1), 21±28. awaliyah. (2018). contribution of nurse characteristics influencing patient safety culture in class c hospital, south jakarta. https://doi.org/10.36341/jka.v2i1.465. beginta, r. (2012). the influence of culture..., romi beginta, fkmui, 2012. in the influence of patient safety culture, leadership style, team work, on perceptions of service error reporting by nurses at the inpatient unit of the bekasi district general hospital. dewi anggraeni, ahsan & misbahuddin azzuhri. (2016). the effect of patient safety culture on incident reporting attitudes to nurses at the tk. hospital inpatient installation. ii dr. soepraoen. jurnal application management. vol 16. no 02. hal 309-301. el-jardali, f., sheikh, f., garcia, na, jamal, d., & abdo, a. (2014). patient safety culture in a large teaching hospital in riyadh: baseline assessment, comparative analysis and opportunities for improvement. bmc health services research, 14.https://doi.org/10.1186/1472-6963-14-122. hammer, a., ernstmann, n., ommen, o., wirtz, m., manser, t., & pfeiffer, y. (2011). psychometric properties of the hospital survey on patient safety culture for hospital management (hsops_m). bmc health services research, 11(1), 165.https://doi.org/10.1186/14726963-11-165. jeffs, l., law, m., & gr, b. (2007). creating reporting and learning cultures in health care organizations . national library in medicine, 17410924. kkprs. (2015). guidelines for reporting patient safety incidents (ikp). in guidelines for reporting patient safety incidents (ikp) (pp. 1± 56). najihah. (2018). patient safety culture and patient safety incidents in hospitals: literature review. journal of islamic nursing, 3(1), 1. najjar, s., nafouri, n., vanhaecht, k., & euwema, m. (2015). the relationship between patient safety fxowxuhdqgdgyhuvhhyhqwvdvwxg\ in palestinian hospitals. safety in health, 1(december). https://doi.org/10.1186/s40886-015-0008-z. najjar, s., nafouri, n., vanhaecht, k., & euwema, m. (2015). the relationship between patient safety culture and adverse events: a study in palestinian hospitals. safety in health, 1(1), 1±9. https://doi.org/10.1186/s40886-015-0008-z. nie, y., mao, x., cui, h., he, s., li, j., & zhang, m. (2013). hospital survey on patient safety culture in china. retrieved from http://www.biomedcentral.com/147 26963/13/228%0apage. nivalinda, d., hartini, mci, & santoso, a. (2013). the influence of the nurse's motto and the leadership style of the head of the room on the implementation of patient safety culture https://thejnp.org/ https://doi.org/10.1186/1472-6963-%2014-122 https://doi.org/10.1186/1472-%206963-11-165 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.168-175 175 by implementing nurses at a government hospital in semarang. journal of nursing management, 1(2), 138±145. nurmalia, d. (2013). the effect of mentoring programs on the implementation of patient safety culture. journal of nursing management, 1(2), 79±88. setiowati, d. (2018). relationship between effective leadership of head nurse and patient safety culture by implementing nurses at rsupn dr. cipto mangunkusumo jakarta, university of indonesia. zulkifli. (2019). the relationship between tenure and nurse compliance in the implementation of patient fall prevention measures at the samarinda government regional general hospital. borneo student research. https://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.96-101 96 the effect of giving purple sweet potato leaves toward the involution of mother in the posture and sufficient mother breast milk on babies 0-6 months nur zad malikha, retno dewi prisusanti* akademi kebidanan wijaya kusuma malang, east java indonesia corresponding author: ikkamalikha@yahoo.com abstract background: one of the exclusive breastfeeding failures is because of low milk production, while uterine involution is also a complication that often occurs in the puerperium that can contribute to maternal mortality, nonpharmacological therapy that can be given, among others, the provision of purple sweet potato leaves. purpose: this study aimed to determine the effect of giving purple sweet potato leaves to uterine involution in puerperal mothers and the adequacy of breast milk. method: this type of research is a quosy experimental only with a sample of 35, sampling with the purposive sampling technique. the provision of purple sweet potato leaves is given for 7 days, namely the 8-14 day of the puerperium, and measurement of uterine involution indicators and the adequacy of breast milk is done before and after administration of purple sweet potato leaves. analysis using the wilcoxon test. results: the results of the study are the effect of giving purple sweet potato leaves to uterine involution in postpartum mothers and the adequacy of breast milk in infants 0-6 months (p-value = 0,000). conclusion: there is an effect of giving purple sweet potato leaves to uterine involution in puerperal mothers and the adequacy of breast milk in infants aged 0-6 months. keywords: purple sweet potato leaves, uterine involution, breast milk adequacy received july, 29, 2019; revised august 30, 2019; accepted september 22, 2019 how to cite: malikha, m.z., & prisusanti, r.d. (2019). the effect of giving purple sweet potato leaves toward the involution of mother in the posture and sufficient mother breast milk on babies 0-6 months. journal of nursing practice, 3(1), 96-101. https://doi.org/10.30994/jnp.v3i1.70 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:ikkamalikha@yahoo.com https://doi.org/10.30994/jnp.v3i1.70 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.96-101 97 background the recommendation for exclusive breastfeeding during the first 6 months is based on several studies on the benefits of breastfeeding for the baby's immune system, growth, and development. indonesia has set a national target in 2014 of 80% as the exclusive asi coverage figure (moh, 2014) involution or contraction of the uterus is a process in which the uterus returns to prepregnancy conditions weighing about 60 grams. this process begins immediately after the placenta is born due to the contraction of the smooth muscles of the uterus (anggraeni, 2010). postpartum mothers need nutritional quality foods that are high in protein, vegetables, and fruits that contain lots of vitamins that support the healing process (mochtar, 2011). purple sweet potato leaves (ipomoea batatas var ayamurasaki) contain high fe, provitamin a, and protein, carotenoids, and iron as well as oxytocin/prolactin which can support the success of breast milk and accelerate the process of uterine involution (truong, 2010). from the description above, the researcher wants to research the effect of giving purple sweet potato leaves to uterine involution in postpartum mothers and the adequacy of asi (breast milk) in infants 0-6 months. to determine the effect of giving purple sweet potato leaves to uterine involution in postpartum mothers and the adequacy of asi (breast milk) in infants 0-6 months. exclusive breastfeeding can reduce infant mortality due to various diseases such as diarrhea and inflammation of the lungs, and accelerate recovery when sick and spacing pregnancy. and the occurrence of uterine sub involution can increase the maternal mortality rate in the puerperium. objectives this study aimed to determine the effect of giving purple sweet potato leaves to uterine involution in puerperal mothers and the adequacy of breast milk methods this type of research is experimental research, with a quantitative approach. the study design uses a quasy experiment. the population in this study was the post-partum mother’s day 8-14 in may july at 8 tlogowaru village integrated healthcare centre. the sampling technique was a purposive sampling of 35 postpartum mothers. criteria included in this study are: 1) mother childbirth more than 7 days 2) mother childbirth involution is not normal 3) postpartum mothers who do not experience asi dams 4) postpartum mothers whose milk is not smooth 5) postpartum mothers who are willing to become research respondents 6) babies are born at term 7) babies older than 7 days 8) a healthy baby 9) babies without congenital abnormalities such as labioskisis and labio palatoskisis bivariate analysis using the wilcoxon test. the participants were assured that their engagement was voluntary, and that anonymity, privacy, and confidentiality of the data were guaranteed. furthermore, they were informed about the purpose and the method of the study before signing a written informed consent. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.96-101 98 the questionnaires were distributed to eligible participants at the tlogowaru village integrated healthcare centre, and respondents were asked to complete and return them in the same time. result 1. general data a. age of respondents no old frequency (n) percentage (%) 1 20-25 year 2 5,7 2 26-30 year 21 60,0 3 31-35 year 11 31,4 total 35 100 b. education of respondent no level of education frequency (n) percentage (%) 1 junior high school 2 5,7 2 senior high school 29 82,9 3 collage 4 11,4 total 35 100 c. respondents job no job frequency (n) percentage(%) 1 work 24 68,6 2 does not work 11 31,4 total 35 100 d. parity of respondents no parity frequency (n) percentage (%) 1 parity 1 14 40,0 2 parity 2 17 48,6 3 parity 3 or more 4 11,4 total 35 100 2. special data a. uteric involution no uteric involution before treatment after treatment frequency (n) percentage (%) frequency (n) percentage (%) 1 normal 19 54,3 2 not normal 35 100 16 45,7 total 35 100 35 100 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.96-101 99 b. adequacy of asi no adequacy asi before treatment after treatment frequency (n) percentage (%) frequency (n) percentage (%) 1 enough 26 74,3 2 less 27 77,1 9 25,7 3 very less 8 22,9 total 35 100 35 100 c. data analysis test statistics day 15th involutionday 17th involution asi 15th dayasi 7th day z -4,359b -5,353c asymp. sig. (2-tailed) ,000 ,000 analysis of the effect of giving purple sweet potato leaves to uterine involution in puerperal mothers and the adequacy of breast milk in infants 0-6 months in tlogowaru village integrated healthcare center with a significance value of 0,000 <0.05 can be concluded that h1 is accepted and h0 is rejected. discussion the results of the research analysis showed a change in which before being given treatment all respondents (100%) had abnormal uterine involution so that after treatment as many as 54.3% of respondents had normal uterine involution. whereas for the adequacy of asi before being treated as much as 77.1% the asi was lacking and after being treated as much as 74.3% of respondents asi was sufficient. the results obtained h1 accepted so that there is an effect of giving purple sweet potato leaves to uterine involution in puerperal mothers and the adequacy of breast milk in infants 0-6 months. this result is following abdul bari's theory. s, et al, (2002) which says that the presence of oxytocin effect causes uterine contractions. the oxytocin hormone that has been released from the pituitary gland strengthens and regulates uterine contractions, compresses blood vessels and helps the hemostatic process. the uterine muscle contractions and retractions reduce the blood supply to the uterus. this process helps reduce bleeding. breastfeeding immediately after the baby is born will stimulate the release of oxytocin due to the baby sucking on the breast. this theory is supported by prof. dr. ahmad sulaeman, food expert from ipb that "sweet potato leaves can improve infant nutrition, because these leaves can increase milk production," prof. ahmad explained that there were efforts to increase milk production through consumption sweet potato leaves, this is because in these leaves there are lactagogum substances that can increase milk production, in addition to this leaf there are also caroteniid and iron contents. ritawati l, (2012), in her research on the success of exclusive breastfeeding with sweet potato leaves in postpartum mothers that sweet potato leaves contain oxytocin/prolactin which can increase milk production. increased milk production will encourage mothers to breastfeed more frequently and with breastfeeding more often there journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.96-101 100 will be positive feedback on the increase in the hormone oxytocin which is very helpful for uterine contractions, compressing blood vessels and helping the hemostatic process. this process will help reduce bleeding so that lochea in the puerperal mother will be reduced and decrease the uterine fundus height. thus the research hypothesis can be proven that consumption of sweet potato leaves can accelerate the involutional process in puerperal mothers, ie accelerate the decrease in tfu and accelerate the decay of puerperal blood/lochea. sweet potato leaves are believed to be very effective as herbal medicines. that is because sweet potato leaves contain various kinds of substances that the body needs such as vitamin a, vitamin b, vitamin b6 vitamin c. sweet potato leaves also contain almost 7% protein, 15% crude fiber. this leaf is rich in vitamin a, in addition to provitamin a (beta carotene), b and c, iron, calcium, phosphorus and fat (raifa, 2008). the supply of asi is a very matter to play a role in the lactation/breastfeeding process. the more adequate milk supply for babies the more successful the process of breastfeeding is done and vice versa. adequacy of baby's milk obtained by consuming sweet potato leaves decoction regularly ie every 2x / day for 7 days, with a dose of 100 grams of sweet potato leaves every day during the process of breastfeeding will get maximum results, with that the adequacy of breast milk will meet the nutrients needed by the baby will be fulfilled properly. conclusion uterine infusion in postpartum mothers before treatment in the abnormal category (35 respondents), after consuming purple sweet potato leaves as many as 54.3% of respondents in the normal uterine involution category. likewise, from the indicator of asi adequacy from the beginning in the category of insufficient and very insufficient, after receiving adequate treatment the milk is sufficient and insufficient. there is an effect of giving purple sweet potato leaves to uterine involution in puerperal mothers and the adequacy of breast milk in infants aged 0-6 months in the tlogowaru village integrated healthcare center (p-value = 0,000). suggestion it is hoped that with this research, respondents who are postpartum and breastfeeding mothers can understand the importance of nutrition to restore the function of reproductive organs and support the supply of breast milk by making purple sweet potato leaves present in a variety of foods or drinks. it is hoped that with this research, the land that is the location of the study will be more open to all information related to the efforts that can be made by the relevant sectors and work together with the local health office in an effort to develop awareness and the ability of the community to provide support to postpartum mothers to pay attention to their health and for mothers breastfeed to keep giving milk to babies to improve the degree of health of mother and baby. references depkes ri. 2014. petunjuk pelaksanaan peningkatan asi ekslusif. jakarta : depkes ri anggraini. 2010. asuhan kebidanan masa nifas. yogyakarta: cv pustaka rihama mochtar rustam. 2011. sinopsis obstetri fisiologi dan obstetri patofisiologi edisi 3 jilid i. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.96-101 101 jakarta: egc. truong. 2010. kajian aspek pembibitan, budidaya, dan pemanfaatan umbi-umbian sebagai sumber pangan alternative, laporan hasil penelitian. kerjasama bapeda propinsi bali dengan fakultas pertanian universitas udayana. raifa. 2008. daun ubi jalar sehatkan ibu dan bayi. majalah kartini. nomor:2134, hal.148 rahayu m. dkk, 2006 pemanfaatan tumbuhan obat secara tradisional oleh masyarakat lokal di pulau wawonii, sulawesi tenggara. jurnal bioversitas volume 7 nomor 3 (hal 245-250) issn: 1412-033x ritawati l 2012, jurnal penelitian sukses asi eksklusif dengan daun ubi jalar pada ibu nifas. sujiyatini, dkk 2010. catatan kuliah asuhan ibu nifas askeb iii. yogyakarta : cyrillus journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.96-101 102 journal of nursing practice http://strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.2 april 2019. p. 97-101 97 effect of humor therapy on chronic pain: a literature review yusnaeni y, kadek ayu erika, rini rachmawaty magister of nursing science, hasanuddin university, south sulawesi, indonesia corresponding author: enhirfan@gmail.com abstract background: chronic pain is an unpleasant sensory and emotional experience with actual or potential tissue damage, or is described as a damage lasting more than 3 months with heavy or moderate intensity. the patient's response to the pain he experienced was done in different ways such as shouting, grimacing, crying, etc. repair of pain is likely to occur more quickly when psychological intervention is included in medical care because it requires alternative and complementary treatment to overcome the pain including prayer, humor, hypnosis, and group support. growing evidence-based nursing practice shows progress in helping patients deal with the pain. one of the evidence-based nursing practices is humor therapy. method: the literature search was done through searching the results of scientific publications 2010-2018 using several databases, such as such as google scholar, pubmed, doaj, and cochran, with keyword "humor therapy and chronic pain. result: obtained 6 fulltext articles, were obtained with various methods used, such as quasi-experimental preand posttest control group design, randomized two-group review literature, concluded that humor therapy proved effective in reducing chronic pain in all ages. conclusion: the humor therapy is effective in reducing chronic pain in patients of all ages, both children, adults and the elderly, besides humor therapy can also be used to increase endurance and quality of life in elderly who are cared for in nursing homes. keywords : chronic pain, humor therapy, literature review. received: january 12, 2019; revised : february 24, 2019; accepted march 14, 2019 how to cite: yusnaeni, y., erika, k.a., & rachmawaty, r. (2019). effect of humor therapy on chronic pain: a literature review. journal of nursing practice. 2(2). 97-101. https://doi.org/10.30994/jnp.v2i2.51 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. journal of nursing practice http://strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.2 april 2019. p. 97-101 98 background chronic pain is an unpleasant sensory and emotional experience with actual or potential tissue damage, or described as a damage lasting more than 3 months with severe or moderate intensity (herdman & kamitsuru, 2018). the patient's response to the pain he experienced was done in different ways such as shouting, grimacing, crying, etc., while the physiological reaction to pain is divided into sympathetic stimulation response characterized by dilatation of bronchial blood vessels and increased respiratory rate, increased heart rate, increased sugar levels blood, diaphoresis, increased muscle tension, pupillary dilatation, and decreased digestive movements. while parasympathetic stimulation response is characterized by palor, muscle tension, decreased heart rate and blood pressure, and rapid and irregular breathing (potter & perry, 2010). pain perception is influenced by an individual's tolerance of pain. to understand the tolerance, people must distinguish between the limits of pain and pain tolerance. the limit of pain is perceived as the lowest intensity of a painful stimulus that can vary depending on physiological factors, but is basically the same for all individuals if the central and peripheral nervous systems are normal (sherwood, 2016). moderate to severe chronic pain occurs in 19% of european adults, which greatly affects the quality of their social life and work. scrimpy of people are managed by pain specialists and almost half receive inadequate pain management (breivik, collett, ventafridda, & cohen, 2006). in indonesia, chronic pain is not included in basic health research, but based on data on cancer in indonesia which is the most common cause of acute pain. it is estimated that annual cancer cases will increase from 14 million in 2012 to 22 million in the next two decades. the journey of pain includes a series of complex neurophysiological processes referred to as nociception which reflects four real component processes, namely transduction, transmission, modulation and perception, where the occurrence of strong stimuli in peripheral until the pain is felt in the central nervous system (cortex cerebri) (sherwood , 2016) chronic pain has significant consequences for patients, as well as for their families, their social and professional environment, leading to a decline in the quality of life of patients and those close to them (salazar, mico, & failde, 2016). restoration of pain is likely to occur more quickly when psychological interventions are included in medical care because it requires alternative and complementary treatment to overcome the pain including prayer, humor, hypnosis, and group support. the improvement evidence-based nursing practice shows progress in helping patients deal with the pain. one of the evidence-based nursing practices is humor therapy. the synthesis of 20 studies shows that humor is an effective nursing intervention and has a large potential impact on the health and well-being of patients in various situations, namely a decrease in pain, quality of life, psychology, and an increase in the immune system (christie & moore, 2004). humor therapy has been defined as "any intervention that promotes health and well-being by stimulating pleasant acceptance, expression, or appreciation of the absurdity or incompatibility of life situations. this intervention can improve health or be used as a complementary treatment in a disease to facilitate healing or prevention, both physical, emotional, cognitive, social, or spiritual (lindquist, snynder, & tracy, 2014). effects of humor therapy on pain are able to stimulate the release of endogenous opiates that inhibit the transmission of information by delta a cell fibers. inhibition of delta a cell fibers lead to disconnection of pain information delivery from nociceptors to girus post journal of nursing practice http://strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.2 april 2019. p. 97-101 99 central. slow delivery of pain stimuli lead to a slowing the body's response to pain (sninder & lindquist, 2009). methods literature review is carried out by searching the results of scientific publications using n several databases, namely google scholar, pubmed, doaj, and cochran. google scholar with the first keyword was "humor therapy" found 921 articles then the second keyword using "chronic pain" found 1,140.00 articles, then the two keywords were combined and found 146 articles filtered in 2010-2018. after the filter is done by looking at the title that corresponds then found two articles found. the second database is pubmed with the keyword "humor therapy" found 7,289 articles limited using a quotation mark and 26 articles appear. then the second keyword using "chronic pain” found 104,437 articles, after the first and second keywords are combined, there are 2 articles found. the next database is doaj with the first keyword was "humor therapy" found 128 articles then keyword 2 using "chronic pain" found 9042 articles, and then both keywords were combined and found 2 articles. next using cochrane with the first keyword was "humor therapy" found 3,633 articles the second keyword was " chronic pain" found 3,210 articles, then the two keywords are combined so that found 364 articles. however, after searching, there is no article title that matches the keyword are looking for. overall, the databases found 6 articles that have passed the title screening, duplication, and year. result 1. chronic pain chronic pain is usually considered as pain that lasts more than 6 months or 3 months which is unknown when it will end unless there is slow healing, such as in scorch. malignant pain is considered a great pain, both acute pain and chronic pain. this category is considered to be included in neuropathy, visceral, internal, and bone pain. each type of pain can be well managed by specific strategies to deal with the pain (black & hawks, 2014). regardless of how patients treat chronic pain, long-term pain can cause disability. patients with several chronic pain syndromes reported depression, anger, and fatigue (smeltzer & bare, 2011). 2. pain management patients with chronic pain often require pain specialist care, however, pain management is the responsibility of all providers, including primary care physicians. although there are limited data on how individuals with chronic pain must be treated, there are many treatment options that need to be considered. these people have chronic conditions that will require continuous therapy with regular reassessment to get the best results. if possible, care must be evidence-based. however, care must always be focused on patients with the aim at reducing pain and suffering and improving physical and mental functioning (ashburn, 1999). the gate control theory of melzack and wall (1965) suggests that pain impulses can be regulated or inhibited by defense mechanisms along the central nervous system. this theory says that pain impulses are delivered when a defense is opened and impulses are blocked when a defense is closed. the effort to close the defense is the basis of pain relief theory. humor therapy is one of the evidencebased pain treatments (behrouz et al., 2017). it is done using some humor media such as videos, comics, etc. journal of nursing practice http://strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.2 april 2019. p. 97-101 100 3. effect of humor therapy on chronic pain laugh and humor therapy has been used in health care to achieve benefits related to physiological and psychological health. the implementation of these therapies in the dialysis context is still unclear. studies from other groups such as children, parents, and people with mental health, cancer, and other chronic conditions were included to inform the application of potential laugh therapy to dialysis populations. therapeutic interventions can be obtained from funny videos, stories, clown laugh to fabricated laughs and laugh yoga. the effects of laugh and humor on depression, anxiety, pain, immunity, fatigue, sleep quality, respiratory function and blood glucose may have applications in the dialysis context and require further research (bennett et al., 2014). a study in a nursing home in iran shows that humor therapy can have a positive impact in reducing chronic pain experienced by the elderly living in nursing homes (tse et al., 2010), besides humor therapy is considered as an uncomplicated method and costeffective that does not require professional staff and skills to improve elderly health in general, and can be used to make the elderly are closer to their families (behrouz et al., 2017). other research also suggests that humor is effective in controlling pain in adults and children, while humor also has a positive effect in enhancing immune function. in his study this study found that watching funny videos reduced children's pain response by assessing their cortisol hormone (evans, tsao, & zeltzer, 2008). but research conducted by (ghafouri, 2016) stated that humor therapy gives patients the opportunity to forget their anxiety and pain, if only for a short period of time, meaning that humor therapy is only to temporarily reduce the patient's pain. another study that supports the effectiveness of humor therapy on pain is what is done by (leise, 2015) which stated that there is a positive relationship between reducing chronic pain in adult patients. discussion based on globocan estimates, around 14.1 million new cancer cases and 8.2 million deaths occurred in 2012 worldwide due to cancer (torre, bray, siegel, & ferlay, 2015). one serious problem in survivors of cancer is to face pain that can come at any time, including breast cancer patients. this is caused by infiltration of tumor cells in painsensitive structures such as bone, soft tissue, nerve fibers, internal organs, and blood vessels. pain can also be caused by surgical therapy, chemotherapy, or radiotherapy (schmidt, hamamoto, simone, & wilcox, 2010) pain that persists in cancer patients is common and is often associated with inadequate provision of targeted analgesia (mi bennett, rayment, hjermstad, aass, & caraceni, 2012), so that other treatments are needed to treat pain in patients, pain relief must be done immediately to helping patients get a good quality of life, as well as feeling comfortable.) cancer pain repair is likely to occur more quickly when psychological interventions are included in medical care (bruera & russel k pertonoy, 2016). one evidence-based nursing practice is humor therapy in cancer patients. conclusion based on several studies above can be drawn a conclusion that humor therapy is effective in reducing chronic pain in patients of all ages, both children, adults and the elderly, besides that humor therapy can also be used to increase endurance and quality of life in elderly treated at a nursing home. journal of nursing practice http://strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.2 april 2019. p. 97-101 101 references ashburn, m. a. (1999). management of chronic pain, 353, 1865–1869. behrouz, s., mazloom, s. r., kooshyar, h., aghebati, n., reza, h., & vashani, b. (2017). investigating the effect of humor therapy on chronic pain in the elderly living in nursing homes in, (098 51). https://doi.org/10.22038/ebcj.2017.24247.1529 bennett, m. i., rayment, c., hjermstad, m., aass, n., & caraceni, a. (2012). prevalence and aetiology of neuropathic pain in cancer patients : a systematic review. pain, 153(2), 359–365. https://doi.org/10.1016/j.pain.2011.10.028 bennett, p. n., parsons, t., ben-moshe, r., weinberg, m., neal, m., gilbert, k., … hutchinson, a. (2014). laughter and humor therapy in dialysis, 488–493. https://doi.org/10.1111/sdi.12194 black, j. m., & hawks, j. h. (2014). keperawatan medikal bedah: manajemen klinis untuk hasil yang diharapkan. breivik, h., collett, b., ventafridda, v., & cohen, r. (2006). survey of chronic pain in europe : prevalence , impact on daily life , and treatment, 10, 287–333. https://doi.org/10.1016/j.ejpain.2005.06.009 bruera, e. e., & russel k pertonoy. (2016). cancer pain assessment and management (second). london: cambridge university press. christie, w., & moore, c. (2004). the impact of humor on patients with cancer, (june), 211–219. evans, s., tsao, j. c. i., & zeltzer, l. k. (2008). paediatric pain management : using complementary and alternative medicine complementary and alternative medicine for paediatric pain, (7), 14–20. ghafouri, r. (2016). humor as a complementary therapy : a narrative review, 1375– 1380. herdman, h., & kamitsuru, s. (2018). nanda-i diagnosa keperawatan definisi dan klasifikasi 2018-2020 (11th ed.). jakarta: egc. leise, c. mcm. (2015). the correlation between humor and chronic pain of arthritis. lindquist, r., snynder, m., & tracy, mary fran. (2014). complementary and alternative therapies in nursing. (sevent edition, ed.) (newyork). springer publising company. potter, p. a., & perry, a. g. (2010). fundamental keperawatan buku 3 edisi 7 (edisi 7). jakarta. salazar, a., mico, j. a., & failde, i. (2016). a review of chronic pain impact on patients , their social environment and the health care system, 457–467. schmidt, b. l., hamamoto, d. t., simone, d. a., & wilcox, g. l. (2010). mecanisms of cancer pain. molecular intervention, 164–178. sherwood, l. (2016). fisiologi manusia; dari sel ke sistem (introduction to human physiology). (h. octavius, a. a. mahode, & d. ramadhani, eds.) (edisi 8). jakarta: egc. smeltzer, & bare. (2011). keperawatan medikal bedah. jakarta: egc. sninder, m., & lindquist, r. (2009). complementary & alternative therapies in nursing (sixth edit). new york: springer publishing company. tse, m. m. y., lo, a. p. k., cheng, t. l. y., chan, e. k. k., chan, a. h. y., & chung, h. s. w. (2010). humor therapy : relieving chronic pain and enhancing happiness for older adults, 2010. https://doi.org/10.4061/2010/343574 https://doi.org/10.22038/ebcj.2017.24247.1529 https://doi.org/10.1016/j.ejpain.2005.06.009 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.214-220 214 the effect of benson and autogenic relaxation therapy on sleep quality, blood pressure and anxiety of hypertension patients sutrisno1*, nursalam2 1 department of nursing, faculty of nurse and midwifery, institut ilmu kesehatan strada indonesia 2 department of nursing, universitas airlangga, indonesia *corresponding author: sutrisno12@iik-strada.ac.id abstract background: hypertension increases with age, and causes several signs and symptoms that can interfere with the patient's quality of life, including sleep quality and anxiety. purpose: this study aims to analyze the effect of benson and autogenic therapy on blood pressure, anxiety and sleep quality in patients with hypertension. methods: this study used pre-experimental research design with one group pre-test and posttest design. this research was conducted in the working area of pukesmas balowerti, kediri city, with a sample of 20 respondents determined by purposive sampling technique. results: statistical test it is known that the p value 0.000 < 0.05 on blood pressure reduction, p value 0.001 < 0.05 on sleep quality, p value 0.000 < 0.05 on anxiety levels, it can be concluded that there is an effect of relaxation therapy benson and autogenic to decrease blood pressure, anxiety level and sleep quality of hypertensive patients. conclusion: benson and deep autogenic relaxation techniques can be used by someone who is healthy or sick and is a non-pharmacological effort to help reduce muscle tension so that the body becomes comfortable, relaxed, reduces pain and stress intensity, increases pulmonary ventilation and increases blood oxygenation. keywords: anxiety, benson and autogenic therapy, hypertension, sleep quality received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.379 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:sutrisno12@iik-strada.ac.id https://doi.org/10.30994/jnp.v6i2.300 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.214-220 215 background hypertension is a non-communicable disease (ncd). hypertension or known as the silent killer which attacks many people as the cause of death and causes the highest disease. the risk of developing hypertension increases with age, as a person ages, the incidence of hypertension increases. this was analyzed because of changes in cardiovascular structure and function, hypertension often occurs in the elderly (bruner and suddart, 2013). hypertension is the main cause of premature death in the world. one of the global goals of ncd is to reduce the prevalence of hypertension by 25% by 2025. the number of adults aged 30-79 with high blood pressure (hypertension) is expected to nearly double to 1.28 billion between 1990 and 2019, mainly due to population growth and aging. there has been little change in the overall rate of hypertension globally, although the burden has been shifted from high pours to low and low states (who, 2022). riskesdas data (2018) shows a prevalence of hypertension of 34.11%. the prevalence of hypertension in women is 36.85%, higher than in men 31.34%. it is estimated that the number of cases of hypertension in indonesia is 63,309,620, while the death rate due to hypertension in indonesia is 427,218. data from the east java health service (dinkes) stated that the total number of hypertension sufferers in east java in 2017 was 335,524 patients. this data was taken from the integrated disease surveillance of community health centers in east java. this amount is calculated from january to september. data from the east java health office stated that the number of hypertension sufferers in all east java health centers in 2017 reached 15,321 visits. the results of observations on april 22, 2022 at the balowarti health center found 36.3% with a total of 4789 male sufferers and 4868 female sufferers with 700 male and 1504 female sufferers and a total of 2204 (22.82), while the achievements on in 2021 the number of residents served at least once a year is 22.82% based on the services served at the balowarti health center (pustu & fktp network). the results of interviews with 10 patients found that those with hypertension also had a high level of anxiety, with a percentage of 7 people (70%) and 3 people (30%) having moderate anxiety. anxiety that arises can be due to fear of comorbidities that arise due to hypertension, thinking too much about the illness without any significant cause, lack of motivation or support from the family. in addition to anxiety and stress, there are sleep disturbances that are felt by some hypertensive patients, namely they find it difficult to get to sleep, 4 of the respondents cannot start sleeping within 30 minutes, sleep time is less than 7 hours and 1 of them even uses sleeping pills 2 times a week. two respondents also admitted that they often experienced pain, even waking up at night. this is in accordance with research by suwartika and cahyati (2015) that most respondents who suffer from heart disease have poor sleep quality. people with high blood pressure also experience symptoms such as dizziness, fatigue, dyspnea, sleep disturbances, and mild tiredness. these symptoms can cause sufferers to wake up from sleep, so it usually takes longer to fall asleep, sleep less, and affect activity (potter & perry, 2010). one of the non-pharmacological therapies in lowering blood pressure is relaxation techniques. the benson relaxation method can control the nervous system which is useful for lowering blood pressure (suiraoka, 2016). the basic concept of relaxation techniques is essentially a way of relaxation that is needed to reduce tension in the muscles which can improve pulse, blood pressure and breathing (aspiani, 2015). relaxation therapy can help individuals develop cognitive skills to reduce negative energy and respond according to the surrounding environment (perry & potter, 2010). benson relaxation is a method of relaxation techniques created by herbert benson, a medical researcher from the harvard medical school who examines some of the health benefits of prayer and meditation. this relaxation is a combination of relaxation response techniques https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.214-220 216 with individual belief systems or faith factors. the focus of this relaxation is on certain phrases that are repeated using a regular rhythm accompanied by a resigned attitude. the expressions used can be in the form of god's names or words that have a calming meaning for the patient himself. the benson relaxation is done by doing a long inspiration which will slowly stimulate the lung stretch receptors due to lung inflammation. this situation provides a signal which is then sent to the medulla oblongata which will provide information about increased blood flow. this information will be forwarded to the brainstem, as a result the parasympathetic nerves experience increased activity and the sympathetic nerves experience decreased activity on the chemoreceptors, so that an increase in blood pressure and lung inflammation will reduce the heart rate and cause vasodilation in a number of blood vessels (atmojo et al., 2019). in addition to the benson relaxation, there are also the autogenic relaxation techniques. the autogenic relaxation is relaxation that seems to put oneself into a mild hypnotic state. this therapy orders the legs and arms to feel heavy and warm, the heart rate and breathing rate are stable, the stomach is relaxed, and the forehead is clean and cold. then you repeat the easiest and most relevant command to deal with stress symptoms, for example ordering the forehead to feel cool and to relieve headaches, while repeating it by bringing your fingers together (kanji et al, 2006). the autogenic relaxation will help the body carry out orders through autosuggestion to relax so that it can control breathing, blood pressure, heart rate and body temperature. visual imagination and verbal mantras that make the body feel warm, heavy and relaxed are standard autogenic relaxation exercises (lutfi, 2019). this study aims to analyze the effect of the benson and autogenic therapy on blood pressure, anxiety and sleep quality in hypertensive patients. methods pre-experimental research design with one group pre-test and post-test design. this research was conducted in the working area of the balowerti community health center, kediri city, with a sample size of 20 respondents determined by purposive sampling technique. the instruments used were the hars (hamilton anxiety rating scale) questionnaire to measure anxiety levels which contained 14 assessment indicators, a digital tensimeter and the psqi (the pittsburgh sleep quality index) questionnaire to measure sleep quality levels which contained 7 assessment indicators. the analytical test used is the wilcokson test. results the results showed that the characteristics of the respondents were the majority of women 12 respondents (66.7%), the age of the majority was more than 60 years as many as 10 respondents (55.6%), the occupation of the majority of housewives was 9 respondents (50%). table 1. characteristics of variables based on anxiety levels before and after being given therapy category anxiety pre post frequency percent frequency percent mild 5 25% moderate 7 35% 12 60% severe 13 65% 3 15% total 20 100% 20 100% based on table 1, it was found that the level of anxiety before the intervention was mostly in the severe category, 13 respondents (65%), while after the intervention, most of the 12 respondents (60%) were in the moderate category. table 2. characteristics of variables based on the level of sleep quality before and after being https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.214-220 217 given therapy categori sleep quality pre post frequency percent frequency percent bad 16 80% 4 20% good 4 20% 16 80% total 20 100% 20 100% based on table 2, it shows the quality of sleep before the intervention. most were in the bad category, 16 respondents (80%), while after the intervention, most respondens were in the good category, 16 respondents (80%). table 3. characteristics of variables based on the level of hypertension before and after being given therapy category level of hypertension pre post frequency percent frequency percent pre hypertension 9 45% mild hypertension 12 60% 10 50% moderate hypertension 8 40% 1 5% total 20 100% 20 100% based on table 3, it shows that most of the hypertension before being given therapy was in the mild hypertension category, 12 respondents (60%), while the category after being given the intervention, the majority of mild hypertension were 10 respondents (50%). statistical test results showed that the p value is 0.000 <0.05 for decreased blood pressure, the p value is 0.001 <0.05 for sleep quality, the p value p value is 0.000 <0.05 for anxiety levels, so it can be concluded that there is an effect of therapy benson and autogenic relaxation to decrease blood pressure, anxiety level and quality of sleep in hypertensive patients. discussion the results showed that the characteristics of the respondents were the majority of women, 12 respondents (66.7%), the age of the majority were more than 60 years, 10 respondents (55.6%), the occupation of the majority of housewives was 9 respondents (50%). this is in accordance with the theory which states that as get older, the risk of developing hypertension and heart disease increases and the increased age factor also indicates the menopause phase in women, this increases the risk of hypertension and heart disease. menopausal conditions cause a decrease in the hormone estrogen in women, this is what is considered to cause an increased risk of developing hypertension or heart disease (prince and wilson, 2012). the results of the study were also related to the level of anxiety before the intervention, namely the majority were in the severe category, 13 respondents (65%), while after the intervention, most were in the moderate category, 12 respondents (60%). meanwhile, the respondents' hypertension level was mostly hypertension before being given therapy in the mild hypertension category, 12 respondents (60%), while the majority after intervention was given the mild hypertension category, 10 respondents (50%). the quality of sleep before the intervention was mostly in the bad category, 16 respondents (80%), while after the intervention, the majority were in the good category, 16 respondents (80%). statistical test results show that the p value is 0.000 <0.05 for decreased blood pressure, the p value is 0.001 <0.05 for sleep quality, the p value p value is 0.000 <0.05 for anxiety levels, it can be concluded that there is an effect of therapy benson and autogenic relaxation to decrease blood pressure, anxiety level and quality of sleep in hypertensive patients. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.214-220 218 based on the results of the sleep quality measurement (psqi) study after relaxation therapy, it was shown that the majority of respondents had good sleep quality, as many as 16 respondents (80%). this means that the sleep quality of hypertensive patients after being treated experienced an increase in sleep quality with a good category. the quality of a person's sleep is said to be good if it is marked by a calm sleep, feeling fresh in the morning, and feeling enthusiastic about doing activities, showing no signs of sleep deprivation and not having problems sleeping. the results of this study are in line with research conducted by indah maulinda (2017) on "the influence of benson relaxation therapy on the sleep quality of elderly at posyandu permadi tlogomas malang city" which is known that the quality of sleep in the elderly at posyandu permadi tlogomas malang city that performs benson relaxation is partly categorized as good, as many as 7 people (70.0%). sleep quality was categorized as good in the group that did benson relaxation because there was an increase in sleep quality in the elderly, where previously it was not good enough in this case. these results are supported by research conducted by dewi (2021) which shows that the average score for sleep quality in pre-test patients was 15.21, with the majority of bad categories experiencing a decrease in score to 7.18 with the majority of good categories. this means that there is an increase in the quality of the respondent's sleep after the therapy is better. the results of the study also showed a decrease in the respondent's level of anxiety and blood pressure, this is because the benson relaxation technique is a religious therapy that involves religious belief factors. in the elderly, they tend to improve their spirituality and get closer to god so that the right relaxation technique to do in dealing with discomfort is the benson relaxation technique (novitasari, 2014). the goal is to increase alveoli ventilation, maintain gas exchange, prevent lung atelectasis, increase cough efficiency, reduce stress both physical and emotional stress, namely reducing pain intensity and reducing anxiety and reducing systolic and diastolic blood pressure (soeharto, 2009). while the autogenic relaxation techniques have the benefit of increasing concentration and increasing a sense of well-being in the body and providing a sense of comfort and not causing any side effects. besides that, autogenic relaxation can reduce heart rate, blood pressure, and respiratory rate, and reduce oxygen demand, feelings of peace, and reduce muscle tension and metabolic rate (aji & armiyati, 2017). the relaxation techniques have benefits for our minds, one of which is to increase alpha (α) waves in the brain so that a relaxed state is achieved, increased concentration and increased sense of well-being in the body (potter & perry, 2010). the benson relaxation is also the development of a breathing relaxation response method by involving the patient's belief factor that can create an internal environment so that it can help patients achieve a higher state of health and well-being. the benson relaxation has several advantages, namely the method is simple because it relies on deep breathing efforts interspersed with prayers to god almighty, this technique can also be done anytime and anywhere without the need for a very special room. the benson's relaxation will produce an alpha wave frequency in the brain which can cause feelings of happiness, joy, excitement and confidence so that it can suppress the release of the hormones cortisol, epinephrine and norepinephrine which are strong vasoconstrictors in blood vessels. suppression of these hormones can result in dilation of blood vessels which results in a decrease in vascular resistance so that the end result is a decrease in blood pressure (price and wilson, 2012). while the autogenic relaxation can be said to be a technique that can reduce hypertension because relaxation is expected to eliminate tension where the person imagines a quiet place and then focuses on different physical sensations from the feet to the head, while progressive muscle relaxation is a deep muscle relaxation technique. which does not require imagination, persistence, or suggestion, this relaxation technique focuses attention on a muscle activity by https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.214-220 219 identifying tense muscles and then reducing tension by performing relaxation techniques to get a relaxed feeling. relaxation is essentially a way of being treated to reduce muscle tension which can improve pulse rate, hypertension and respiratory rates. the response from relaxation will return the body to a state of balance. pupils, hearing, blood pressure, heart rate, breathing and circulation will return to normal and muscles will relax (dewi, 2017). this research is also in line with research conducted by vera, et al (2021), which shows the results of a bivariate test using the wilcoxon test. the results showed a p-value of 0.000 <0.05. it was concluded that autogenic relaxation techniques could significantly affect anxiety levels in primigravid pregnant women. another study by mardiani (2014), the results showed that there were differences in anxiety levels before and after being given the benson relaxation technique and deep breathing (p-value= 0.000). this research is in line with research conducted by ismasyah (2021), showing the results of statistical tests using the paired t test obtained a p value= 0.000 <0.05. the conclusion of the research results is that there is a significant difference in pain scores between before and after being given interventions, both autogenic relaxation and benson relaxation interventions, with a p value= 0.000 <0.05. these results indicate that there is a difference in the pain scores of fracture patients between those who were given autogenic relaxation interventions and benson relaxation, where benson relaxation was more effective in reducing fracture patient pain. researcher argue that the benson and autogenic relaxation therapy can be used as a way to reduce anxiety levels, improve sleep quality and help hypertensive patients control blood pressure so that they can be used as psychotherapy methods, because it will make the heart peaceful, calm and peaceful. based on this, it is proven that the level of anxiety, sleep quality and blood pressure in hypertensive patients can be reduced through the benson and autogenic relaxation therapy. these changes also show that researchers have received positive responses from patients in the working area of the balowerti health center in kediri city and provided changes in the form of changes in anxiety levels, sleep quality and blood pressure in hypertensive patients. conclusion the benson and deep autogenic relaxation techniques can be used by someone in a healthy or sick condition and are a non-pharmacological effort to help reduce muscle tension so that the body becomes comfortable, relaxed, reduces pain and stress intensity, increases lung ventilation and increases blood oxygenation. these techniques can reduce anxiety, improve sleep quality and lower blood pressure in hypertensive patients. references aji, y, armiyati, s. sn. (2017). efektifitas antara relaksasi autogenik dan slow deep breathing relaxation terhadap penurunan nyeri pada pasien post orif di rsud ambarawa. aspiani, r. y. (2015). buku ajar asuhan keperawatan klien gangguan kardiovaskular aplikasi nic & noc. (egc, ed.). jakarta. atmojo, j. t., putra, m. m., astriani, n. m. d. y., dewi, p. i. s., & bintoro, t. (2019). efektifitas terapi relaksasi benson terhadap tekanan darah pada penderita hipertensi. interest : jurnal ilmu kesehatan, 8(1). https://doi.org/10.37341/interest.v8i1.117. brunner, & suddarth. (2013). buku ajar keperawatan medikal bedah vol. 2. (m. ester, ed.) (8th ed.). jakarta: egc. dewi dyah palupi puspita. (2021). pengaruh teknik relaksasi autogenik terhadap kualitas https://thejnp.org/ https://www.semanticscholar.org/author/s.-aji/2059088741 https://www.semanticscholar.org/author/y.-armiyati/71767435 https://www.semanticscholar.org/author/s.-sn/148141471 https://doi.org/10.37341/interest.v8i1.117 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.214-220 220 tidur penderita hipertensi di puskesmas sumbang i. jurnal keperawatan muhammadiyah. 6 (4): 114-121. dewi erika untari. (2017). teknik relaksasi autogenik dan relaksasi otot progresif terhadap tekanan darah pada lansia dengan hipertensi. seminar nasional dan workshop publikasi ilmiah. 68-79. dinas kesehatan (dinkes) jawa timur. (2017). profil kesehatan jawa timur. imansyah. (2021). penerapan relaksasi autogenik dan relaksasi benson terhadap nyeri pasien fraktur. jurnal kesehatan. 11(1), 29-41. indah maulinda, erlisa candrawati, ragil catur adi w. (2017). pengaruh terapi relaksasi benson terhadap kualitas tidur lansia di posyandu permadi tlogomas kota malang. nursing news, volume 2, nomor 3. kanji, n.,white, a.,& ernst, e. (2006). autogenic training to reduce anxiety in nursing students : randomized controoled trial. journal of advanced nursing, 53(6), 729735. lutfi rosida, imardiani, joko tri wahyudi. (2019). pengaruh terapi relaksasi autogenik terhadap kecemasan pasiendi ruang intensive care unit rumah sakit pusri palembang. indonesian journal for health sciences vol.3, no.2, september 2019, hal.52-56. issn: issn 2549-2748 (online). mardiani ike yuyun. (2014). perbedaan efektifitas teknik relaksasi benson dan nafas dalam terhadap tingkat kecemasan pasien pre operasi bedah adomen di rsud kota salatiga. jurnal ilmu keperawatan dan kebidanan (jikk). 1-9. novitasari, ike. (2014). pengaruh terapi relaksasi benson terhadap penurunan tingkat stres. jurnal ilmu keperawatan dan kebidanan, (juli), 3. potter & perry. (2010). buku ajar fundamental keperawatan. jakarta : ecg. price, s. a., & wilson, l.m., (2012). patofisiologi: konsep klinis prosesprosespenyakit, 6 ed. vol. 1. alih bahasa : pendit bu, et al. editor : hartanto, h., et al. jakarta: egc. riskesdas. (2018). hasil utama riskesdas 2018 kesehatan. 20–21. retrieved from http://www.depkes.go.id/resources/download/infoterkini/materi_rakorpop_2018 /hasil riskesdas 2018.pdf. soeharto. (2009). pengaruh teknik relaksasi benson terhadap kualitas tidur pasien yang mendapatkan terapi hemodialisis di unit hemodialisis rsup dr m djamil padang. skripsi, program studi keperawatan, fakultas keperawatan, universitas andalas, padang. suwartika, peni cahyati. (2015). analisis faktor yang berpengaruh terhadap kualitas tidur pasien gagal jantung di rsud kota tasikmalaya. jurnal skolastik keperawatan vol. 1, no.1 januari ² juni 2015. issn: 2443-1699. suiraoka, i. (2016). penyakit degeneratif. yogyakarta: nuha medika. mengenal, mencegah dan mengurangi faktor resiko 9 penyakit degenaratif, (penyakit degeneratif), 41–54. vera iriani abdullah, rina andika saputri ikraman, harlina. (2021). pengaruh penerapan teknik relaksasi autogenik terhadap tingkat kecemasan ibu hamil primigravida. jurnal kesehatan. vol 15(1) 2021: 17-23. eissn : 2655-2434, doi: 10.36082/qjk.v15i1.199. world health organization (2022). world health statistics 2022– monitoring health for the sdgs. https://thejnp.org/ journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.73-79 73 diet compliance analysis towards blood sugar levels for diabetes mellitus patients septi dwi rahmawati, atik setiawan wahyuningsih, eva agustina yalestyarini 1 1 stikes surya mitra husada, kediri, east java, indonesia corresponding author : atiksetiawan9@gmail.com abstract background: people with diabetes mellitus are increasing in number. controlling blood sugar levels is an action that must be taken to get normal and stable blood sugar levels. self-control takes precedence over treatment. compliance with diet is one of the important things in controlling blood sugar levels. raflesia room as one of the internal medicine inpatients in dr. soedomotrenggalek, received inpatient care for the majority of diabetes mellitus patients. purpose : the purpose of this study was to analyze the relationship between diet adherence and blood sugar levels in people with diabetes mellitus. methods : the research design used descriptive analytic with cross sectional approach. the population in this study were patients with diabetes mellitus in the raflesia room of dr. soedomotrenggalek hospital in january 2017 with 30 patients. with a simple random sampling technique so that 29 samples were obtained. result : the results showed that almost all respondents, namely 25 (86%) respondents, had abnormal blood sugar levels. almost all respondents, 23 (79%) did not comply with the diet. chi square test results obtained 0.004 which means there is a relationship between dietary compliance with blood sugar levels of diabetes mellitus patients in raflesia room dr. soedomo hospital trenggalek in 2017. conclusion : old age is an age that is susceptible to a decrease in body function, especially hormonal causes of decreased pancreatic function resulting in a decrease in insulin sensitivity which causes high blood sugar levels. the level of education has an important role in diet compliance where patients are required to understand 3j "types, amounts and schedules" so that the lower level of education causes lower diet compliance. disobedience to diets causes sufferers to consume irregular foods which cause a pile of glucose and blood so that hyperglycemia occurs. keywords : diabetes mellitus, blood sugar levels, dietary compliance received july, 25, 2018; revised august 24, 2018; accepted september 14, 2018 how to cite: rahmawati, s., wahyuningsih, a., yalestyarini, e. (2018). diet compliance analysis towards blood sugar levels for diabetes mellitus patients. journal of nursing practice, 2(1), 73-79. https://doi.org/10.30994/jnp.v2i1.46 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v2i1.46 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.73-79 74 background diabetes mellitus (dm) is a cause of high mortality due to the resulting cardiovascular disease. patients with diabetes mellitus have 2-3 times higher risk than nondm populations (siregar, 2010). diabetes mellitus (dm) is a chronic syndrome of metabolic disorders of carbohydrates, proteins, and fats due to insufficient insulin secretion or insulin resistance in tissues (dorland, 2002). according to riyadi&sukarmin (2008) there are several factors that cause an increase in blood sugar levels, namely genetic factors, age, stress, wrong diet and obesity. raflesia room is an internal medicine inpatient room at rsud dr. soedomotrenggalek. patients who were hospitalized in the raphlesia room were mostly diabetic mellitus. patients with diabetes mellitus who are hospitalized due to problems with an increase in uncontrolled blood sugar. the latest data from the (international diabetes federation, 2018) at the diabetes comolications congress shows that currently the complications of dm lead to 425 million adults and will increase to 629 million in 2045. world pratiwi, 2007 included data from the health organization (who) predicts the increase in the number of people with diabetes mellitus in indonesia from 8.4 million in 2000 to around 21.3 million in 2030, even indonesia ranks fourth in the world as the largest number of people with diabetes mellitus after india, china and america (as cited in aini et al., 2012). (kominfo, 2015) based on data from basic health research (riskesdas) in indonesia there are 10 million people with diabetes, and 17.9 million people at risk of developing this disease. while east java province entered the top 10 prevalence of diabetics throughout indonesia or ranked ninth with a prevalence of 6.8. monthly report in the raflesia room of rsud dr. soedomo trenggalek, the number of patients with diabetes mellitus who were treated in october to december 2016 was 72 patients. based on the results of the diet obedience interview on 10 patients, 6 people were obedient and 3 people were not compliant. plasma glucose levels are determined at a time by the balance between the amount of glucose entering the bloodstream and the amount that leaves it. therefore, the main determinant of input is from diet, the rate of entry into muscle cells, adipose tissue, and other organs, and liver glucostatic activity. five percent of glucose consumed is converted directly into glycogen in the liver, and 30-40% is converted to fat. the rest is metabolized in muscles and other tissues. during fasting, liver glycogen is broken down from the liver to increase blood glucose levels. if there is a longer fasting, the liver glycogen is depleted and glycogenogenesis occurs from amino acids and glycerol in the liver (ganong, 2010). so that to keep controlling the sugar levels diet compliance becomes one of the important elements to control sugar levels. but in reality not all people with diabetes mellitus are able to obey their diet. disobedience of patients in managing diabetes mellitus will have a very large negative impact including increased health costs and diabetes complications (aini et al., 2012). from the description above the author will conduct research on the relationship of blood sugar levels with diet adherence in patients with diabetes mellitus in the raflesia room of rsud dr. soedomotrenggalek. objective the purpose of this study was to analyze the relationship between diet adherence and blood sugar levels in people with diabetes mellitus. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.73-79 75 methods the research design used in this study is descriptive analytical method and cross sectional research type. the population in this study were all dm patients in the raphlesia room in rsud dr. trenggalek in january 2017, totaling 30 patients with simple random sampling obtained 29 respondents. the statistical test used was chi square. the measuring instrument used to measure blood sugar levels using a glumometer to determine normal levels and abnormal blood sugar levels. diet compliance measuring tool uses a questionnaire to identify compliance and non-compliance. results a. characteristics of respondents age table 1. age characteristics of dm patients in the raflesia room of rsud dr. soedomo trenggalek dated april 5 to april 18 2017 characteristics amount percentage ≤20 years old 0 0 21-25 years old 0 0 26-35 years old 2 6 >35 years old 27 93 totals 29 100 primary source : 2017 from table 1 shows that the majority of respondents aged> 35 years were 27 respondents (93%). b. characteristics of respondents based on gender table 2. sex characteristics of dm patients in the raflesia room of rsud dr. soedomo trenggalek dated april 5 to april 18 2017 characteristics amount percentage laki-laki 17 58 perempuan 12 42 totals 29 100 primary source : 2017 based on table.2 shows that more than some respondents were male as many as 17 respondents (58%). c. characteristics of respondents based on education level table 3. characteristics of education level of dm patients in the raflesia room of rsud dr. soedomo trenggalek dated april 5 to april 18 2017 characteristics amount percentage sd 3 10 smp 9 32 smu 17 58 pt 0 0 totals 29 100 primary source : 2017 from table 3 shows that more than half of respondents with high school education were 17 respondents (58%).. d. characteristics of respondents based on job table 4. job characteristics of dm patients in the raflesia room of rsud dr. soedomotrenggalek dated april 5 to april 18 2017 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.73-79 76 characteristics amount percentage unemploy 5 17 farmer 7 25 entrepreneur 17 58 civils/self employ 0 0 jumlah 29 100 primary source : 2017 based on table 4, showed that more than some respondents were entrepreneur as many as 17 respondents (58 %) e. blood sugar levels based on diagram 1 shows that almost all respondents have abnormal sugar levels, namely there are 25 (86%) of the total 29 respondents f. compliance with diet based on diagram 2 shows that almost all respondents did not comply with the diit, namely 23 respondents (79%) of the total respondents 29 respondents g. tabulation tabulation of diet compliance with blood sugar levels table 5 cross tabulation of sugar content with diit adherence to diabetes mellitus patients in the raflesia room of rsud dr. soedomotrenggalek dated april 5 to april 18 2017 comply diet uncomplyed diet total valuep normal blood sugar 4 14.8% 23 79.3% 27 93.1% abnormal blood sugar 2 6.9% 0 0% 2 6.9% 0.004 total 6 20.6% 23 79.3% 29 100 based on table 5 shows almost all respondents had sugar levels in the abnormal category and did not comply with diit as many as 23 respondents (79.3%). discussion a blood sugar levels journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.73-79 77 based on diagram 1, it is known that almost all respondents had abnormal sugar levels, namely 25 (86%) of the total 29 respondents and almost all respondents aged> 35 years, as many as 27 respondents (93%) of a total of 29 respondents. based on research conducted by wahyuningsih& nusantara (2017) in the title of patients with dm with insomnia in terms of characteristics shows that diabetes mellitus is the most common in the elderly. diabetes mellitus (dm) is a group of heterogeneous disorders characterized by increased levels of glucose in the blood or hyperglycemia. glucose normally circulates in a certain amount in the blood. glucose is formed in the liver from the food consumed. insulin is a hormone produced by the pancreas, controlling glucose levels in the blood by regulating its production and storage (smeltzer& bare, 2002). increased sugar levels can be influenced by age and stress, where humans generally experience a physiological decline that dramatically decreases rapidly after age 40. this decrease will be at risk for decreasing the endocrine function of the pancreas to produce insulin. elderly age is the age at which respondents experience a decline in all tissue functions, disrupted hormone production including decreased insulin production and decreased long-term memory that causes uncontrolled respondents in medication adherence. besides diabetes mellitus is a type of disease that can only be controlled, but can not be cured, so suffering from long-term disease can cause the boredom of respondents so often do not pay attention to the condition of blood sugar conditions, respondents began to not care about the disease so that abnormal blood sugar increases not give any influence to the respondent. b compliance with diet based on diagram 2, it is known that most of them do not comply with the diet, which is 79% of the total respondents of 29 respondents. compliance is a behavior in keeping a recommendation on daily habits and can be scored with the research score. a compliance is influenced by the level of education, where education is a major basis in the success of prevention or treatment (tjokroprawiro, 2002). based on table 3 it is known that more than half of respondents with high school education were 17 respondents (58%). this shows that 42% of other respondents still lack education, namely elementary and junior high school. this is consistent with the research conducted by senuk et al., 2013 that education has a role to play in increasing compliance with the information provided. in regulating the diet for people with diabetes mellitus, the principle is 3j, namely: a) amount the amount of food consumed is adjusted to height, weight, type of activity, and age. you can calculate your calorie needs based on guidelines on daily calorie requirements. b) type food preparation for people with diabetes mellitus includes carbohydrates, proteins, fats, and fruits and vegetables. nutritional needs must be fulfilled with the right menu so as not to raise blood sugar. c) schedule that is a fixed meal time including breakfast, lunch, dinner, and a snack. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.73-79 78 compliance is an order in carrying out actions that are in line with the objectives to be achieved. understanding the purpose of treatment in patients with diabetes mellitus is influenced by maturity in thinking. compliance with the dm treatment diet requires adequate education so that the patient is able to control the desire to consume the desired food but must be avoided. education is one of the milestones of knowledge to take real action. with education that is insufficient for patients with dm, they will find it difficult to determine 3j, namely the exact number, the right type and the right schedule. dm sufferers are required to know how many calories must be consumed every meal and what time or time the patient is allowed to consume food. this condition requires dm sufferers to process their knowledge and be shown clearly in the form of compliance with dm treatment die. so that if education is insufficient it will tend to look less obedient in treatment and have an impact on deviant behavior with goals. c blood sugar levels and dietary compliance based on the results of the statistical test in table 1, the results of the statistical value (p-value) chi square obtained sig (2-tailed) is equal to = 0.004 means <of the value of  (alpha) = 0.05. then h0 is rejected and h1 is accepted which means that there is a correlation between sugar levels and diet adherence in patients with diabetes mellitus in the raflesia room of rsud dr. soedomotrenggalek 2017. wahyuningsih&utami (2017) stated in his study that patients who were less able to control food consumption caused blood sugar levels to rise despite regular exercise, so it was important for dm sufferers to comply with the 4 pillars of dm treatment according to the perkeni program. health research journal results, about the relationship of blood sugar levels with diet compliance (reizel et al, 2003) states that there is a significant relationship between blood sugar levels with diet adherence in patients with diabetes mellitus associated with the theory of blood sugar levels that blood sugar levels are influenced one by diet compliance. stating that by increasing one's adherence it will cause the patient to be careful in his diet, so that blood sugar levels can be controlled. diabetes mellitus is a group of heterogeneous disorders characterized by increased levels of glucose in the blood or hyperglycemia. glucose normally circulates in a certain amount in the blood. glucose is formed in the liver from the food consumed. insulin, which is a hormone produced by the pancreas, controls the level of glucose in the blood by regulating its production and storage (smeltzer& bare, 2002). referring to the results of the research above that sugar levels have a relationship with diet compliance, it is in accordance with the theory that in diet compliance which is related to the amount of food consumed, the type of food that is appropriate and the right schedule too, diet compliance becomes very important. compliance is influenced by several things, including work, due to the work of the respondent as an entrepreneur. this type of work such as self-employment makes respondents often forget about and become disobedient with their diet because of the many activities, then causing blood sugar to increase. entrepreneurial work also deals with many people, which allows many supporters who can remind respondents of their compliance. social support in the form of emotional support from other family members and friends can help reduce anxiety, they can eliminate the temptation to non-compliance, journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.73-79 79 and they often become support groups to achieve compliance. as a supporter, the need for people with diabetes mellitus to always re-control their illness so they can always control their blood sugar levels, so they don't fall into poor health. in addition, the age of respondents is a factor that influences respondents. the respondent's age was almost entirely more than 35 years, where the age showed a decrease in organ function in the body, decreased long-term memory and the length of time to suffer from diabetes mellitus made the respondents reluctant to return to the diet. the thing that is most likely to be done by patients with diabetes mellitus is only to reduce drinking and sweet foods, but often forget the schedule and the amount that must be consumed. thus blood sugar levels are closely related to diet adherence to diabetes mellitus patients. conclusion almost all respondents have abnormal sugar levels, and most of them do not obey their diit. there is a correlation between sugar levels and diit adherence in diabetic patients in the raflesia room of rsud dr. soedomotrenggalek 2017. references arikunto, suharsimi. (2002). prosedurpenelitian. jakarta: rinekacipta basuki, e (2005). teknik penyuluhan diabetes melitus. penatalaksanaan diabetes melitus terpadu. jakarta :fkui. guntur. (2006). faktor yang berhubungan dengan pengendalian kadar gula darah pada penderita diabetes mellitus diperkotaan indonesia. badan penelitian dan pengembangan depkes ri. jakarta depkes. (2011). prevalensi penyakit diabetes melitus. diakses: 20 januari 2015. dari: http://www.depkes.go.id/download.publikasi ditjen guntur. (2009). penatalaksanaan diabetes melitus terpadu. edisi ii cetakan ke-5. jakarta: fakultas kedokteran ui. guyton, a.c., dan hall, j.e. (2008). buku ajar fisiologi kedokteran. edisi 11. jakarta: egc kominfo. (2015). masih tinggi prevalensi diabetes di jatim tahun 2015 pratiwi. (2013). kiat perawatan diabetes melitus. htpp://www. sehattanpa diet” purwanto. (2012). mencegah komplikasi penyakit kencing manis. diakses 20 januari 2015. dari: http://www.sinarharapan.konsultasi/html riwidikdo. (2007). statistik kesehatan. jakarta: mitra cendikia smeltzer dan bare. (2008). buku ajar keperawatan medikal bedah brunner dan suddarth (ed.8, vol. 1,2), alih bahasa oleh agung waluyo (dkk), egc, jakarta. sugiyono. (2011). statistik untuk penelitian. bandung: cv alfabeta soekarmin, riyadi, dkk. (2002). dari empat sehat lima sempurna kepedoman gizi seimbang dan buku hidup sehat gizi seimbang dalam siklus kehidupan manusia. prima media pustaka. jakarta tim penyusun depkes ri. (2005). pharmautical care untuk penyakit diabetes melitus. jakarta :dirjen bina kefarmasian dan alat kesehatan depkes ri journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.109-113 109 moringa nastar increase prolaktin as support of 1000 hpk action with unicef consept approach ely isnaeni , erna rahmawati iik bhakti wiyata kediri, east java, indonesia corresponding author: ely.isnani@iik.ac.id abstract background: the percentage of exclusive breastfeeding decreases with increasing age groups of infants. the desire for exclusive breastfeeding is not supported by maximum milk production and the main reason is time constraints due to work so that it is not possible to provide breast milk directly or by way of pumping breast milk. the more nutrients that enter the mother, the more the hormone prolactin, and the more milk production. moringa contains phytosterol compounds that work to increase and facilitate the production of breast milk (lactagogum effect). purpose: this study aimed to analyze the effect of moringa moringa to increase prolactin as a supporter of the 1000 the first day of life (hpk) movement with the unicef concept framework approach. methods: the research design uses pre-experiment research design with one group prepost tests design. data were collected using purposive sampling with a total sample of 10 respondents. data were analyzed using non-parametric data analysis techniques with the mann whitney test with α = 0.05, to see the effect of nastar moringa increasing prolactin as a supporter of the 1000 hpk movement with increased unicef conceptual framework result: the results of the study with the mann whitney test showed that the influence of moringa nastar to increase prolactin levels was pvalue = 0.047. before given moringa nastar, the mean was 37.06 and after given moringa nastar increased to 56.51. conclusions: it is concluded that there is an influence of nastar moringa to increase prolactin as a supporter of the 1000 hpk movement. based on the results of this study it is recommended that mothers consume moringa nastar to increase levels of prolactin keywords: moringa nastar, prolactin, 1000 the first day of life received july, 29, 2019; revised august 30, 2019; accepted september 22, 2019 how to cite: isnaeni, e., & rahmawati, e. (2019). moringa nastar increase prolaktin as support of 1000 hpk action with unicef consept approach. journal of nursing practice, 3(1), 109-113. https://doi.org/10.30994/jnp.v3i1.72 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v3i1.72 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.109-113 110 background in indonesia, the percentage of exclusive breastfeeding decreases with increasing age groups of babies. in infants aged 5 months exclusively breastfeeding was only 15.3% in 2010, but has increased by 36.2% in 2013, while infants 6 months exclusively breastfeeded by 30.2% 1. the target of exclusive breastfeeding is 80% in 2015. the results of the talk show "philips avent new parents class", 60% of breastfeeding mothers stop breastfeeding earlier than they want. a survey from de jager in 2013 said that 1 in 10 mothers stopped breastfeeding because they felt uncomfortable breastfeeding outside the home. another survey also showed that more than 30% of breastfeeding mothers felt comfortable pumping breast milk in a closed room5. this study uses 10 mothers at gambiran city hospital in kediri taken through a purposive technique in which the researcher chooses to marry, work, have children, give breastfeeding although not exclusively and formula milk or other complementary foods when the baby is 0-6 months old. the results of the study show that the desire for exclusive breastfeeding is not supported by maximum milk production and the main reason is the limited time due to work so it is not possible to provide breast milk directly or by way of pumping breast milk and the lack of full support from families to provide exclusive breastfeeding. the hassle if you have to pump breast milk when working, the distance is too far between the place of work and home, must consume fibrous food. the cause of nutritional problems in 1000 hpk (first day of life) for example infants do not get exclusive breastfeeding. although the data above requires validation, what is clear is that the scope of exclusive breastfeeding is still far from the target that must be achieved in 2015, which is 80%. according to unicef, "out of control" is an obstacle that causes ineffective promotion of exclusive breastfeeding. all efforts to improve nutrition outside this period have been proven unable to resolve the nutritional problems of the community thoroughly6. many factors affect the production of milk, milk production in the body depends on two hormones, namely prolactin and oxytocin. the more nutrients that enter the mother, the more the hormone prolactin, and the more milk production. rahayu's research results stated that food factors significantly influence milk production in addition to psychological factors and baby sucking. moringa plants are local food ingredients that have the potential to be developed in culinary nursing mothers, because they contain phytosterol compounds that function to increase and facilitate the production of breast milk (lactagogum effect) 2. theoretically, compounds that have the effect of lactagogum are sterols. sterols are steroid compounds3. the results of fuglie's research on malnourished communities in senegal, africa with moringa leaf flour therapy showed significant results on the nutritional status of individuals4. in addition to vitamin c, the nutritional content will increase in quantity if moringa leaves are consumed after drying and turned into powder (flour). vitamin a in moringa leaf powder is equivalent to 10 times vitamin a in carrots, equivalent to 17 times calcium in milk, equivalent to 15 times calcium in bananas, equivalent to 9 times protein in yogurt and equivalent to 25 times iron in spinach7. some of the above theories strengthen researchers to package moringa leaf extract into a form of processed nastar bread so that it becomes an economical, practical, high nutritional value snack with the aim of analyzing the influence of moringa nastar influence to increase prolactin as a supporter of the 1000 hpk movement with the unicef concept framework approach. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.109-113 111 objective this study aimed to analyze the effect of moringa nastar to increase prolactin as a supporter of the 1000 hpk movement with the unicef concept framework approach, which was carried out in nursing mothers. methods the research method uses a pre-experimental design with one group pre-post test design research design, aimed to determine the effect of moringa nastar on increasing levels of prolactin in nursing mothers aged 0-6 months at gambiran city hospital in kediri. the study population was breastfeeding mothers of infants aged 0-6 months, samples taken were some of the population that met the inclusion criteria, namely: 1) nursing mothers of infants aged 0-6 months, 2) working at the gambiran city hospital in kediri. purposive sampling technique with a sample size of 10 respondents. the research location used is the gambiran city hospital environment in kediri because 65% of the employees who work are women. the participants were assured that their engagement was voluntary, and that anonymity, privacy, and confidentiality of the data were guaranteed. furthermore, they were informed about the purpose and the method of the study before signing a written informed consent. the questionnaires were distributed to eligible participants at the gambiran city hospital, and respondents were asked to complete and return them in the same time. results the results of the study with the mann whitney test showed that the influence of moringa nastar to increase prolactin levels was pvalue = 0.047. before given moringa nastar, the mean was 37.06 and after given moringa nastar increased to 56.51. discusions the results of the study with the mann whitney test showed that the influence of moringa nastar to increase prolactin levels was pvalue = 0.047. before given moringa nastar, the mean was 37.06 and after given moringa nastar increased to 56.51. the initial puerperium amount of milk produced correlates with the amount of prolactin released during breastfeeding after birth, the main stimulus that maintains the secretion of prolactin is sucking, milk production will continue as long as the baby continues to suck breast milk. every time a mother feeds her baby, nerve signals from the nipple to the hypothalamus will cause a surge of prolactin secretion of about 10 to 20 times which lasts about 1 hour, this prolactin works on the breast of the mother to maintain the mammalian glands to secrete milk into the alveoli for alveoli to subsequent lactation production (guyton & hall, 2007). this is supported by the results of research that prolactin levels differ in each preode, the results of research conducted on 16 breastfeeding mothers obtained different serum prolactin levels between groups of breastfeeding mothers 1 week postpartum, 4 weeks postpartum, 8 weeks postpartum, during the first menstruation after delivery and after the baby weaning. prolactin levels of breastfeeding mothers 4 weeks post partum are higher compared with others (glaiser, 2006). increased levels of the hormone prolactin because in nastar moringa contains phytosterol chemical compounds namely poliferol and sterol, where these compounds play a role in increasing levels of prolactin, high levels of prolactin function to increase, accelerate, and journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.109-113 112 facilitate the production of breast milk. phytosterol and steroid compounds contained in moringa leaves have lactagogum effect power, in which the mechanism of lactagogum power of a compound can occur among others by: directly stimulating the protoplasmic activity of mammary gland secretory cells, stimulating the secretory nerve endings in the mammary gland so that secretion increased milk, or stimulates the prolactin hormone that acts on alveolar epithelial cells. prolactin or luteotropin or lth is a lactagonic and proliferative hormone against the mammary gland. the effect of prolactin in humans or mammals is stimulating lactation (puspita, 2013). in addition, the function of lactogogum can also increase glucose metabolism for lactose sites, thus increasing milk production. conclusions there is an effect of nastar moringa to increase prolactin levels with a pvalue = 0.047. before given moringa nastar, the mean was 37.06 and after given moringa nastar increased to 56.51. ackowledgment the author would like to thank the institut ilmu kesehatan bhakti wiyata for providing financial assistance in publishing this research. references ministry of health. highlights of the 2013 indonesian riskesdas results. 2014. titi mutiara k. test the effect of breastmilk smoothing powder for moringa oleifera (lamk) in white wistar strain mice. doctoral dissertation research report. poor; 2011 nurmalasari md. isolation of compounds of leaves of leaves sauropus androgynus (l.) merr (isolate of n-hexane faction: ethyl acetate = 80: 20). undergraduate thesis of airlangga university. 2008. p. 4–6. fuglie lj. the moringa tree a local solution to malnutrition? 2005 wayan diananto. 5-star tabloid important facts about career women breastfeeding tuesday, 4 october 2016 03:00:56 wib bank world, 2006, "repositioning nutrition as center for development"). joni m.s, sitorus m, and katharina n. 2008. prevent malnutrition with moringa. yogyakarta. canisius publisher winarti sri. 2010. functional food. yogyakarta: graha science zakaria, et al., .2012. addition of moringa leaf flour to daily food menus in efforts to overcome malnutrition in toddlers. food nutrition media 8 (1) journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.109-113 113 dachana, k.b, et al. 2010. effect of dried moringa (moringa oleifera lam) leaves on rheology, microstructural, nutritional, textural and organoleptic characteristics of cookies. kristina, n.n and syahid, s.f, balitro. 2014 utilization of moringa (moringa oleifera) plants to increase breast milk production. news of research and development of industrial plant food. vol. 20 number 3, december 2014 speroff l, fritz ma. clinical gynecologic endocrinology and. infertility. 8th ed philadelphia, pa usa: lippincot williams & wilkin. 2011 vyas 2012. risk of breast cancer due to hyperprolactinemia caused by antipsychotics (neuroleptics). british journal of medical practitioners, december 2012, volume 5, number 4 unicef (united nations children's fund) (1990) strategy for improved nutrition of children and women in developing countries. policy review paper e / icef / 1990 / 1.6, unicef: new york zakaria, veni hadju, suryani as'ad, and burhanuddin bahar. 2016. effect of extract moringa oleifera on quantity and quality of breastmilk in lactating mothers, infants 0-6 month. urnal mkmi, vol. 12 no. 3, september 2016 simbolon, jonni marjuang, sitorus m., and katharina nelly. 2008. prevent malnutrition with moringa. yogyakarta: canisius journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.122-129 122 social demographic factor on early detection ability of acute coronary syndrome in blitar regency indonesia novita ana anggraini1, faridah moh said2, nur syazana umar2, rahmania ambarika1, reni nurhidayah1 1 department of nursing, institut ilmu kesehatan strada indonesia, kediri, indonesia 2 lincoln university college, malaysia *corresponding author: phitphita@gmail.com abstract background: the prevalence of acs in indonesia is high, at least 2 million people in indonesia are diagnosed with acs. it is one of the main causes of death among adults in many countries around the world, including indonesia with prevalence of heart disease in indonesia is estimated at 2 million acs cases. one of the causes of the high acs mortality rate is a prehospital delay. decision time delay refers to the length of time the patient takes for early detection or to make a decision to seek help. this study will focus on the influence of social demographic factors on the ability of early detection of acs. purpose: this study aims to explain the relationship between treatment-seeking behavior, transportation, and socio-demographic factors (age, gender, socio-economic, educational status, health insurance). methods: a prospective cross-sectional study was conducted in this study. the samples will be obtained in blitar regency with 22 public health center sub-districts with sample 126 respondents. the correlation among variables was analyzed using chi-squared (χ2), and for determining the dominant factors, multiple logistic regression with the enter method was used. a p value <0.05 was considered significant. results: the study found that the age, health insurance status, education level, and employment status of the patients were significant factors for early detection. delay to early detection increased with the increase in age of the patients, although it was not significant by logistic regression. conclusions: this study reveals that several sociodemographic factors that can affect early detection abilities are education, employment status, and health insurance. keywords: acs, early detection, socio demographic received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.368 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:phitphita@gmail.com https://doi.org/10.30994/jnp.v6i2.368 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.122-129 123 background acute coronary syndrome (acs) is one of the most common cardiovascular problems. acs is also known as unstable angina, st-segment elevation myocardial infarction (stemi), and non-stemi(demisse et al., 2022; schiavone et al., 2020). the morbidity rate of acs is quite high and leads to defects in the quality of life after an attack. acs is the biggest cause of death and loss of disability-adjusted life years (dalys) in the world. more than 7 million deaths and 129 dalys annually (hayajneh et al., 2021; knoery et al., 2020). the prevalence of acs in indonesia is high, at least 2 million people in indonesia are diagnosed with acs (arrebola‐moreno et al., 2020; arrebola-moreno, petrova, garcia-retamero, rivera-lópez, jordan-martinez, et al., 2020; stolic et al., 2019). it is one of the main causes of death among adults in many countries around the world, including indonesia. according to data from the ministry of health indonesia (2019) and a study in 2020, the prevalence of heart disease in indonesia is estimated at 2 million acs cases (kemenkes, 2021). one of the causes of the high acs mortality rate is a prehospital delay. prehospital delay is influenced by two factors, decision-making, and mobilization to the hospital (hadid et al., 2020; mirzaei et al., 2020b). the total prehospital delay period includes the time taken by patients to recognize the seriousness of their symptoms and to contact medical help (decision time) and the time taken from requesting help to admission to a center where emergency coronary care service is available (home-to-hospital delay) (khaled et al., 2022). decision time delay is the initial factor that causes delays in handling acs (hoschar et al., 2020; mirzaei et al., 2020a). decision time delay refers to the length of time the patient takes for early detection or to make a decision to seek help. the longer it takes for early detection of acs, the longer it takes to make a decision to seek help, which means it will cause prehospital delay (arrebolamoreno, petrova, garcia-retamero, rivera-lópez, jordan-martínez, et al., 2020; garrido et al., 2020). knowledge related to acs symptoms is very important to speed up the acs early detection process. knowledge of acs is influenced by many factors, ranging from education level, exposure to information, and experience with symptoms, to knowledge related to risk factors (chau et al., 2018; demisse et al., 2022). all of the above components will affect a person's assessment of the perceived acs symptoms so it will affect the time needed for early detection (demisse et al., 2022; khaled et al., 2022). the above explains that social demographic factors are closely related to the ability to recognize acs symptoms which will have an impact on accelerating early detection of acs. this study will focus on the influence of social demographic factors on the ability of early detection of acs. methods a prospective cross-sectional study was conducted in this study. the population of this study is the community with a high risk of acs in blitar with 4282 cases of cardiovascular disease. the samples will be obtained in blitar regency with 22 public health center subdistricts, they are bakung, binangun, doko, gandusari, garum, kademangan, kanigoro, kesamben, nglegok, panggungrejo, ponggok, sanankulon, selorejo, and selopuro. of 22 subdistricts, 4 sub-districts will be taken with the highest acs incidence rate, there are srengat, wonodadi, kademangan, and selorejo. the sampling technique in this study is a probability sampling technique. the samples of this study will be calculated using g*power. the researcher decide to use a large effect size suggested by cohen d (0,8) with α= 0,05, β=0,95. the estimation for the minimum sample of 105 and assuming an attrition rate of 20% (126 respondents) so that the total minimum sample will be 126 respondents. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.122-129 124 inclusion criteria from this study are age >45 yo; obesity; smoker; history of hypertension, diabetes mellitus, hyperlipidemia, hyper cholesterol, cvd; family history of cardiovascular disease, hypertension, diabetes mellitus, hyperlipidemia; patients who are willing to be respondents. exclusion criteria from this study are a community with no high risk for acs, and patients who are not willing to be respondents. the instrument of this study is a checklist sheet which is divided into 3 sections, there are sociodemography data and early detection skills. this questionnaire is modified from several works of literature. the data collection process is carried out from march to june 2022. the data used in quantitative research are primary data and secondary data. primary data is obtained from interviews directly with respondents, then the researcher fills out observation sheets according to the data submitted by respondents. secondary data is data obtained from reports or health documents from the blitar public health center and other data that support research, such as supporting documents and an overview of the research site. the univariate analysis will be carried out descriptively to describe the sociodemographic data (age, bmi, gender, education, marital status, health insurance, employment status). the correlation among variables was analyzed using chi-squared (χ2), and for determining the dominant factors, multiple logistic regression with the enter method was used. a p value <0.05 was considered significant. results table 1. characteristics of respondents characteristic f % hypertension yes 91 72.2 no 35 27.8 total 126 100 diabetes mellitus yes 38 30.2 no 88 69.8 total 126 100 hyperlipidemia yes 88 69.8 no 38 30.2 total 126 100 current smoker yes 33 26.2 no 93 73.8 total 126 100 obesity/bmi <18.5 : underweight 20 15.9 18.5-24.9 : normal weight 32 25.4 25.0-29.9 : overweight 48 38.1 30.0-34.9 : obesity class i 26 20.6 total 126 100 history acs yes 82 65.1 no 44 34,9 total 126 100 age <45 years old 23 18.3 45-59 years old 68 54.0 60-75 years old 35 27.8 https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.122-129 125 total 126 100 gender male 53 42.1 female 73 57.9 education elementary school 30 23.8 junior high school 35 27.8 senior high school 42 33.3 bachelor’s 19 15.1 total 126 100 marital status single 10 7.9 married 116 92.1 total 126 100 health insurance non bpjs 10 7.9 bpjs 116 92.1 total 126 100 employment status employed 60 47.6 unemployed 50 39.7 retired/sickness disability 16 12.7 total 126 100 the data above show that the respondents experience hypertension (72.2%). most of them had no history of diabetes mellitus (69.8%). however, the clinical factors of hyperlipidemia indicated most of them had hyperlipidemia (69.8%). meanwhile, when viewed from the aspect of smoking history as most of them had a smoking history (73.8%). other clinical factors suggested that most of the respondents had an overweight bmi was 38.1%. most of the respondents participating in the study had acs history with 65.1%. the results of the research in the table above indicated that the ages of most respondents are in the range of 45-59 years old (54%). most of them are female with 57.9%. respondents in this research have a good education and most of them finished their high school education (sma). when viewed from other aspects such as marital status (92.1%) were married. most of the respondents participating in this research had bpjs health insurance (92.1%). most of them also worked 47.6%). table 2. association between sociodemographic characteristics and early detection characteristic f % early detection p-value ≤ 60 min > 60 min univaria te multivaria te age <45 years old 23 18. 3 16(69,6%) 7(30,4%) 0,001 0,125 45-59 years old 68 54. 0 35(51,5%) 33(48,5 %) 60-75 years old 35 27. 8 17(48,6%) 18(51,4 %) gender male 53 42. 1 33(62,3%) 20(37,7 %) 0,125 0,224 female 73 57. 9 51(69,9%) 22(30,1 %) education elementary school 30 23. 8 17(56,7%) 13(43,3 %) 0,001 0,001 https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.122-129 126 junior high school 35 27. 8 23(65,7%) 12(34,3 %) senior high school 42 33. 3 25(59,5%) 17(40,5 %) bachelor’s 19 15. 1 16(84,2%) 3(15,8%) marital status single 10 7.9 6(60%) 4(40%) 0,408 0,228 married 11 6 92. 1 75(64,6%) 41(35,4 %) health insurance non bpjs 10 7.9 6(60%) 4(40%) 0,001 0,001 bpjs 11 6 92. 1 102(87,9 %) 14(12,1 %) employme nt status employed 60 47. 6 48(80%) 12(20%) 0,001 0,001 unemployed 50 39. 7 16(32%) 34(68%) retired/sickne ss disability 16 12. 7 6(37,5%) 10(62,5 %) a total of six variables were analyzed to identify the sociodemographic causes of prehospital delay in acs patients (table 2). the study found that the age, health insurance status, education level, and employment status of the patients were significant factors for early detection. delay to early detection increased with the increase in age of the patients, although it was not significant by logistic regression. approximately 30.4% of the patients below 40 years of age concluded that they experienced acs after 60 minutes of the first onset of symptoms, whereas for the aged patients (> 60 years), this value was 51.4%. the percentage of early detection of acs after 60 minutes of acs onset was 40% and 12.1% in non-bpjs vs. bpjs. the study revealed that the patient's education level was directly proportional to the rate of early detection. the percentage of early detection within 60 minutes of the onset of symptoms in elementary school, junior high school, senior high school, or higher-level educated patients were 56.7%, 66.7%, 59.5%, and 84.2%, respectively. unemployment was associated with a delay in early detection, with 68% of detection after 60 minutes of acs onset. on the other hand, 80% of the job holders were early detection with acs within 60 minutes. discussion knowledge of the symptoms of acs is very important in reducing prehospital delay. good knowledge of acs symptoms will increase public awareness and make it easier for them to recognize perceived acs symptoms (darsin singh et al., 2018; demisse et al., 2022). with increased knowledge, patients do not need to wait for symptoms to worsen, they can already recognize that the symptoms they feel require immediate action to receive treatment at the hospital(chau et al., 2018). one of the factors that cause high knowledge of acs symptoms is the level of education. the results of the study show that higher education is linear with an increase in early detection abilities. education will improve the ability to comprehend, literature search, and decision making (allana et al., 2018; garrido et al., 2020). this condition will speed up the process of understanding the symptoms of acs that are felt so that it will be faster in the decision-making process to seek help at the hospital (chau et al., 2018; garrido et al., 2020). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.122-129 127 apart from education, occupational factors and having health insurance also affect the speed of early detection. employment and insurance ownership are driving factors that accelerate the decision to seek help(al barmawi et al., 2021; arrebola-moreno, petrova, garrido, et al., 2020). this is because, with a job and health insurance, a person will feel safer and more secure when they have to seek treatment because they do not need to be burdened with costs. reduced financial distress makes someone more quickly detect acs due to decreased anxiety so they can focus more on analyzing the symptoms they feel (al barmawi et al., 2021; mujtaba et al., 2021). the existence of financial guarantees can prevent prehospital delay in acs sufferers which will increase the output of care performed(arrebola‐moreno et al., 2020; khaled et al., 2022). age is one of the factors that affect the speed of early detection but in multivariate analysis, the effect is not too significant. old age is one of the inhibiting factors for early detection. the elderly's reduced physical activity and a lower ability to perceive pain. in addition, the elderly will also have an increased likelihood of atypical symptom presentation and an increased prevalence of comorbidities in older patients, which may result in a delay in seeking medical care (khaled et al., 2022). older people will also have a decreased ability to recognize warning symptoms and an inadequate perception of the risks associated with them and their increased wish to avoid burdening family members seen in the elderly population(khaled et al., 2022). gender and marital status have no effect on the ability to early detection of acs. this proves that gender does not affect the speed of decision-making in seeking help (allana et al., 2018). marital status also does not correlate with early detection ability. it's not always that unmarried people don't have a support system that will motivate them to seek help immediately (arrebola-moreno, petrova, garcia-retamero, rivera-lópez, jordan-martinez, et al., 2020). so that these two things do not have a significant effect on increasing the ability of early detection of acs in this study. conclusion this study reveals that several sociodemographic factors that can affect early detection abilities are education, employment status, and health insurance. increasing knowledge related to the early detection of acs can be a solution to increase knowledge which will have an impact on increasing the ability of early detection of acs. references al barmawi, m., al hadid, l. a., & al kharabshah, m. 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(2022). factors responsible for prehospital delay in patients with acute coronary syndrome in bangladesh. medicina, 58(9), 1206. knoery, c. r., heaton, j., polson, r., bond, r., iftikhar, a., rjoob, k., mcgilligan, v., peace, a., & leslie, s. j. (2020). systematic review of clinical decision support systems for prehospital acute coronary syndrome identification. critical pathways in cardiology, 19(3), 119. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.122-129 129 mirzaei, s., steffen, a., vuckovic, k., ryan, c., bronas, u. g., zegre-hemsey, j., & devon, h. a. (2020a). the association between symptom onset characteristics and prehospital delay in women and men with acute coronary syndrome. european journal of cardiovascular nursing, 19(2), 142–154. mirzaei, s., steffen, a., vuckovic, k., ryan, c., bronas, u. g., zegre-hemsey, j., & devon, h. a. 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(2019). randomized controlled trial of symptom management patient education for people with acute coronary syndrome. journal of nursing care quality, 34(4), 340–345. https://doi.org/10.1097/ncq.0000000000000383. https://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.8-13 8 the effectiveness of health promotion in reducing of skabies in the islamic boarding school indriati, tutik setyowati, m. zainal abidin poltekkes kemenkes semarang, indonesia corresponding author : iinbimi1234@gmail.com abstract background: the results of interviews with the school health unit in 3 islamic boarding schools (pesantren) in blora city district showed that 75% -90% of santri had been exposed to scabies. purpose: this study aims to analyze the effectiveness of health promotion in reducing the incidence of scabies methods: interventions in the form of health promotion (counseling, and community development). independent health promotion variables, the dependent variable is the incidence of scabies, the variable between knowledge, attitude, and behavior. the research design is quasi-experimental one group (pretest-posttest). place of research for islamic boarding schools in blora city district. the research population of the santri was a sample of students in grades 8 and 9. proportional random sampling sampling technique. the intervention is carried out on august, 26, 2018 until october, 23, 2018. result: mean knowledge, attitude, and behavior before intervention 69.76; 69.86; 54.65. after intervention 87,18; 88.06; 63.35. p value of knowledge, attitudes, and behavior = 0.00; meaning that there are differences in knowledge, attitudes, and behaviors before and after the intervention. before the intervention students were exposed to 128 scabies (75.29%) and after intervention 5 people (2.94%). there is a difference in the proportion of scabies before and after the intervention with p value = 0.00 conclusion: health promotion is effective in reducing the incidence of scabies in islamic boarding schools in blora city. keywords: scabies, student islamic boarding schools, clean behavior lifestyle received july, 25, 2019; revised august 24, 2019; accepted september 13, 2019 how to cite: indriati., setyowati, t., abidin, m.z. (2019). the effectiveness of health promotion in reducing of skabies in the islamic boarding school. journal of nursing practice, 3(1), 8-13. https://doi.org/10.30994/jnp.v3i1.60 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:iinbimi1234@gmail.com https://doi.org/10.30994/jnp.v3i1.60 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.8-13 9 background islamic boarding schools are educational institutions that have the best curriculum and system. not only armed with worldly knowledge, pesantren also teach ukhrawi knowledge. students will be forged maximally and intensively. in the pesantren also inserted the meanings of discipline, besides being useful as a school, islamic boarding schools are also used as a place of residence for the santri. therefore, the health of santri and the environment around islamic boarding schools is a very important thing in implementing community care. the health of santri can be maintained by a clean and healthy lifestyle. many diseases can be avoided by clean healthy life behaviors, including scabies (scabies). scabies or commonly known as scabies / gudig (in indonesia) is a disease caused by mites, sarcoptes scabei, which is in the lower canal of the skin. scabies transmission can be through direct contact with patients and indirectly between exchanging towels, pillows, and other sheets. scabies usually only causes discomfort due to skin rashes / itching. secondary bacterial infections due to frequent and tight scratching can cause impetigo, abscesses, cellulitis, and septicemia to even cause death (handoko, 2007) the results of interviews with the uks section in three islamic boarding schools in blora city district showed that 75% to 90% of female students had been exposed to scabies. this could happen because students do not know how to prevent and transmit scabies, health workers or huts are not maximal in conveying the importance of clean healthy living behavior, or maybe students of islamic boarding schools that have not implemented clean healthy lifestyle. objective this study aimed to analyze the effectiveness of health promotion in reducing the incidence of scabies. methods type of quasi-experimental quantitative research (quasi experimental) with one group (pretest-posttest) design research design. place of research for islamic boarding schools (islamic boarding schools) in blora. the study population was all santri in blora kota district. the research sample was some santri from islamic boarding schools in blora subdistrict and fulfilled the inclusion criteria, namely students who stayed overnight or spent the night in boarding schools, recorded as active students or students in grades 8 or 9 in smp or mts, agreed to be involved in research. in blora kota district, there are 11 islamic boarding schools, seven of which have students in grades 8 and 9. the researcher used proportional random sampling sampling technique. by using the taro yamane formula, the researcher determines the number of islamic boarding schools that will be used as research sites and the number of samples from each islamic boarding school. after being calculated, the seven islamic boarding schools were used as research sites and the total sample was 170. the seven islamic boarding schools were banjari, khozinatul ulum, nurul istiqomah, roudhotul falah, an nur, al hikmah, and al ikhlas. this study consisted of three variables, namely the independent variable (health promotion / health promotion), the dependent variable (incidence of scabies), the intermediate variable (knowledge, attitudes and behaviors of scabies prevention). health promotion is a process of health education, community empowerment, and assistance to santri and fostering an atmosphere towards the management of islamic boarding schools so that students are able to maintain and improve their own health by having clean and healthy knowledge, attitudes journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.8-13 10 and behaviors to avoid scabies. data types: categorical (nominal). the incidence of scabies is divided into two, before and after health promotion. the occurrence of scabies before health promotion is the number of scabies occurrences suffered by santri in the last three months before counseling, mentoring, and fostering the atmosphere. diagnosis of scabies is enforced by a doctor. the occurrence of scabies after health promotion is the number of scabies occurrences suffered by santri after counseling, mentoring, and atmosphere building. diagnosis of scabies is enforced by a doctor. the instrument of this research is a questionnaire. there are two types of questionnaires, namely pre and post health promotion questionnaires. each questionnaire contains 4 parts. part a asks for the identity of the respondent (name, age, class, and name of the boarding school). part b asks about the incidence of scabies. part c to find out the knowledge of respondents, consists of 10 questions. each question is worth 10 if the respondent correctly answers it and is worth 0 if the respondent incorrectly answers it. part d to find out the attitude of the respondents, consisting of 10 questions. each question is worth 10 if the respondent correctly answers it and is worth 0 if the respondent incorrectly answers it. part e to find out the behavior of respondents, consists of 12 questions. each question is worth 10 if the respondent correctly answers it and is worth 0 if the respondent incorrectly answers it. the researcher used a paired t test to find out the mean differences in knowledge, attitudes, and behaviors before and after treatment. the paired t test is used when paired data and its scale are measured in intervals or ratios (numerical data types). if the assumptions are not met (data is not normally distributed), then use the wilcoxon test (dharma, 2011). the researcher used the chi square test to determine the proportion of the incidence of scabies before and after health promotion. chi square is used to test different proportions (nominal data) of 2 events. if the expected value <5 in more than 20% of the cell numbers, then the fisher exact test is used. the participants were assured that their engagement was voluntary, and that anonymity, privacy, and confidentiality of the data were guaranteed. furthermore, they were informed about the purpose and the method of the study before signing a written informed consent. the questionnaires were distributed to eligible participants at the islamic boarding schools in blora, and respondents were asked to complete and return them in the same time. results the results showed the mean (knowledge) of respondents' knowledge before intervention 69.76 and after intervention 87.18. the mean score before the intervention was 69.86 and after the intervention 88.06. the mean value of the respondent's behavior before intervention was 54.65 and after intervention 63.35. the results of the study describe the average value of respondents' knowledge about scabies before health promotion 69.76. this means that respondents have sufficient knowledge about scabies. the results showed an increase in the value of the average knowledge of respondents after health promotion compared to before health promotion, namely from 69.76 to 87.18. the results also showed that there were differences in knowledge before and after health promotion, with a value of p value 0.00. the results showed that the average value of respondents' knowledge and attitudes before the intervention was in a fairly good range of 69.76 and 69.86. this means that there is a positive correlation between knowledge and attitudes other than that. the results of the study show that there is an increase in the average journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.8-13 11 value of attitudes before and after health education, which is from 69.86 to 88.06. the results also showed that there were differences in attitudes before and after the intervention with a value of p value 0.00. the results showed the mean (mean) value of respondents' behavior before intervention 54.65. if we use the category of knowledge, according to machfoedz (2009), the value of 0-55 is categorized as less. this is different from the mean of knowledge and attitudes of respondents before being interved which is in the sufficient category. this means that there is a less positive correlation between knowledge and attitudes toward behavior. discussion the results of the study describe the average value of respondents' knowledge about scabies before health promotion 69.76. this means that respondents have sufficient knowledge about scabies. according to machfoedz (2009), the level of knowledge of respondents said enough if the subject was able to answer correctly 56-75% of all statements. sufficient level of knowledge is one of the supporting factors for the success of behavior change in a positive direction. this is consistent with lawrence r green's theory, which says one of the driving factors (predisposing factors) of behavior is knowledge (azwar, 2005) respondents were 8th and 9th grade students. the respondents' knowledge about scabies was very likely to be obtained from the education bench, according to (notoatmodjo, 2010), there are several factors that influence a person's knowledge, namely education, mass media, social culture and economy, experience, and environment. education is an attempt to develop personality and abilities inside and outside school and last a lifetime. the junior high school curriculum contains biology subjects that study the disease and its causes. in the above, it has been stated that one of the factors that influence knowledge is the mass media. in the current millennial era, many young people access information from digital mass media, including smartphones. don tapscott in his book entitled grown up digital: how the net generation is changing your world, 2008, says that there are currently three generations, namely the baby boomers (born 1946-1964), generation x (1965-1976), and generation net or net generation born after 1976. respondents are net generation. net generation uses almost instinctive technology. they use the latest smartphones without opening a guidebook compared to the previous generation, with the aim of learning, seeking information, interacting socially, playing, shopping, and so on. net generation uses technology to solve their problems and find messages that suit their needs. the results of the research that can be seen from the respondents' answers when filling out the questionnaire stated that the respondents actually already knew that they should not borrow from private property to avoid infectious diseases. they learned that one method of transmission of scabies was through mattresses, sheets, towels and slippers. however, they said that they were used to sleeping with their friends using the same mattress because not all santri had mattresses. the management of islamic boarding schools does not require every santri to bring one mattress and the boarding school does not provide mattresses. respondents also said that they were used to borrowing slippers, especially flip-flops. there are only a few students who have flip-flops. the management of the islamic boarding school does not require every santri to bring flip-flops, as well as no written rules governing this. some respondents washed their clothes after using it for more than 2 days, washed the sheets after using them for more than a month, and never even washed pillowcases or bolsters. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.8-13 12 even though they use bed linen, pillows, and bolsters together. when asked why they said they were lazy to wash it. the results showed that there was an increase in the average value of behavior before and after health promotion, ie from 54.65 and to 63.35. the results also showed that there were differences in behavior before and after health promotion with a value of p value 0.00. this phenomenon shows that health promotion is able to improve respondents' behavior in a more positive direction. health promotion is not only oriented to the realm of knowledge, but also oriented to the realm of attitudes and behavior by empowering and fostering an atmosphere. empowerment is the provision of information and assistance in preventing and overcoming health problems, in order to help individuals, families or community groups undergo stages of knowing, wanting and being able to practice clean and healthy living behaviors. building an atmosphere is the establishment of a conducive atmosphere of the social environment and encouraging the practice of clean and healthy life behavior and the creation of role models in adopting clean and healthy life behaviors and preserving them (ministry of health, 2011). the creation of role models in adopting clean, healthy lifestyle is one of the reinforcing factors. in islamic boarding schools, teachers called ustadz and managers or administrators of islamic boarding schools called kyai or nyai are their role models. they will obey what the ustadz and kyai say (sami’na wa atho’na = we hear and we obey). besides that they will also imitate what the ustadz and kyai do. so teachers and administrators of islamic boarding schools are key figures for the adoption of clean and healthy life behaviors. thus it is necessary to conduct health education and assistance in adopting clean and healthy life behaviors with the aim of clerics and clerics. besides that, it is also necessary to build an atmosphere with them to create a conducive social atmosphere. the results showed a decrease in the incidence of scabies after health promotion, which was from 75.29% to 2.94%. this is the impact of the increase in respondents' healthy hygiene behavior. after health promotion, respondents did not borrow from each other to borrow personal property, there were cleaning activities at least once a week to clean public facilities, there were daily pickets to clean each room. conclusion there are differences in knowledge before and after intervention; there are differences in attitudes before and after intervention; and there were differences in behavior before and after the intervention. effective health promotion reduced the incidence of scabies in islamic boarding schools in blora city. someone who has sufficient knowledge and attitudes towards a clean, healthy lifestyle, will not necessarily practice it in the form of behavior references azwar, s. (2005). prosedur penelitian suatu pendekatan praktek, edisi revisi v. yogyakarta: rineka cipta akmal, s. c., & semiarty, r. (2013). artikel penelitian hubungan personal hygiene dengan kejadian skabies di pondok pendidikan islam darul ulum, palarik air pacah , kecamatan koto tangah padang tahun 2013, 2(3), 164–167 bodgan, robert, c, biklen, s.k. (2006).qualitative research for education: an introduction to theories and methods, fifth edition, usa, pearson. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.8-13 13 bungin, burhan.(2010). penelitian kualitatif: komunikasi, ekonomi, kebijakan publik, dan ilmu sosial lainnya, jakarta, kencana. dhofier, z.(1983). tradisi pesantren studi tentang pandangan hidup kyai, jakarta lp3s. don tapscott. (2008). grown up digital: how the net generation is changing your world. 1st edition. publisher: mcgraw-hill education. erika kusumawardani. 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(2014). faktor yang berhubungan dengan kejadian scabies pada nelayan di desa weru kecamatan paciran kabupaten lamongan, 1(1), 132– 143. rina, w., & indriani, d. (2015). scabies infection control analysis at pondok pesantren ( boarding school ) darussalam banyuwangi district. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.25-32 stress levels and physio-psycho-social responses on undergraduate nursing students undertaking their thesis at harapan bangsa institute of health sciences, purwokerto: a correlation study murniati, noor yunida triana, adita silvia fitriana 1 1 institute of health science harapan bangsa purwokerto, indonesia corresponding author : murniati@shb.ac.id abstract background: senior nursing students possibly experience stress due to the difficulties encountered in the process of writing a thesis. the difficulties experienced are commonly making research background, looking for the related theory and proper methods, having pressure from supervisor, feeling saturated, and many more. the stress experienced by students can also cause various responses such as physical, psychological, and social. purpose : the aim of this study is to analyze the correlation among stress levels andphysio-psycho-social responses of nursing students undertaking thesis. methods : this analitic cross sectional study was conducted at harapan bangsa institute of health sciences, purwokerto on may-july 2018. a total of 117 senior nursing students undertaking a thesis were taken by simple random sampling. research data were collected utilizing stress questionnaire and physio-psycho-social responses. the data analysis used was univariate analysis with frequencydistribution, and bivariate analysis used was spearman correlation. result : findings of this research indicated that the senior nursing students undertaking a thesis experienced moderate level of stress (51,3%) and excellent physio-psycho-social responses (73,5%). in addition, this research showed a significant relationship between stress levels with physio-psycho-social responses (p value=0,000; r=0,508). conclusion : the results indicated that senior students undertaking thesis can experience stress varying from mildto moderate that potentially cause physio-psycho-social responses. keywords : stress levels, physio-psycho-social responses, nursing students, thesis received july, 25, 2018; revised august 24, 2018; accepted september 5, 2018 how to cite: murniati, m., triana, n., fitriana, a. (2018). stress levels and physio-psycho-social responses on undergraduate nursing students undertaking their thesis at harapan bangsa institute of health sciences, purwokerto: a correlation study. journal of nursing practice, 2(1), 25-32. https://doi.org/10.30994/jnp.v2i1.39 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v2i1.39 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.25-32 26 background thesis is a scientific work written by undergraduate students at the end of their studies. it becomes one of the requirements accomplished by undergraduate candidates (sujono & altiarika, 2014). this paper is based on the results of research (saifuddin, ismail, dan wekke, 2018). moreover, thesis must be conducted in the last semester that makes them feel worried about. this becomes a phenomenon in almost all college environments because students are less accustomed to writing, especially writing scientific papers. as the results, students regard the assignments given by their lecturers as a burden including in terms of thesis writing. the common problems experienced by students are the difficulty in finding literatures, the limited budged, unhabitual scientific paper writing, unfamiliar with systematic-organised paper consultation, and fear of facing thesis supervisors (mage, 2008). the previous issues are in line with the results of a preliminary survey conducted by the researchers on 22 students working on their thesis in march 2018.the data showed that 63.7% of students sometimes felt depressed during doing their thesis, 59.1% of students felttheir heart pounding when having consultation with theirsupervisors, 50% ofstudents were worried that their thesiswould not be completed on time, 45.5% of students sometimes felt burdened in completing their thesis, 63.6% of students wanted to cry when there were a lot of revisions from their supervisors, 31,8% of them sometimes avoidedwhen asked about the progress of their thesis, 68.2% of students sometimes were lazy to have consultation with their supervisors, 63.6% of students sometimes were annoyed and often complained of their thesis, and 54.5% of students sometimes felt being chased when working on their thesis.the results of the survey show that students in working on their thesis experience stressors in their work which inevitably can be an obstacle or obstacle in completing their thesis. those problems cause students to get stress.secondary stress occurs when an individual determines their capacity to manage environmental demands.stress experienced by students working on their thesis can cause various problems. sukadiyanto (2010) states that individuals who experience stress can cause the emergence of symptoms both physically and psychologically. physically, individuals may have heart problems, high blood pressure, muscle tension, headaches, indigestion, insomnia, sexual disorders, etc. whereas, psychologically it can cause feelings of nervousness, anxiety, irritability, reluctance to do activities, working ability and decreased appearance, feelings of fear, self-isolation from the group and pobia. in addition, symptoms of stressexperienced by students include sleep disorders such as difficulty sleeping, frequent anxiety, irritability, and evenretention problem (januarti, 2009). according to the study conducted by rizqiea and hartati (2012), the data showed that students experienced insomnia while doing thesis where the average sleep duration of 4-5 hours, sleep late at night and have an impact on the decrease of their activity, health problems and decreased mood. based on the description presentedpreviously, it can be seen that stress is a common condition that is often experienced by students who work on their thesis or final assignment and can cause various impacts such as physical, psychological and social responses.therefore, researchers are interested in examining the correlation of stress levels with physio-psycho-social responses of nursing students undertaking their thesis at stikes harapan bangsa purwokerto. the result of this study is expected that lecturers / educators especially in nursing can identify the needs of their journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.25-32 27 students especially in doing the final project, facilitate them in the process of thesis writing, and provide good strategy in preparing the thesis to reduce students’ stress experienced in writing final task / thesis objective the aim of this study is to analyze the correlation among stress levels andphysiopsycho-social responses of nursing students undertaking thesis. methods this study is an analytic survey research with cross sectional approach. the study involved 117 respondents who were calculated using the slovin formula for 170 nursing students undertaking their thesis based on krs even semester 2017/2018. the samples were collected by using a random sampling technique. the sampling flow is presented in chart 1. the instrument used in this study was a modified stress level questionnaire from hermawan's study (2016) consisting of 31 questions and 21 questions of physio-psychosocial responses. data was collected in may-july 2018.then, it was analyzed by using univariate analysis presented in the form of frequency distribution and bivariate analysis using spearman correlation with a significance level of 5%. chart 1. the flowchart of research sampling results the results of research conducted on 117 respondents are presented in the table below: tabel 1 the descriptions of stress levels and physio-psycho-social responses of nursing students working on their thesis at harapan bangsa institute of health sciences, purwokerto. (n=117) research variables n (%) stress levels mild stress moderate stress severe stress 57 (48.7) 60 (51.3) 0 (0) physio-psycho-social response students undertaking thesis n= 170 119 respondents (n=119) the processed samples n= 117 simple random sampling two(2)unreturned questionnaires journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.25-32 28 excellent health status good health status bad health status 86 (73.5) 29 (24.8) 2 (1.7) table 1 shows that students writing their thesis experienced stress with a similar percentage between mild and moderate stress (48.7% and 51.3%).meanwhile, there were no respondents who experienced severe stress.more than half of the respondents had a good physio-psycho-social response in order that it was concluded that they had the best health status (73.5%) and the table also shows that there are about 1.7% of respondents who have poor health status when it wasviewed from physio-psycho-social responses tabel 2. the relationship relationship between stress levelsandphysio-psychosocial responses of nursing students undertking their thesis at harapan bangsa institute of health sciences, purwokerto (n=117) physio-psycho-social response stress levels r = 0.508 p = 0.000 n= 117 *spearman correlation test the analysis resultabove, p = 0.000 (p <α, α = 0.05) shows that the correlation between stress levels and physio-psycho-social response of nursing students undertaking their thesis in harapan bangsa institute of health sciences, purwokerto is meaningful. spearman correlation value of 0.508 shows a positive correlation with a moderate correlation strength.it means that the lighter the stress level, the better the physio-psychosocial response is. discussion 1. stress levels of students undertaking their thesis at harapan bangsa institute of health sciences, purwokerto based on the results of the study it was found that students undertaking their thesis experienced stress with almost the same percentage of mild stress and moderate stress (48.7% and 51.3%). meanwhile, there were no respondents experienced severe stress.this provides a description that students working on thesis have varying levels of stress. thesis is one of the scientific papers that must be done by graduate candidatesof undergraduate programs through a simple research process. students often assume that a thesis is a frightening thing, and another information that may be obtained from their seniors. furthermore, the other problems among students are commonly difficulties in finding literature, lack of research methods mastery, unfamiliar with the consultation process that requires students to personally contact with their supervisor (mage, 2008). according to theresearchers, those things can trigger off stress. according to santrock (2012), stress is the response of an individual to stressful situations that interfere with and threaten a person's ability to experience problems. in this study, it is found that the source of stress with the biggest score is that students felt there was a conflict with their supervisors and felt that they failedin their live. moreover, the lack journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.25-32 29 of family support became a stress source of them.in addition, the manifestations that arise due to stress on students such as changingof appetite, having frequent urination and getting cold sweat appearing every time when meeting with their supervisors, avoiding when being asked about their thesis,and feeling guilty fortheir thesis. stress can be caused by both intrinsic and extrinsic factors. based on the study of gunawati, hartati, and listiara (2006), internal factors that can trigger the emergence of stress include gender, socioeconomic status, personality characteristics of students, students’ coping strategies, ethnicity and intelligence, while external factors such as academic task demands (related to assignments during college or final assignment) and students’ relations with their social environment. some of theother effects of stress are biological aspects (loss of appetite, not sleeping well, production of excessive sweating, etc.) and psychological aspects (decreased concentration, irritability, excessive anxiety, blaming others, ignorance to the environment) (sarafino, 2008). the results of setyawati and murniati's research in 2016 also stated that nursing students experienced sufficient levels of stress (71.5%).research conducted by hermawan (2016) also further strengthened the results of this study where nursing students who were preparing their thesis at stikes jenderal achmad yani yogyakarta experienced stress levels in the medium category (51.2%), low category (17.1%) and high category (31.7%). 2. physio-psycho-social response of students undertaking their thesis at harapan bangsa institute of health sciences, purwokerto in this study it was found that physio-psycho-social response of stress in excellent health status category (73.5%), followed by good health status (24.8%) and only about 1.7% who have bad health status.this shows that students were able to overcome various stressors experienced when writing their thesis. this finding further reinforces the theory of lazarus & folkman (2004) that stress can affect the physical, psychological, and social health of the community if the result of the adaptation is not achieved. the results of this study are in accordance with labrague's (2013) study, which states that stress is a common thing in nursing education and can have an impact on the physical-psychological-social health of students. furthermore, the results of this study are also in line with the results of setyawati & murniati's research in 2016 that nursing students experienced physio-psycho-social responses in the sufficient category (54.7%). 3. the correlation between stress levels and physio-psycho-social response of students undertaking their thesis at harapan bangsa institute of health sciences, purwokerto in this study, the results show a significant relationship between stress levels and physio-psycho-social response of students undertaking their thesis with the strength of moderate relations and the direction of a positive relationship. the better the student's stress level, the better the physio-psycho-social response will be. therefore, the health status of a student will be good condition. the results of the study contributes an idea that the stress experienced by a person can have an impact both negative and positive depending on the level of stress experienced.this statement is supported by the study of dickinson (2007) who states that stress can increase the risk of various mental and physical disorders on students including anxiety, depression, journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.25-32 30 decreased immune, headaches, heart diseases, blood pressure disorders, energy loss, allergies and strokes (sari, d., & mahardyka, m, 2017). the results show that three subscales in the physio-psycho-social response gain the highest points on emotional symptom aspect, physical symptoms, and finally the symptoms of social behavior. in emotional symptoms, students mostly complain of feeling anxious, easily nervous and stressed lately. based on the physical symptoms often experienced by respondents, they often feel headache, vertigo, frequent colds and fever, abdominal pain, and diarrhea. in conclusion, stress experienced by students undertaking their thesis can indeed affect the body's response in terms of physical, psychological and social.this is in accordance with the theory stated by hawari (2011) that stress can have an impact on two things: physiological impact (retention, tensed-face, shortness of breath, beating heart, nausea and pain, frequent urination) and impact psychologically (anxiety, anger and aggression, depression). the appearance of physio-psycho-social responses due to stress might also be influenced by the level of stress experienced by respondents. from the results of this study obtained the levels of stress experienced by respondents were mild and moderatelevel, and there was no stress on the level of severe. according to the theory of hartono (2016), there are several levels of stress that occur in humans: if a person is at the stage of mild stress, s/he may have a desire to work, while the second stage of stress is usually accompanied by various complaints such as feeling of fatigue after waking up in the morning, getting tired quickly during the afternoon, experiencing beating heart, feeling uncomfortable with stomach, getting on tense on neck and back. if the individual has reached the third to sixth stage, the complaints following stress will beworse. for example, starting from sleep disturbances, disrupting routine activities, feeling anxious and fearful, inability to complete work, physical and mental fatigue, severe digestive disorders, and even shortness of breath, cold sweat and trembling body. the above gives an explanation that the higher the level of stress experienced by a person, the more severe complaints will be physically, psychologically and socially conclusion to sum up, more than half of the respondents had moderate stress levels (51.3%) and excellence physio-psycho-social response (73.5%). the result of spearman correlation test shows a significant relationship among stress levelsand physio-psycho-social responses, positive relationship direction, moderate relationship strength (p-value = 0,000; r = 0,508). suggestion this research is expected to provide information about symptoms, stress levels and the negative effects caused by stress namely the appearance of physio-psycho-social responses to students undertaking their thesis on.students undertaking their thesis are expected to identify the positive and negative impacts of stress experienced so that they can perform good stress management and minimize stress.for researchers, further analysis can be carried out on the correlation of stress levels with subscales both from physio-psychosocial responses and sleep quality subscales journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.25-32 31 references candra, i.w., i.g.a harini, dan i.n sumirta.2017. psikologi:landasan keilmuan praktik keperawatan jiwa. yogyakarta: cv.andi offset dickinson, wendy lynn. 2007. incresing coping resource: an experimental intervention approach. disertasi, georgia state university. <http://scholarworks.gsu.edu/cps_diss/6>.(diunduh tanggal 25 juli 2018) gunawati, r., hartati, s., dan listiara, a.2006. hubungan antara efektifitas komunikasi mahasiswa-dosen pembimbing utama skripsi dengan stress dalam menyusun skripsi pada mahasiswa program studi psikologi fakultas kedokteran universitas d i p o n e g o r o . j u r n a l p s i k o l o g iuniversitas diponegoro, vol.3, no.2, desember 2006 hartono, dudi. 2016. psikologi. modul bahan ajar cetak keperawatan. jakarta: pusat pendidikan sumber daya manusia kesehatan hawari, d. 2011. manajemen stres cemas dan depresi. jakarta: fakultas kedokteran universitas indonesia hermawan, ilham. 2016. gambaran tingkat stress pada mahasiswa keperawatan angkatan 2011 yang sedang menyusun skripsi di sekolah tinggi ilmu kesehatan jenderal achmad yani yogyakarta. skripsi. stikes a.yani yogyakarta hidayat, a.a. 2006, pengantar kebutuhan dasar manusia, salemba medika, jakarta. januarti, r. (2009). hubungan antara persepsi terhadap dosen pembimbing dengan tingkat stress dalam menulis skripsi (skripsi). universitas muhammadiyah surakarta kozier, b., erb, g., berman, a., dan snyder, s.j. 2010, bukuajar fundamental keperawatan: konsep, proses &praktik., edisi 7, volume 2, egc, jakarta. labrague, leodoro j. 2013, stres, stressors, and stress responses of student nurses in a government nursing school. health science journal, volume 7, issue 4, hal.424435 lazarus, r.s, dan folkman, s. 2004. stress, appraisal, and coping. springer: publishing company lin, s. h., & huang, y. c. 2014. life stress and academic burnout. active learning in higher education, 15 (1), 77-90. doi: 10.1177/1469787413514651 mage, r.i.2008. kiat sukses menghadapi pembimbing skripsi dan tesis. jakarta: citra harta prima potter, p.a dan perry, a.g. 2010. fundamental keperawatan. edisi 7. jakarta: egc journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.25-32 32 putri, sabrina dwi. 2016. hubungan tingkat stres dengan kualitas tidur pada mahasiswa semester vii di fakultas kedokteran universitas sumatera utara tahun 2016. skripsi. fakultas kedokteran universitas sumatera medan rizqiea, n.s dan elis hartati.2012.pengalaman mahasiswa yang mengalami insomnia selama mengerjakan tugas akhir. jurnal nursing studies, volume 1, nomor 1, halaman 231-236 saifuddin, muhammad syuhudi ismail, dan ismail s. wekke. 2018. strategi dan teknik penulisan skripsi. ed.1. yogyakarta: deepublish santrock, john w. 2012. life-span development. 13 th edition. university of texas, dallas: mc grawa-hill sari, d., & mahardyka, m. 2017. penerapan wudhu sebagai hydro therapy terhadap tingkat stres pada lansia upt pslu blitar di tulungagung. journal of nursing practice, 1(1), 24-32. https://doi.org/10.30994/jnp.v1i1.19 saputra, o. dan wahidatur rohmah. 2016. gangguan tidur akibat kebisingan lingkungan malam hari dan pengaruhnya terhadap kesehatan. majority, vol.5, no. 3, hal.183-187 sarafino, e. p. 2008. health psychology, byopsychosocial interactions. 6th ed.new york: john wiley & sons inc. setyawati, martyarini b. dan murniati. 2018. stres, stresor dan koping stres pada mahasiswa keperawatan dan kebidanan di stikes harapan bangsa purwokerto. viva medika, volume 10, no.02, hal.6-12 sujono & altiarika, eka. 2014. panduan skripsi strata i. pangkal pinang:sekolah tinggi manajemen informatika dan komputer atma luhur pangkal pinang sukadiyanto.2010.“stress dan cara menguranginya”. <http://eprints.uny.ac.id/3706/1/06sukadiyanto.pdf>.(diunduh tanggal 16 april 2018) wardhana, made.2011. psikoneuroimunologi di bidang dermatologi. mdvi, vol.38, no.4, hal.175-180 zimmerman, f.j. 2008, children’s media use and sleep problems: issues and unanswered questions, the henry j. kaiser family foundation, washington, <http://files.eric.ed.gov/fulltext/ed527857.pdf>. diakses pada 13 juni 2018 https://doi.org/10.30994/jnp.v1i1.19 http://files.eric.ed.gov/fulltext/ed527857.pdf journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.51-57 readiness of lecturers as a facilitator in interprofessional education learning in antenatal care dina zakiyyatul fuadah, muhammad taukhid 1 1 stikes karya husada kediri, east java, indonesia corresponding author : dinazakiyya@gmail.com abstract background: many educational institutions in indonesia are familiar with the concept of interprofessional learning or interprofessional education but not many have applied. facilitator readiness, one of the causes of this method has not been implemented optimally. purpose: this study aims to determine the readiness of the lecturer as a facilitator in interprofessional learning. methods: the pre-experimental design, pre and posttest design was used to examine a sample of 20 respondents which included the lecturers of nursing, midwifery and nutrition obtained by purposive sampling. instrument to measure the readiness of lecturers using the ripls questionnaire. result: the results of statistical tests using the t-test found that the readiness of lecturers in the positive category where there was a change in readiness before and after being given an intervention in the form of interprofessional learning training with a pvalue of 0.021. conclusion: educational institutions are recommended to start developing interprofessional education models that are mutually agreed upon and supported by clear facilities, policies and regulations. subsequent research is expected to explore more appropriate interprofessional learning models through both qualitative and quantitative approaches. keywords : readiness of lecturers, facilitators, interprofessional education received july, 25, 2018; revised august 24, 2018; accepted september 14, 2018 how to cite: fuadah, d., taukhid, m. (2018). readiness of lecturers as a facilitator in interprofessional education learning in antenatal care. journal of nursing practice, 2(1), 51-57. https://doi.org/10.30994/jnp.v2i1.43 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v2i1.43 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.51-57 52 background the ability to work interprofessionally (interprofessional teamwork) does not come out of nowhere, but must be found and trained early from the lecture stage so that students have the knowledge and experience on how to work in good team with other professions before they enter the world of work (wagner, 2011). world health organization (2010) states that ipe is a process in which a group of students or health workers with different backgrounds learn together in a certain period of time during education, with interaction as the main goal, for collaboration in providing preventive, promotive, rehabilitative and other health services. in antenatal care, the ipe learning method is carried out by nursing, midwifery, nutritionists. one important factor in ipe learning is the role of facilitators conducted by lecturers. the role of the facilitator facilitates the learning process in students. the introduction of ipe learning to lecturers is an effort to improve the readiness of lecturers as facilitators through training, where this method is an effective way to improve the readiness of lecturers in assisting students in ipe learning. through training allows lecturers to be able to explore collaborative ways to improve the communicative aspects of clinical care that must be taught to students as prospective health workers (liaw, s.y., et al, 2011). currently the development of the ipe curriculum has not been developed evenly in educational institutions. who (2010) issued data on the application of ipe in several countries, namely at the institutional level of 10.2% of doctors, 16% of nurses or midwives, 5.7% of nutritionists, and other health workers had received ipe-based learning. in the university setting results from surveys from 42 countries stated that as many as 24.6% had obtained the ipe curriculum at the academic stage. while in indonesia it is not yet included, for this purpose there is a need to socialize the ipe learning method as a whole in all educational institutions considering that health science high schools are the main providers of prospective health workers who are expected to have good competence, especially the ability to collaborate with other health workers. research conducted in the field of interprofessional education (ipe) has traditionally been concentrated on the learner's perspective (gentry et al. 2001; hind et al. 2003; johnson et al. 2006). as a result, while the literature provides a detailed understanding of their ipe experience, little is known about the readiness and the facilitator's perspective on this type of learning. so there is still a need for research that identifies the readiness of lecturers as facilitators of interprofessional learning. objective this study aims to determine the readiness of the lecturer as a facilitator in interprofessional learning. methods pre experimental research design (pre posttest design), namely in this study intervention was carried out in the form of giving material about interprofessional education (ipe) learning, with pre-test conducted on the readiness of the lecturer as a facilitator of ipe learning, then continued with the posttest implementation about the readiness of the lecturer as learning facilitator ipe uses a readiness measurement instrument using the modified readiness interprofessional learning scale (ripls) questionnaire. the purposive sampling technique was used to determine the sample according to the inclusion and exclusion criteria with a sample size of 20 respondents. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.51-57 53 data collection was carried out in april-may 2018 in the lecturers of the karya husada kediri high school of health sciences. data collection begins with informed consent to respondents, followed by focus group discussion (fgd) as much as one time in preparation for the intervention and respondents were given a questionnaire for initial data collection (pretest). the intervention was in the form of training in ipe learning on antenatal care for two days, the first day of material giving, the second day of application in the form of role play of ipe learning using cases. final data collection (posttest) was carried out two days after intervention. furthermore, the data was analyzed using computerized assistance results respondents in this study amounted to 20 lecturers who completed the research process from pretest to posttest. respondents consisted of lecturers from the nursing study program, midwifery study program, nutrition study program. this data collection was completed in april may 2018. the characteristics of respondents in this study which included the origin of the study program, length of work, gender and interprofessional learning experience are described in the table as follows: 1. characteristics of research respondents characteristics respondents f (%) program study nursing 8 40 midwifery 8 40 health nutrition 4 20 length of work 5-10 years 16 80 11-15 years 16-20 years 3 1 15 5 gender man 2 10 woman 18 90 interprofessional experience yes 7 35 never 13 65 (n=20) distribution of respondent characteristics refers to a similar study conducted by curran et al (2007), the results of the study mention that several types of characteristics related to the attitude and readiness of lecturers towards interprofessional cooperation are gender and previous work experience of interdisciplinary collaboration. turner (1999) states that professional background influences ipe readiness. thoha (in fauziah, 2010) asserts that differences in the characteristics of respondents cause differences in perceiving something, including perceptions and readiness for ipe. 2. readiness of lecturers as interprofessional education learning facilitators in antenatal care interventions carried out in this study were to improve readiness in facilitating interprofessional learning by holding an interprofessional learning training that was supplemented by role play cases. antenatal care was used as a trigger case in this study. measurement of lecturer readiness was measured using the readiness journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.51-57 54 interprofessional learning scale (ripls) instrument. based on the results of statistical tests using the t-test there are differences in the readiness of the lecturer between before and after being given an intervention in the form of interprofessional education (ipe) training on the entire lecturer with pvalue = 0.021. in this study the attitude of the lecturer was measured using the ripls questionnaire where data collection was carried out 2 times (pretest and posttest). test results statistically show that all lecturers show a positive attitude to be a facilitator of interprofessional learning. the mean value shows close to 95 (pretest = 82.83; posttest 1 = 87.22; where the value 95 indicates that the student's attitude is more positive. instrument to measure the component of readiness in the readiness interprofessional learning scale (ripls) consists of three sub-variables namely cooperation and collaboration, professional identity and roles and responsibilities (parsell & bligh, 1999). based on the results in this study shows the value of p in the sub-variables of collaboration and collaboration (p = 0.001) and professional identity (p = 0.003) significantly increased, but not in the sub-variables of roles and responsibilities (p = 0.210). 3. comparison of readiness of interprofessional education facilitators in antenatal care comparison of the readiness of lecturers to ipe in each department using the kruskall-wallis test because the data distribution is not normal. the test results show that there is no significant difference in the perception of the readiness of lecturers in each department (p = 0.685). a comparative test was conducted to determine the differences in the readiness of lecturers towards ipe between the three departments. from the results of the kruskall-wallis test, p = 0.685 which can be interpreted that there is no difference in the value of the readiness of the lecturer to facilitate meaningful ipe between two groups of teaching places discussion 1. readiness of lecturers as interprofessional education learning facilitators in antenatal care. a more in-depth discussion is carried out on each component of preparedness for ipe. through a deeper analysis of the components which include: 1) cooperation and collaboration, 2) professional identity and 3) roles and responsibilities, all components of the readiness of lecturers towards ipe are in the good category. the collaboration and collaboration sub-variables are known to have a significant p value at all data collection times. this shows that the lecturer experienced a significant increase in the statement to facilitate the collaboration and collaboration component after the intervention. as revealed by barr (1998), that one outcome expected in the implementation of ipe is the occurrence of strong collaboration and collaboration between health professionals, especially from different disciplines. respondents in this study mostly showed a positive attitude that interdisciplinary learning in the classroom would help them become members of a better health care team. sub variables in professional identity have increased in pre-post data retrieval (p = 0.001). professional identity reflects the importance of professional profession identity to define the life and cultural strength of each individual's profession. morison journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.51-57 55 et al., (2004) states that medical, nursing and health nutrition students are more likely to have a strong sense of association with their own professional roles after obtaining ipe training. similarly, coster et al. (2008) stated that students who have a positive professional identity towards ipe while at the academic stage will be more interested in collaborating with other professional students, because they bring more positive perceptions when entering clinical education. important moments for the future development of professional identity occur at the beginning of professional and career training. therefore, it is very important to create an effort to foster readiness for facilitators and strengthen confidence in positive professional identities. sub-variables of professional roles did not experience significant changes (p = 0.210) after attending ipe training. the absence of changes in the role and professional responsibility sub-variables can be influenced by the short time of the ipe training, so that lecturers have not experienced the process of internalizing the role of facilitator to the fullest. barr (1998) explains that lecturers with good readiness to facilitate ipe will help students to achieve the expected ipe competencies. readiness measurement uses 19 statements with choices "strongly agree", "agree", "disagree" and "strongly disagree". from this statement, it is known that the answers of respondents who approached strongly agree, namely: 1) "the ability of teamwork is very important"; 2) "studying with other health profession students will help students become members of a better health care team". conversely, disagreeing answers appear in the statement: 1) "not important for students of the health profession to study together" and 2) "i do not want to waste my time educating students in other professions". both of these questions are negative questions. so, the respondent's answer shows that the lecturer is aware of the importance of learning to collaborate. the thing that needs to be considered in this ipe learning is the clarity of competency standards that must be achieved by the students themselves, so that the existence of ipe will clarify the contribution of every health profession in the health care system. this is like the statement of soedyowinarso (2011) that although ipe is designed for groups, ultimately it aims to develop each individual. this is similar to the results of research conducted by aryakhiyati (2011) which shows the teamwork and collaboration components have the highest value while the roles and responsibilities have the lowest value in the lecturers of gadjah mada university medical faculty. the highest value shown in the teamwork component and collaboration can be assumed that the lecturer has realized that the importance of ipe. integrated learning models, such as ipe, can make students ready to work in teams. as one of the competencies that must be possessed by a student in ipe, it is expected that each student has the ability to: 1) various resources, skills and responsibilities to achieve common goals in collaborative practice, 2) build commitment and maintain participation in an interprofessional team, 3) recognize when there is a discrepancy in collaboration practices, 4) overcome problems and conflicts using appropriate problem solving and conflict management techniques, 5) use decision making that is in accordance with the collaboration team (interprofessional education consortium, in fauziah, 2010). the low value shown in the role component and responsibility can be assumed that understanding between health professionals about the role of each health profession in the lecturer needs to be improved. an understanding of the roles and responsibilities of each profession makes health professionals understand what each profession will actually do in its work (gilbert et al, 2005). knowledge of the roles and responsibilities of each profession journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.51-57 56 makes the implementers of ipe learning more ready to work together in teams (morison et al, 2003). 2. comparison of readiness of interprofessional education facilitators in antenatal care this result is different from the research conducted by aryakhiyati (2011) which shows that there are significant differences with p = 0.032. post hoc analysis shows that there is a mean difference in the value of readiness of medical and nursing lecturers as well as differences in average readiness values of medical and nutrition lecturers' readiness. the implementation of ipe urgently requires role models, namely teaching lecturers who are committed to ipe and learning environments that support the creation of teamwork and are able to combine theory and prakatik (gaudet et al, in aryakhiyati, 2011). good readiness from all lecturers on ipe implementation is the potential to develop this ipe learning model. the comparative test results of the teacher's readiness to facilitate ipe based on the characteristics of respondents including gender, collaborative experience and length of teaching showed no significant differences. this result is different from the results of research conducted by curran et al (2007) which states that there are significant differences in lecturer readiness between male and female lecturers. female lecturers have a higher average attitude score. aryakhiyati (2011) also shows that there is a significant difference in the value of the readiness of lecturers at the faculty of medicine ugm based on teaching experience. the difference in the readiness of the lecturers towards the implementation of ipe still varies between age and collaborative experience. gender and collaborative experience from previous research cannot be used as a reference in making conclusions. conclusions based on the discussion discussed, it can be concluded that the majority of respondents from nursing and midwifery majors, female, do not have collaborative work experience, with a minimum of experience of less than or equal to 5-10 years. lecturers have positive readiness for ipe. educational institutions are recommended to start developing models that are mutually agreed upon and supported by facilities and clear policies and regulations. subsequent research is expected to explore more appropriate ipe learning models through both qualitative and quantitative approaches. acknowledgements thanks to the ministry of research, technology, and higher education republic of indonesia for the support for this research (ristekdikti). references aryakhiyati, n. 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(2010) framework for action on interprofessional education and collaborative practice. geneva, switzerland: who http://dx.doi.org/10.1016/j.nedt.2013.02.019 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.14-21 14 pain level in critical patients with sleep hygiene care in intensive care unit heru suwardianto, dyah ayu kartika wulan sari stikes rs baptis kediri, east java, indonesia corresponding author: herusuwardianto@gmail.com abstract bacground: complaints in critical patients are an unpleasant experience as long as patients are admitted to the icu. critical patients with pain are still common and need collaboration to reduce patients in the icu. purpose: this study aimed to determine the pain level description of critical patients with sleep hygiene care in the intensive care unit. method: research design is descriptive-analytic. the study population was all critical patients in the icu. the study sample was a portion of critical patients who received 170 sleep hygiene care patients. the sampling technique is purposive sampling. the research variable is a description of the patient's pain level. the research instrument used a questionnaire. data were collected and analyzed using the frequency distribution method. result: the results of the pain indicator on the facial expression study found that the majority of respondents showed grimacings (46.6%), body movements study found that most showed restlessness (39.4%), vocalization found that almost all respondents showed tolerating ventilator or movement / talking in normal tone / no sound (72.9%), muscle tension assessment found that most respondents showed relaxed as much (51.8%). the results of the study showed that the pain scale based on cpot of the majority of respondents had mild pain as many as 64 respondents (37.6%). conclusion: pain description in critical patients with sleep hygiene care shows that there are still many patients who feel pain and need identification and further intervention to reduce it. keywords: sleep hygiene, pain, critical patients received july, 27, 2019; revised august 24, 2019; accepted september 19, 2019 how to cite: suwardianto, h., & sari, d.a.k.w, m. (2019). pain level in critical patients with sleep hygiene care in intensive care unit. journal of nursing practice, 3(1), 14-21. https://doi.org/10.30994/jnp.v3i1.61 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v3i1.61 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.14-21 15 background pain in critical patients is a real and disturbing problem in critical patients. some conditions in critical patients are a decrease in the level of consciousness, limited body movement, and cannot express what is felt including the pain experienced. the pain is caused by the study of pain in critical patients with a decrease in an awareness that is a challenge for nurses(gelinas, 2016). patients in the intensive care unit have a variety of complex experiences and poor prognosis and have problems with pain and discomfort. data shows that the incidence of pain in critically ill patients is greater than 50%, the experience of pain is felt during rest and during routine clinical procedures (barr et al., 2013; puntillo, 2014). some of the causes of pain are identified as traumatic injury, standard procedure (tube removal, early mobilization, endotracheal suction, and other invasive actions), acute disease, surgery, invasive equipment (abelha, santos, maia, castro, & barros, 2007; barr et al., 2013). environmental factors can also affect the pain response in patients, especially with the assessment of inappropriate pain can cause pain unknown problems so that pain is not handled (rimawati, suwardianto, & vw, 2018; h. suwardianto, 2016). pain in critical patients who have not received optimal nursing care can have an impact on physiological functions, cognitive, mental and physical disorders, increase hospitalization time in the icu, increase the time of ventilator use. critical patients with untreated pain can also cause an increase in intracranial pressure (al sutari, abdalrahim, hamdan-mansour, & ayasrah, 2014; ayasrah, 2014). if we do not recognize the causes of pain in critical patients then also have the consequences of causing posttraumatic stress disorder (jackson, pandharipande, girard, brummed, & thompson, 2014; nathan e, brummel, james c. jackson, 2013). the role of nurses in the proper management of pain depends on the assessment of pain in systematic and accurate assessment of the occurrence of pain (h. suwardianto, prasetyo, & utami, 2018; h. suwardianto & selvia, 2015). pain in critical patients should be studied routinely and structurally, seeing that each of the factors causing pain is the icu environment, but this is often not done. critical patients in the icu because of the condition of the disease, causing patients to not be able to express pain subjectively, therefore nurses sometimes do not see the pain response expressed by patients because of the condition. the results of the data show that critical patients have a severe anxiety level of 41.7%, moderate anxiety level 29.2%, mild anxiety 18.8%, and no anxiety at 10.4% (iskandar, 2016). vap (ventilator-associated pneumonia) is a nosocomial infectious disease that still causes deaths of around 24-50% and reaches 76% if experiencing complications (heni, 2014). more than 63% of critical patients complain of pain and get sedation when complaining of pain and anxiety. the role of nurses to detect and assess environmental factors, in this case, is when patients sleep which is often called sleep hygiene. critical patients need to identify current conditions, images that occur in critical patients when patients are admitted to the icu. the role of nurses is very important in the assessment of critical patients and this is a challenge for icu nurses because the severity of the patient's pain intensity is often underestimated (georgiou, 2015; heru suwardianto, 2018). critical patients in expressing their pain responses who cannot communicate effectively need another technique (hoppkins, rr, l, spuhler, & g.e, 2012). in the critical nursing area, many patients with sedation and intubation were unable to communicate to show their level of pain, either verbally or by showing their level of pain using pain scale tools, this made the pain journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.14-21 16 assessment difficult in this group of patients (h. suwardianto, 2014). this is what makes the assessment of pain in the critical nursing area very complex. nurses in the assessment of pain in critical nursing areas require comprehensive pain assessment as an objective evaluation through observation of pain indicators. the use of a pain scale based on behavioral indicators is recommended for patients who cannot communicate their pain, by observing their motor function. the nurse in understanding and identifying critical patients to understand the condition of the next critical patient is very important and supports patient recovery. objective this study aimed to determine the pain level description of critical patients with sleep hygiene care in the intensive care unit. methods the design of this study is descriptive-analytic. the population of this study was all critical patients who entered the icu. the sample of this study amounted to 170 critical patients. the independent variables of this study were the diagnosis, age, sex, education, occupation. the dependent variable of this study is the critical patient pain scale. the research instrument used a questionnaire. data is collected, tabulated, and coding then statistical tests are performed using frequency distribution. the study was conducted after receiving a letter ethical clearance with letter number 024/01 / v / ec / kepk / stikes rsbk / 2019 and had obtained a research permit from the research site. the participants were assured that their engagement was voluntary, and that anonymity, privacy, and confidentiality of the data were guaranteed. furthermore, they were informed about the purpose and the method of the study before signing a written informed consent. the questionnaires were distributed to eligible participants at the baptis hospital, and respondents were asked to complete and return them in the same time. results table 1. characteristics of critical patients in icu (n = 170) no. characteristics ∑ % mean ± sd a diagnosis 4,9±2,8 1 chf 30 17,6 2 hypovolemic shock 3 1,8 3 miokard infark 15 8,8 4 respiratory failure 47 27,6 5 cardiogenic shock 17 10,0 6 dcfc 11 6,5 7 septic shock 6 3,5 8 ckd 14 8,2 9 dengue shock syndrome 17 10,0 10 head injury 6 3,5 11 tubercolosis 2 1,2 12 hyponatremi 1 0,6 13 hhf 1 0,6 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.14-21 17 no. characteristics ∑ % mean ± sd b gender 1,50±0,50 1 male 84 49,4 2 women 86 50,6 c age 55,24±19,94 1 6-11 years 12 7,1 2 26-35 years 5 2,9 3 36-45 years 2 1,2 4 46-55 years 17 10,0 5 56-65 years 31 18,2 6 > 65 years 51 30,0 c education 3,12±1,11 1 no school 18 10,6 2 elementary 33 19,4 3 junior high school 38 22,4 4 senior high school 72 42,4 5 college 9 5,3 d occupation 2,68±1,57 1 does not work 44 25,9 2 housewife 53 31,2 3 employee 29 17,1 4 entrepreneur 17 10,0 5 pns 11 6,5 6 other 16 9,4 e use of mechanical ventilators 1 use 63 37,1 1,37±0,48 2 do not use 107 62 based on the results of the study it was found that almost half of the respondents had diagnosed respiratory failure as many as 47 respondents (27.6%), most of the respondents were female respondents as many as 86 respondents (50.6%), almost half of the respondents had 56-65 years old as many as 51 respondents (30%), almost half of the respondents had a high school education of 72 respondents (42.4%), almost half of the respondents were housewives as many as 53 respondents (31.2%) and patients using mechanical ventilators as many as 63 patients (37.1% ) table 2. secondary data of critical patients in icu (n = 170) no variable mean sd 1 temperature (o c) 38,90 25,17 2 systolic blood pressure (mmhg) 119,64 37,10 3 diastolic blood pressure (mmhg) 74,56 23,64 4 pulse rate (times / minutes) 107,58 73,2 5 respiratory rate (times / min) 26,34 10,91 6 mean aterial pressure (mmhg) 104,56 47,29 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.14-21 18 based on the results of the study obtained secondary data that the mean variable with an abnormal value is temperature (38.9o c), blood pressure (119.64 / 74.56 mmhg), pulse frequency (107.58 times/minute), and breathing frequency (26.34 times/minute) tabel 3 pain indicator in critical patients (n=170) no indicator (cpot indocators) ∑ % mean sd a facial expression 1,34 0,68 1 relaxed, neutral 21 12,4 2 tense 70 41,2 3 grimacing 79 46,5 b body movements 1,00 0,88 1 absence of movements or normal position 66 38,8 2 protection 37 21,8 3 restlessness 67 39,4 c compliance with ventilator or vocalization 0,32 0,57 1 tolerating ventilator or movement /talking in normal tone/no sound 124 72,9 2 coughing but tolerating /sighing, moaning 37 21,8 3 fighting ventilator/ crying out, sobbing 9 5,3 d muscle tension 0,58 0,67 1 relaxed 88 51,8 2 tense, rigid 64 37,6 3 very tense or rigid 18 10,6 e cpot 3,25 1,41 1 no pain 88 51,8 2 mild pain 64 37,6 3 moderate pain 18 10,6 4 severe pain 5 5,9 the results of the cpot indicator on the facial expression study found that the majority of respondents showed 79 grimacings (46.6%), body movements study found that most showed restlessness of 67 respondents (39.4%), compliance with ventilator or assessment. vocalization found that almost all respondents showed tolerating ventilator or movement / talking in normal tone / no sound of 124 respondents (72.9%), muscle tension assessment found that most respondents showed relaxed as much as 88 respondents (51.8%). the results of the study showed that the pain scale based on cpot of the majority of respondents had mild pain as many as 64 respondents (37.6%). journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.14-21 19 discussion based on the results of the study it was found that almost half of the respondents had a diagnosis of respiratory failure (27.6%). critical patients are patients with organ failure one or more target organs (suwardianto & selvia, 2015). patients to express pain are basically subjective but in patients who fail breathing identification of the scale of pain cannot be done. this makes nurses need to use different methods in patients with respiratory failure and attached a mechanical ventilator to determine the level of pain. critical patients who are unconscious and/or have mechanical ventilators attached, for measuring pain can use cpot. critical patients were mostly female (50.6%) and almost half of respondents had 56-65 years of age (30%). this shows that critical patients are at the age of the elderly and during menopause. this is likely because some hormones have stopped working like the estrogen hormone (suwardianto, 2016) (barr et al., 2013). critical patients almost half of the respondents had high school education (42.4%), almost half of the respondents were housewives (31.2%), this shows that education can be an indicator of perceived pain, pain experiences in critical patients (al sutari et al., 2014). some critical patients use mechanical ventilators (37.1%). poor prognosis and in accordance with the patient's diagnosis that at most patients have respiratory failure and need to use an airway. a mechanical ventilator is one of the causes of pain, invasive action and an environment that does not support. sleep hygiene is a modification of the environment when the patient sleeps at night. environmental modification in the form of temperature, noise and lighting settings (dakin & margarson, 2010; faraklas, 2013). based on the results of the study obtained secondary data that the mean variable with an abnormal value is temperature (38.9o c), blood pressure (119.64 / 74.56 mmhg), pulse frequency (107.58 times/minute), and breathing frequency (26.34 times/minute). this shows that the process of sleep rest is important to support the patient's hemodynamics and respond to decreased pain (barr et al., 2013; skrobik, 2013). critical patients treated in the icu need to be identified with hemodynamic conditions so that they are able to show their best condition in the repair process. hemodynamic improvement can be done with sleep hygiene by increasing optimal resting response. sleep hygiene improves the quality of sleep, improves regulation of organ balance, and rests organs. critical patients can interpret the experience of pain without expressing it. critical patients experience pain because of the environment, actions, and response to the disease. patient pain can be identified using cpot. the results of the study on cpot indicators on the facial expression study found that most respondents showed grimacing (46.6%), body movements study found that most showed restlessness (39.4%), assessment of compliance with ventilator or vocalization found that almost all respondents showed tolerating ventilator or movement / talking in normal tone / no sound (72.9%), muscle tension assessment found that most respondents showed relaxed (51.8%). the results of the study showed that the pain scale based on cpot of the majority of respondents had mild pain as many as 64 respondents (37.6%). critical patients with pain need to continue to get attention from measurement methods, and appropriate nursing care. the condition of the patient can continue to change to achieve optimal conditions. the role of nurses in carrying out nursing care needs to be continuously supported in achieving nursing care to reduce optimal pain. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.14-21 20 conclusion critical patients with complaints of pain in the icu had facial expression. it was found that the majority of respondents showed grimacing (46.6%), body movements study found that most showed restlessness (39.4%), the compliance with ventilator or vocalization study found that almost all respondents showed tolerating ventilator or movement / talking in normal tone / no sound (72.9%), muscle tension assessment found that most respondents showed relaxed (51.8%). the results of the study showed that the pain scale based on cpot of the majority of respondents had mild pain (37.6%). acknowledgments we thank the ministry of science, research, technology and higher education of indonesia (ristekdikti ri) for research grants 2018 and providing 2019. we thank you to director of kediri baptist hospital, nurse erina the chief of icu baptist hospital icu and all research respondents. reference abelha, f. j., santos, c. c., maia, p. c., castro, m. a., & barros, h. 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(2018). pelatihan penangganan korban tersedak terhadap pemahaman tujuan, prosedur, kewaspadaan, dan evaluasi tindakan. jurnal penelitian keperawatan, 4(2), 1. suwardianto, h. (2014). the effectiveness of deep breathing and slow stroke back massage to decrease the blood pressure on a patient with hypertension. indonesian nursing journal of education and clinic (injec), 1(1), 1–12. suwardianto, h. (2016). tardive dyskenesia, motor activity, sedation scale, and cardiac workload in baptis kediri hospital. world society of disaster nursing, 4(1), 1. suwardianto, h., prasetyo, a., & utami, r. s. (2018). effects of physical-cognitive therapy (pct) on criticaly ill patients in intensive care uni. hiroshima journal of medical sciences, 67(1), 63–69. suwardianto, h., & selvia, d. (2015). buku ajar keperawatan kegawatdaruratan (perspektif, konsep, prinsip, dan penatalaksanaan kegawatdaruratan). surabaya: pt. revka petra media. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.102-108 102 effectiveness of toileting training mediated with animated videos against to independence level of toileting on preschool children nunung ernawati, kartika permata nursing program of health politechnic rs dr. soepraoen , malang, east java, indonesia corresponding author: nunungerna@gmail.com abstract background: the one of development tasks for preschooler that must be passed is toileting activity. toileting learning need should start at toodler phase, but many children still enuresis experience in the classroom, all students could not do proper toileting, including not knowing how to go to the toilet, not being able to open the pants and not being able to flush the elimination urine and defecatie in kindergarden-class a of malang city. inability to control of elimination urine that cause of pre schooler are less independece for toileting activity. purpose: this study aimed to find out the effect of toilet training mediated with animated videos againts to independence level of toileting on pre schooler children in kindergartenclass a of malang city. methods: this type of research was analytic observation with a pre-experimental approach. the total population was 38 children, the number of samples 38 children was taken using the total sampling technique. the variable measured is the level of independence of toileting. the data was processed then analyzed using the wilcoxon test with α <0.05. results: based on the results of the study, the level of independence before toileting learning was done 21% independently and 79% not independently. the level of independence after toileting learning is 100% done independently.wilcoxon test was analyzed, the level of independence was obtained with a p-value of 0,000 which means that p-value <α so that h0 is rejected, which means there is an influence of the learning activity of animated videos on the level of independence of toileting. conclusion:based on the results of the study, to improve children's independence, in terms of toileting, can be done early and in the future learning, animated video media can be used as an alternative as a learning media for pre-schooler. keywords: animated videos, toileting independence, pre-schooler received july, 29, 2019; revised august 30, 2019; accepted september 22, 2019 how to cite: ernawati, n., & permata, k. (2019). effectiveness of toileting training mediated with animated videos against to independence level of toileting on pre-school children. journal of nursing practice, 3(1), 102-108. https://doi.org/10.30994/jnp.v3i1.71 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v3i1.71 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.102-108 103 background children are individuals who are in a range of developmental changes starting from infants to teenagers. one of development tasks for children aged 4-5 years old (preschooler) that should be passed is toileting activities. toileting is a teaching process as well as efforts to train the child’s ability to control urination (bak) and defecation (bab) is properly and regularly (hidayat, 2008). toileting learning needs should have been started since the children aged 1-3 years, but in kindergarten-class a are still many children aged 4-5 years who are still experiencing enuresis in the classroom, can not open his own pants, can not control the urge to urinate. inability to control the urge to urinate cause children less independent in toileting needs. the prevalence of enuresis in the world ranged between 11.4%-45%. studies in the usa show of 112 children aged 3-10 years, 45% have daytime wetting or daytime wetting (hodges et al., 2014). qena, egypt, 1,065 (11.4%) school-age children experience enuresis (ismail et al., 2013). in indonesia the estimated number of infants up to 30% of the million population of indonesia in 2011. according to national household health survey in 2012, estimated the number of toddlers who are hard to control bowel movements and urination (enuresis) reach 75 million preschool-age children. according to the preliminary study conducted by researchers at the date of october 1, 2018, the information obtained from the principal of kindergarten that 20 children in kindergarten-class a of malang city are already independent in toileting, while 18 children are still not independently perform toileting. among 5 children do not know how to toilet, 5 children can not open the pants, and 8 children who can not cleanse or flush after urinating or bowel movements. teachers already done verbally teaching, this course is not enough, because children still do not understand what is conveyed by the teacher. toileting failure caused by premature toileting be likely to cause urinary tract infection (uti) (natalia, 2006). in addition, toileting failure can cause a child less independent, have a selfish attitude, stubborn, greedy, tend to be careless, and arbitrarily in performing daily activities (hidayat, 2008). efforts to overcome the problem of toileting in children aged 4-5 years with an interesting learning through the media, for example with animated video, posters, roleplay, and storytelling (maria sicily, 2010). one of the media that will be examined are animated video, selected video as a learning media about toileting can be used both within the children as well as in the environment of adults, in addition to the video animations can be a special attraction for children to consider the content of that learning. objective this study aimed to investigate the effect of exercise toileting through animated videos on the level of toileting independence of pre-school children in kindergarten-class a of malang city. methods the research design was an observational analytic with pre-experiment approach. the study population was the students of kindergarten-class a of malang city numbered 38 children. sampling used total sampling so that the sample was 38 children of kindergarten-class a of malang city. the variables studied were toileting independence through the intervention of toileting training through the media of animated video. the study was conducted in kindergarten-class a of malang city on december 2018. data journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.102-108 104 were collected before and after the intervention of toileting training through the media of animated videos, instructional videos provided 3x in one week was conducted for 2 weeks in the school with a duration of 2 minutes on mondays, wednesdays and friday. after data collection will be conducted editing stages of data processing, coding, tabulating then analysis wilcoxon test with α=0.05. this study was conducted according to the principles of research ethics was anonimyty, confidentiality, inform consent, benefit and potential risk of research. the participants were assured that their engagement was voluntary, and that anonymity, privacy, and confidentiality of the data were guaranteed. furthermore, they were informed about the purpose and the method of the study before signing a written informed consent. the questionnaires were distributed to eligible participants at the kindergarten, and respondents were asked to complete and return them in the same time. . results this research was conducted in kindergarten-calss a at lowokwaru district of malang city. kindergarten of malang city used bi-lingual learning system with total of 75 students divided into kindergarten a 40 children and kindergarten b 35 children, while the total number of teachers and staff there are 10 people. learning is carried out every monday until friday at 07.00-10.00 am. based on the results general data characteristics as follows; diagram 1 based on the above diagram shown that the majority gender of children in kindergarten in class a of malang city were girls (53%). journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.102-108 105 diagram 2 es= elementary school, jhs=junior high school, shs=senior high school based on the diagram above shown that the majority of educational level of parents was senior high school (87%). diagram 3 based on the diagram above, shows that the occupation of parents in kindergarten of palm kids mostly teachers (51%) diagram 4 based on the diagram above shown that the independence of toileting before toileting practice using video was largely self-sufficient (79%) journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.102-108 106 based on diagram above shown that the independence of toileting after toileting drills conducted entirely (100%) in the independent category. the analysis results independence level difference on pre test and post test on kindergarten-class a of malang city n median p (minimum-maximum) pre test independence children 38 23 (19-33) 0,000 post test independence children 38 34 (30-44) (source: primary data research, 2019) based on the above table post test results obtained throughout the child’s level of independence kindergarten-class a of malang city standalone total of 38 children (100%). the result of the level of independence wilcoxon p value of 0.000 and the z value of -5.390 so that h0 is rejected, which there is an influence of the learning activity of animated videos on the level of independence of toileting. discussion the measurement results on the child’s independence level on pre-test shown a level of independence largely independently a number of 30 children (79%) and a small self-contained a number of 8 children (21%). the results of the measurement of the degree of independence post-test showed all respondents independently a number of 38 children (100%), so this suggests that the measurement of the level of independence to experience the difference. so it could be concluded that the intervention video animation can increase the degree of independence of toileting in children. the measurement results between pre-test and post-test level of independence, showing where the wilcoxon test results between pre-test and post-test was obtained p value of 0.000 and -5.390 z of these results indicates that the p value <α so h0 is journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.102-108 107 rejected, it indicates that the measurement results increased level of independence before and after intervention. so it could be concluded that the intervention animated video can increase the level of independence in children 4-5 years old. in this study showed respondents in the age range of 4-5 years old, soegondo (2011) explains that the age is one factor that can affect the level of the child’s independence. mubarok (2007) and notoadmojo (2014) suggests that age is a factor that can affect the level of independence. that is with increasing age there will be changes on the physical and psychological (mental) someone who will be able to affect the level of independence. research conducted by maria sicily (2010) suggested that the age of one can affect the level of independence, because the age-old enough to increase one’s mindset. this study uses a given media video animation as much as 12x in 2 weeks this greatly affects the independence of toileting children for use entrancing impressions in a simple and practical things easier to follow by children. video animation provided directly on the applicative respondents. according wong (2008) that the video animation is a media which is suitable for children aged 4-5 years with a view transform and improve the level of independence of toileting children and to facilitate the achievement of health goals, which effectively motivate change in a structured, through a supportive relationship between the participants and coaches , in line with the research of difran (2015) which states that the coaching support can influence the respondents in the management of its independence. conclusion based on the research that has been conducted, it can concluded that: the level of the child’s independence before being given an animated video obtained largely dependent categorized 30 respondents (79%) and a small self-contained a number of 8 respondents (21%). the independence level of children after toileting training given through the media of animated video showing a 100% self-sufficient. because the results of data analysis by wilcoxon test macth pair obtained p value of 0.000> α 0,05 hence h0 was rejected that meant there is an influence of the learning activity of animated videos on the level of independence of toileting on children of kindergarten-class a of malang city. acknowledgments: 1. letnan kolonel ckm arief efendi, s.m.ph.,sh., s.kep.ners., mm., m.kes. as directory of health politechnic rs dr. soepraoen malang, thanks you for the opportunity given to us as lecturers so that we can carry out the tasks of tri dharma pt in particular this research. 2. headmaster and kindergarten teacher, thanks you for your permission and support so this research can be carried out smoothly 3. all respondents and respondens parents, thanks you for your participating in this research. . conflicts of interest many children still enuresis experience in the classroom, all students could not do proper toileting, including not knowing how to go to the toilet, not being able to open the pants journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.102-108 108 and not being able to flush the elimination urine and defecatie in kindergarden-class a of malang city. references ali, and asrori (2002), factors affecting learning independence. http: // alan-lahallo .com / 2011/06 / factors-yangmempengaruhi.html. accessed on october 29, 2018 aziz, ru (2006), do not let our children grow with bad habit, cet. 1. solo: triad. hidayat, a. aziz alimul (2008), introduction to nursing children 1 jakarta: salemba medika. ____________________, (2009), introduction to nursing children. jakarta: salemba medika. kabang, ms (2010). influence toilet training by using the media image attitude independence against children aged 4-5 years in kindergarten builder negri south pontianak. notoatmodjo, s. (2010), health research methodology. jakarta: rineka reserved. nursalam (2013) nursing research methodology: a practical approach edition 4. jakarta: salemba medika. natalia, s. 2006. "effect" toilet training "against uti recurrent events in girls ages 1-5 years". thesis s2 graduate program in biomedical science and a master of specialist education program 1 child health diponegoro university, semarang. sugiyono. (2013). educational research methods. bandung: alfabeta. wong. donna l. 2008, textbook of pediatric nursing. jakarta: egc journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.113-121 113 self-help group therapy as community nursing intervention to reduce stress response and increase self-efficacy in high-risk pregnant women reni nurhidayah*, prima dewi kusumawati department of nursing, institut ilmu kesehatan strada indonesia, kediri, indonesia *corresponding author: reni.nurhidayah@iik-strada.ac.id abstract background: unexpected and unanticipated obstetric problems that can have a direct or indirect impact on the well-being of mothers and babies are considered high-risk pregnancies. uncertainty in health conditions is felt as a life-threatening event that can threaten the lives of mothers and babies. this condition will trigger various stress responses felt by the mother. moderate to severe stress during pregnancy greatly increases the risk of developing postpartum depression. one of the important coping sources to deal with stress is self-efficacy. personal abilities are all aspects of an individual that can be utilized to solve problems. one of the interventions that can be used to improve coping mechanisms is self-help groups. self help group is a group approach to help its members solve their problems. purpose: this study aims to determine the impact of self-help groups as therapy in the community to reduce stress responses and increase self-efficacy in high-risk pregnant women. methods: the research design used was a quasi-experimental one-group pre-test post-test design. 15 respondents were given intervention in 3 sessions for 90 minutes in each session. stress response and self-efficacy were measured before and after the intervention. data analysis was carried out using the paired sample t-test. results: this study shows that the average assessment stress response and self-efficacy score of mothers before the self-help group therapy is 128 and 35. after the therapy, the average response stress and self-efficacy score of mothers was 86 and 53. the study shows the effect of self-help group therapy on stress response (ρ-value = 0,012) and self-efficacy (ρ-value = 0,021). conclusion: it was concluded that self-help group therapy was effective in decreasing stress respons and improving self-efficacy for high-risk pregnant women. keywords: high risk pregnancy, self-efficacy, self-help group, stress response received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.367 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:reni.nurhidayah@iik-strada.ac.id https://doi.org/10.30994/jnp.v6i2.365 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.113-121 114 background pregnancy is one of the most important life events for women. various physiological and psychological changes occur in this period. this condition makes pregnant women vulnerable to health problems that affect the mother, fetus, or both. unexpected and unanticipated obstetric problems that can have a direct or indirect impact on the well-being of mothers and babies are considered high-risk pregnancies. worldwide, the incidence of highrisk pregnancies is 2 million women and more than 800 pregnant women die every day due to complications and pregnancy problems (holness, 2018; yusriani & septiyanti, 2021). high-risk pregnancies in indonesia are still quite high. based on data from the sampling registration system (srs) in 2018, around 76% of maternal deaths occurred in the labor and postnatal phases with the proportion of 24% occurring during pregnancy, 36% during delivery, and 40% after delivery. the number of maternal deaths in 2019 was sourced from district/city health profiles reporting as many as 684 problems or 74.19 per 100,000 live births, a decrease of 16 cases compared to 2018 which was 700 cases. the cause of maternal death is still dominated by 33.19% bleeding, 32.16% hypertension in pregnancy, 3.36% infection, 9.80% circulatory system (heart) barriers, 1.75% metabolic barriers and 19.74% triggers another (ri kemenkes, 2018). uncertainty in health conditions is felt as a life-threatening event that can threaten the lives of mothers and babies. this condition will trigger various stress responses felt by the mother. stress is our body's natural response when faced with a problem. the stress mechanism will form when we are faced with a stressor. pregnancy complications are a serious stressor for pregnant women. threats to the health of the mother and the fetus, the strict treatment in the hospital, and the bed rest will make pregnant women feel fear and a real threat to the safety of themselves and their babies (akbarian et al., 2018; esfandiari et al., 2020; kinsella & monk, 2013; wesley, 2006). pregnancy complications not only cause physical problems but also psychological problems. the reaction of pregnant women to high risk pregnancy is very much determined by their perception of the problem, starting from the risk, severity, and expectation related to their health condition. the label of high-risk pregnancy will make these pregnant women think negatively about their pregnancy (ahmadi et al., 2019; hassan, mohammed, et al., 2020; holness, 2018; kianpour et al., 2018; yusriani & septiyanti, 2021). qualitative research that has been conducted on mothers with high-risk pregnancies shows that all mothers have negative thoughts regarding pregnancy and their health conditions. pregnant women with high risk often feel that they and their babies are going to die. they are worried about all the possibilities that can happen and are even frustrated with their health and pregnancy conditions. even pregnant women often think that they fail to maintain their pregnancy and health (dijkhuis et al., 2020; harris et al., 2014; roberts et al., 2017). a high-risk pregnancy is a problem causing maternal and fetal morbidity and mortality. the real threat to safety makes pregnant women often show symptoms of stress related to the problem they are experiencing. moderate to severe stress during pregnancy greatly increases the risk of developing postpartum depression (hassan, gouda, et al., 2020; hassan, mohammed, et al., 2020; kendig et al., 2016). research has shown the incidence of postpartum depression is much higher in pregnant women with pregnancy problems. uncertainty in the health condition of pregnant women and the fetus during treatment. various actions are given during treatment. various interventions that may be given during childbirth often increase the trauma felt by pregnant women. trauma that does not go away often increases the risk of postpartum depression experienced by postpartum mothers with a high-risk pregnancy (abedian et al., 2015; akbarian et al., 2018; chen et al., 2019; mbarak et al., 2019). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.113-121 115 stress during pregnancy that is not resolved can trigger mental disorders in pregnant women and postpartum. pregnant women with severe stress can have emotions or moods such as rollercoasters where suddenly anxiety attacks to panic, depression, and even thoughts of suicide can appear. this is due to their fear of not being able to adapt to the traumatic events during the pregnancy. all of the above conditions greatly affect the mental health of the mother and can trigger depression and even psychosis (acosta et al., 2013; caropreso et al., 2019; nasiri, s., akbari, h., tagharrobi, l. and tabatabaee, a.s., 2018; verbeek et al., 2015). in adapting to stressors such as high-risk pregnancy, a mother needs an effective coping mechanism that is supported by adequate coping sources (chapuis-de-andrade et al., 2021; kerns et al., 2018). one of the important coping sources to deal with stress is self-efficacy. personal abilities are all aspects of an individual that can be utilized to solve problems. one of the main factors in personal ability is self-efficacy. self-efficacy is an individual's ability, strength, and ability to solve certain specific problems. self-efficacy in pregnant women is usually associated with the mother's readiness to adapt to her pregnancy. good self-efficacy will help mothers adapt to the conditions of their pregnancy adaptively (abarashi et al., 2014; dwairej & ahmad, 2022; kim & suh, 2018; mohammadpour et al., 2016; nurhidayah, 2017). one of the interventions that can be used to improve coping mechanisms is self-help groups. self help group is a group approach to help its members solve their problems. in a self-help group, each group member shares physical, emotional, or other issues. this group also discussed how to solve these health problems. self-help groups will form a support system where all pregnant women with high risk can share and not feel alone in living their lives so that they can respond to all existing stressors more adaptively (saggurti et al., 2018, 2019; worrall et al., 2018). this study aims to determine the impact of self-help groups as therapy in the community to reduce stress responses and increase self-efficacy in high-risk pregnant women. so it is hoped that this research can provide intervention options in caring for pregnant women with high risk more holistically and optimally. so that the welfare of pregnant women during the process of pregnancy, childbirth, and postpartum can be achieved. methods the research design used was a quasi-experimental one-group pre-test post-test design. respondents in this study were 15 mothers with high risk pregnancy at the posyandu in gempolan village in may 2022. the intervention was given in 3 sessions for 90 minutes in each session. stress response and self-efficacy were measured before and after the intervention. data analysis was carried out using the paired sample t-test. results respondent demographics the characteristics of the respondents in this study were general data which included: age, education, occupation and marital status. table 1. characteristics of respondents n=15 no. characteristics f % age 1 <20 years old 2 13,4 2 20-35 years old 8 53,3 3 >35 years old 5 33,3 https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.113-121 116 based on the table above, it is known that more than a half of the respondents were 2035 years old (53,3%). most of the respondents have a high school education (60%), work as housewives (53,3%), and multipara (86,6%) from a total of 15 respondents. high risk pregnancy are too young mother (13,4%), too old mother (33,3%), hypertension (53,3%), anemia (26,7%), diabetes (13,4%) and twin pregnancy (6,7%). stress response before and after treatment table 2. psychological well being in mothers before and after mindfulness-based stress reduction therapy based on the table above, it is known that the average assessment stress response score of mothers before the self-help group therapy is 128 with the lowest score is 114 and the highest is 146. after the therapy, the average response stress score of mothers was 86 with the lowest score 78 and the highest 117. table 3. results of paired sample t-test the effect of self-help group therapy on stress response the table above shows the effect of self-help group therapy on stress response in high risk education 1 elementary school 1 6,7 2 junior high school 3 20,0 3 senior high school 9 60,0 4 university 2 13.3 profession 1 housewife 8 53,3 2 farmer 4 26,7 3 entrepreneur 2 13,4 4 private 1 6,7 pregnancy status 1 primipara 2 13,4 2 multipara 13 86,6 pregnancy complication 1 hypertension 8 53,3 2 anemia 4 26,7 3 diabetes 2 13,4 4 twin pregnancy 1 6,7 n min max mean sd stress response pre test 15 114 146 128 2,052 stress response post test 15 78 117 86 1,242 https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.113-121 117 the table above shows the effect of self-help group therapy on stress response in high risk pregnancy (ρ-value = 0,012 <0.05, so h0 was rejected). there is an effect of self-help group therapy on stress response in high risk pregnancy at posyandu gempolan. table 4. self-efficacy in mothers before and after mindfulness-based stress reduction therapy the table above shows the effect of self-help group therapy on stress response in high risk pregnancy (ρ-value = 0,012 <0.05, so h0 was rejected). there is an effect of self-help group therapy on stress response in high risk pregnancy at posyandu gempolan. self-efficacy before and after treatment table 5. results of paired sample t-test the effect of self-help group therapy on selfefficacy based on the table above, it is known that the average self-efficacy assessment score of mothers before the mindfulness-based stress reduction therapy is 35 with the lowest score is 13 and the highest is 56. after the therapy, the average score psychological well-being of mothers after treatment was 53 with the lowest score 32 and the highest 71. the table above shows the effect of self-help group therapy on self-efficacy in high risk pregnancy (ρ-value = 0,021 <0.05, so h0 was rejected). there is an effect of self-efficacy in high risk pregnancy at posyandu gempolan. discussion effect of self-help group therapy on stress response the results showed that self-help groups were able to reduce the stress response of pregnant women with high risk. the self-help group is one of the interventions that can optimize the source of coping that is needed by someone who is experiencing stress. self-help group has purpose to make pregnant women able to maintain and improve their self and social pre test post test paired sample t test (t) ρ n mean sd n mean sd self-efficacy 15 35 13,92 15 53 224,73 -2,70 0,021 pre test post test paired sample t test (t) ρ n mean sd n mean sd stress response 15 128 2,052 15 86 1,242 100,347 0,012 n min max mean sd self-efficacy pre test 15 13 56 35 13,92 self-efficacy post test 15 32 71 53 24,73 https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.113-121 118 functions through cooperation and sharing in dealing with pregnancy problems. self-help groups understand people that they are not alone, where members help each other and support each other by telling experiences and alternative ways of solving problems. so a self-help group is an informal group with members who experience similar problems so that they can share experiences, cooperate and support in solving problems related to self and society (saggurti et al., 2018, 2019; worrall et al., 2018). self-help groups will provide social support which is an important factor in the adaptation of high-risk pregnant women. heavy pregnancy can make the mother feel pressured by the health changes she must undergo. so the mother will really need help from others. support plays an important role in reducing stress responses because good family support will make the mother feel valued, and cared for it can reduce feelings of pressure and helplessness that arise due to pregnancy problems experienced. with an effective support system, pregnant women will feel not alone and have a place to share during pregnancy. this effective support system will increase the ability to cope and reduce the stress response felt by pregnant women with high risk (esfandiari et al., 2020; saggurti et al., 2019; spiegel et al., 2007; wesley, 2006; worrall et al., 2018). effect of self-help group therapy on self-efficacy self efficacy is a personal ability to solve problems. so that it can be said that selfefficacy is how a person judges herself to be able to overcome a problem and he shows the ability to overcome the problem. so self-efficacy does not only refer to self-confidence but also refers to one's skills in overcoming the problem. self-efficacy has an important role in improving the performance of mothers in adapting and solving problems encountered. when mothers are faced with problems with their pregnancy, self-efficacy will help them to take better care of their pregnancy. poor self-efficacy will make the mother feel incapable, afraid, and failing so pregnant women will focus on their health problems without thinking of solutions that must be done. on the other hand, if the mother has good self-efficacy, she will try to do her best to maintain a healthy pregnancy(nurhidayah, 2017; salomonsson et al., 2013; zarenejad et al., 2020). the results of the study show that self-help group therapy can increase maternal selfefficacy because self-help group therapy will help pregnant women find advice, role models, and solutions to overcome their problems. a self-help group is a group or peer where each member will share with each other the physical and emotional problems they face during pregnancy. self-help group aims to develop empathy among fellow group members where fellow group members provide reinforcement to each other to form adaptive coping (saggurti et al., 2018, 2019; worrall et al., 2018). conclusion it was concluded that self-help group therapy was effective in decreasing stress respons and improving self-efficacy for high-risk pregnant women. references abarashi, z., tahmassian, k., mazaheri, m. a., panaghi, l., & mansoori, n. 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(2020). the effect of mindfulness-based stress reduction on maternal anxiety and self-efficacy: a randomized controlled trial. brain and behavior, 10(4), 1–7. https://doi.org/10.1002/brb3.1561. https://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.286-290 286 situational leadership as view by nurses in government and private hospitals diwa agus sudrajat, fikri zulfikar, linlin lindayani*. sekolah tinggi ilmu keperawatan jawa barat, indonesia corresponding author: linlinlindayani@gmail.com abstract background: leadership as an indicator of the quality of human resources is a very determining factor in the success of an organization such as a hospital. leadership style depends also on the maturity of individuals or groups as followers. purpose: this study aimed to explore situational leadership of head nurse as viewed by nurses in government and private hospitals. methods: this study uses descriptive research method with cross-sectional approach. the time of the study will begin in may 2019 until june 2019. the instrument used in this study was the leadership style questionnaire model of harsey and blanchard. results: the leadership style of head nurse in the majority government hospitals is delegate (38.5%) and followed by the leadership style of consultation (38.5%), participation (18.5%) and at least instruction (13.8%). the leadership style of head nurses in private hospitals is also almost the same as government hospitals where the majority of implementing nurses rate the room head in the delegate style (48%), which is followed by the leadership style of consultation (23%), participation (20%) and most the least is the leadership style of instruction (9%). conclusion: the leadership style of head nurse both government and private hospitals iwas dominated by delegation and consultation. keywords: leadership, nurse, hospital. received december, 29, 2019; revised february 10, 2019; accepted march 28, 2020 doi: https://doi.org/10.30994/jnp.v3i2.77 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:linlinlindayani@gmail.com https://doi.org/10.30994/jnp.v3i2.77 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.286-290 287 background leadership as an indicator of the quality of human resources is a determining factor in the success of an organization such as a hospital (siagian; 2006). gillies (1996) states that leadership styles can be identified based on the behavior of the leader himself. a person's behavior is influenced by years of experience in his life. therefore, one's personality will be the leadership style used. a person's leadership style tends to be very varied and different. there are many different types of leadership styles developed by many experts, one of which is the situational leadership style developed by harsey & blanchard that the right leadership style depends also on the readiness / maturity of individuals or groups as followers (paul hersey and ken blanchard 1998). situational leadership theory (situational leadership theory-slt) developed based on the thought that there is no effective leadership style for all situations. the strength that is in the leader and owned by the group (interpersonal relationship between the two) and the environment (task orientation) will also determine a person's leadership style if he relates to his staff (munijaya; 2004). according to the research conducted by darmawan insan personal and (insan & yuniawan, 2016) the influence of participative leadership style, compensation work environment and organizational culture on employee performance that the results of the study proved that participative leadership style did not significantly influence employee performance, this can be seen from the value t for participative leadership style is 0.281 with a significance result of 0.780> 0.05. the results of this study support the research of mamesah and kusumaningtyas (2009) which states that the participative leadership style has no effect on employee performance. so that the weaknesses of this study can be seen is only examining one type of leadership style while in situational leadership theory harsey and blanchard there are 4 leadership styles. objective this study aimed to explore situational leadership of head nurse as viewed by nurses in government hospitals and private hospitals. methods this type of research conducted in this study uses descriptive research method with cross-sectional approach. the researchers conducted research at dustira hospital and hermina arcamanik hospital and were conducted in the inpatient room. the time of the study will begin in may 2019 until june 2019. the population in this study is the head of the room in government hospitals and private hospitals. the inclusion criteria were nurses who were active in the dustira hospital and arcamanic hermina hospital. samples were taken using convenience sampling technique. estimated sample size was calculated using g-power software version 3.0.10 for comparison between the two f test groups with the assumption α = 0.05, medium effect size = 0.15, power level = 0.95, 2 repeated measurements. with an estimated minimum sample size of 129 people. in this study researchers only got 100 respondents from both hospitals. the instrument used in this study was the leadership style questionnaire model of harsey and blanchard. where there are 20 questions consisting of 4 styles: instructional leadership style, consultation leadership style, delegation leadership style, and participation leadership style. where in this questionnaire was tested the validity with the results of r table 0.361. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.286-290 288 data analysis that will be conducted in this research is univariate data analysis which aims to explain and describe the characteristics of variables. univariate analysis uses frequency distribution analysis. results from table 1 it can be seen that the most dominant leadership style used by the head of the room in private and government hospitals is the leadership style of participation and participation with a percentage of 38.5% each, then the leadership style which next is the instruction style with percentage 18 , 5% and finally the leadership style of participation. table 1 distribution of leadership styles in government hospitals. leadership style n percetage instructions 12 18.5 % consultation 22 38.5 % delegation 22 38.5 % participation 9 13.8 % total 65 100 % the results obtained in private hospitals are also almost similar to the percentage of leadership styles in government hospitals where the dominant leadership style is delegate style with a percentage of 48%, the second leadership style is consultation leadership style with 22.9% percentage, next is leadership style instruction with a percentage of 20% and the least is the participation leadership style with an amount of 8.6% (table 2). table 2 distribution of leadership styles in private hospitals. leadership style n percetage instructions 7 20 % consultation 8 22.9 % delegation 17 48.6 % participation 3 8.6 % total 35 100 % discussion from the results of the study showed that most respondents rated the leadership style of the head nursesin a private hospital with a government hospital as the leadership style of the delegation (s3 style) as many as 38.5% of respondents. this leadership style has the characteristics of low directing behavior and high supportive behavior. leaders and subordinates give ideas to each other and together make decisions and evaluate the implementation of tasks as well as leaders encourage subordinates to complete tasks. this delegation style is suitable to be applied and is needed for the level of development of capable or hesitant subordinates or executors. the level of ability of subordinates "moderate" to "high" but has an uncertain commitment. cristina catur widianti mentioned in her journal that the style of delegative leadership influences the performance of the employees of pt bank mandiri jakarta city kcp, this means that if the leadership style increases, the employee's performance will also increase. therefore, with the results obtained in government hospitals with the most number of nurses choosing a delegative leadership style, it is suitable to be applied to increase nurse skills and can improve employee performance as explained by kristina chess widianti. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.286-290 289 the leadership style of head nurse that is rated by the next most respondents is the leadership style of consultation (s2 style) as many as 38.5% of respondents with the characteristics of directing high behavior and high support. in this style the leader explains the decisions taken, accepts the opinions of subordinates by conducting two-way communication and directing and continuously supervising the completion of the task. this style is needed in implementing nurses who have low to moderate abilities and low commitment. in his journal toto raharjo also said that the directive style influences employee performance and has the highest variable in relation to performance improvement. it can be seen that the most results in government hospitals are the delegative and participative leadership style, this is possible because both the delegative and participatory styles can influence employee performance. furthermore, an assessment of 18.5% of respondents stated that the head of the room in the government and private hospitals had a participation leadership style (s4 style). the characteristics of this leadership style are low directing and supportive behavior. this style is good for staff who have high ability and commitment. according to yudi atmaja this leadership style was deemed inappropriate. if it turns out the implementing nurse still needs guidance or control from the head of the room, this style will even have a negative impact on the performance of the implementing nurse and the purpose of the room that is the responsibility of the room head. from this it can be seen that in reality the responsibility cannot be delegated. conversely, if the head of the room delegates authority to a capable nurse, the head of the room will no longer be burdened by routine tasks and the nurse will also develop confidence and responsibility for the tasks given. the leadership style of head nurses in government hospitals with private hospitals rated by at least respondents, as many as 13.8% of respondents were instructional leadership styles (s1 style) where this style had the characteristics of high directing behavior and low supportive behavior. leaders in this style provide specific instructions about the role and goals of the leader, explaining what, how, when and where work must be done by subordinates through one-way communication so that the role of subordinates is very minimal and leaders conduct strict supervision and solve problems and make their own decisions . this style is needed for subordinates who have low ability and high commitment. this leadership style is not appropriate to be applied in a hospital room because it does not encourage and involve implementing nurses in thinking of new ideas and ideas in carrying out tasks according to the journalist, audra febriandini nugroho, that to create effective leadership, there are three ways, namely (1) modeling, which means that the example of the principal is modeled or modeled by the teacher in the school he dreams of (2) monitoring means monitoring the performance of the teacher to the classroom when the teacher carries out the learning process in the classroom and utilizes the results of the monitoring for further coaching (3) professional dialogue and discussion means that it means actively discussing the effective aspirational of democratic and scientific productive inspiration about performance results and follow-up plans to improve the quality of the process and student learning outcomes. from the two data above, the researcher analyzes that in order for the leadership style of this instruction to be applied appropriately, a modeling monitoring and professional dialogue discussion must be carried out so that the implementing nurse still feels involved in decision making and problem solving. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.286-290 290 conclusion the leadership style of head nurse in the majority government hospitals is delegate (38.5%) and followed by the leadership style of consultation (38.5%), participation (18.5%) and at least instruction (13.8%). the leadership style of head nurses in private hospitals is also almost the same as government hospitals where the majority of implementing nurses rate the room head in the delegate style (48%), which is followed by the leadership style of consultation (23%), participation (20%) and most the least is the leadership style of instruction (9%). with the results of the dominant leadership style among the delegates, consultations, and participation styles this is appropriate. to carry out the leadership style of instruction, modeling should be done, which means that the example of the principal is modeled or modeled by the teacher in the school whose dreams are monitored, means monitoring the performance of the teacher to the class while the teacher is carrying out the learning process in the classroom and utilizing the results of the monitoring for more coaching continued professional dialogue and discussion. references blancard, h. a. (1993). manajemen of organisation behaviour: utilizing human resources. new jersey: prentice-hall international, inc. blanchard, k. (1985). lba ii, leader behavior analysis ii, self perpection of leadership style. blanchard training and development. blanchard, k. (2007). leading at a higer level. alih bahasa. jakarta: media komputindo. c.j., h. (1998). magement decision making for nurses. edisi 3 . philadelphia: lippincott. gibson. (1996). organisasi, perilaku, struktur, proses. jakarta: binarupa aksara. i., d. k. (2010). rencana pembangunan kesehatan menuju indonesia sehat. jakarta: departemen kesehata r. i. munijaya. (2004). manajemen kesehatan. jakarta: egc. notoatmojo. (2010). metodologi penelitian kesehatan. rineka cipta. nursalam. (2007). manajaemen keperawatan : aplikasi dalam peraktik keperawatan propesional. jakarta: salemba medika. nursalam. (2012). manajemen keperawatan : aplikasi dalam praktik keperawatan profesionaledisi ketiga. jakarta: salemba medika. nursalam. 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(2013). leadership. 29-38. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.42-50 the effect of mind-body-spirit therapy on mood score in patients with chronic renal failure with hemodialysis errick endra cita, dian miftahul mizan 1 1 sekolah tinggi ilmukesehatanmadani, yogyakarta, indonesia corresponding author : endracitta@gmail.com abstract background: the number of new chronic renal failure patients with hemodialysis therapy continues to increase from year to year in indonesia. when people learn they need to begin dialysis, they typically experience a flurry of emotions. the stress is caused by chronic illness accounts for a wide range of feelings and moods. this includes general irritability, anger and frustration over the problems caused by the illness, and feelings of being hopeless and helpless when faced with a life-threatening disease. mind-body-spirit therapy (concepts of islam) focuses on the ability to manage the mindset and psychic that will affect the physical, attitudes and behavior of individuals in addressing their lives. purpose : giving mind-body-spirit therapy to hemodialysis patients to improve quality of life, given for 4 weeks with the frequency twice a week. methods : pre-experimental study with one group pre-test post-test. the sample of 23 patients with hemodialysis therapy taken by purposive sampling. the faces test is a visual analog scale representation of mood was used in this study. early screening on mood was taken in 23 patients (13 men and 10 women, mean age 51.5 years). mind-bodyspirit therapy (islamic concept) consisted of tausiyah (cognitive reconstruction), prayer, dhikr and drinking zam-zam water. the mood score was evaluated at week 4 after 4 weeks of treatments. wilcoxon test results, obtained a significance value of 0,000 (p <0,05). this suggests "there are significant differences in mood conditions before and after the mind body spirit therapy intervention (islamic concept). result : after the treatments, there is an increase in the mood score of hemodialysis patients. conclusion : a mind-body-spirit therapy of 4 weeks is effective for improving the mood of patients with chronic renal failure with hemodialysis therapy. keywords : mind body spirit (islamic concepts), hemodialysis, mood received july, 25, 2018; revised august 24, 2018; accepted september 14, 2018 how to cite: cita, e., mizan, d. (2018). the effect of mind-body-spirit therapy on mood score in patients with chronic renal failure with hemodialysis. journal of nursing practice, 2(1), 42-50. https://doi.org/10.30994/jnp.v2i1.42 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v2i1.42 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.42-50 43 background the number of new chronic renal failure patients with hemodialysis therapy continues to increase from year to year in indonesia. the number of new patients by 2015 is 21050 patients and the number of active patients is 30554 from 249 units of hemodialysis. most of them is patients with end state renal deases (esrd) 89% and followed by patients with acute renal failure (arf) 7%. in 2015 there were 1243 patients who died with a long-life hemodialysis between 1 317 months(indonesian renal registry, 2015). dialysis requires significant time and effort. in addition to the considerable time spent traveling to and from appointments and receiving treatment itself, people receiving dialysis must carefully monitor their diet and fluid intake. it‘s a lot of work, and it takes time to adapt to the changes. when people learn they need to begin dialysis, they typically experience a flurry of emotions. often, the first reaction is shock or denial. people may feel numb or fail to accept the reality of the situation. anger, sadness, worry, and guilt are also common. people may dwell on the past, wondering what they could have done differently (american psychological association (apa). chen (2010) found the fact that from 200 patients with hemodialysis, 35% had depression, 21% had anxiety, and 21.5%with the idea of suicide.(chen, et.al., 2010). moodiness is common among kidney patients. it is often thought to be a result of the following factors:1) uremia, or the buildup of waste products in the blood, can be irritating to the nervous system, causing an increase in irritability mostly in the early stages, 2) some medications may cause moodiness or make you seem depressed, 3) the stress caused by chronic illness accounts for a wide range of feelings and moods. this includes general irritability, anger and frustration over the problems caused by the illness, and feelings of being hopeless and helpless when faced with a life-threatening disease(national kidney foundation, 2015). the national center for complementary/alternative medicine (nccam) uses mind-body-spirit therapy as the alternative complementary therapy. however, from a holistic perspective, spirit is included, as this aspect of human being is an integral part of a number of the therapies, such as prayer, meditation, and yoga. nccam defines this category as encompassing therapies that promote the mind‘s capacity to have an impact on the functioning of the body. in keeping with the perspective of the inclusion of the spirit, this would also encompass the impact that the spirit can be a physical parameters (snyder, 2010). mind-body-spirit therapy (islamic concept) is a religious and spiritual methods based onislamicconceptual approach by having a prayer to (allah ta'la), opening hearts and communicating with allah with an islamic approach to self-healing, establishing a relationship with the creator to strengthen the heart and lean and trust in allah. the patients seek refuge, be humble and show tenderness and pray to allah to get healing done by understanding the aspects of wisdom (tausiah), prayer, dzikr and drinking zam-zam water (cita, 2016). objective this study aims to giving mind-body-spirit therapy to hemodialysis patients to improve quality of life, given for 4 weeks with the frequency twice a week. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.42-50 44 methods patients and study design the population of this study were chronic renal failure patients underwent hemodialysis therapy at the dialysis unit of an hospital in yogyakarta indonesia. sample if this study were 23 patients selected using purposive sampling techniques. the criteria of patients in this study are 1) getting treatment according to hospital standards, 2) can communicate with others, 3) have good hearing, 4) islam, 5) get hemodialysis therapy twice a week, 6) at least 18 years old . the design of this study is pre-experimental design using one group pre-test and post test design. interventions were given for one month, each patient received mind-bodyspirit (islamic concept) therapy twice a week during the process of hemodialysis therapy. data instruments consisted of socio-demographic data and faces test (a visual analog scale representation of mood). the faces test is used to collect the data. the mood of patients is evaluated twice. the faces test instrument is given before intervention of mind-body-spirit and re-evaluated in the 4th week after the intervention of mind-body-spirit therapy. mood refers to the internal emotional state of an individual, as i feel happy, i am angry, i feel sad. this is related to emotions and has the same meaning as the state of feeling or emotion (yosep, 2007). the faces test is a visual analog scale representation of mood, consisting of seven graded faces, 1 being ―happiest mood‖ and 7 being ―saddest mood‖. the seven different faces, separately for men and women, were drawn by an indian artist. the final version of the faces test was the result of an iterative process in which each face and the sequence of faces were evaluated by male and female community key informants in goa. the interviewer showed the card with the faces test (fig. 1) and asked the subject to select the face which most closely described the way he or she had felt emotionally ―these days‖ (puertas, 2004). fig. 1 the faces test journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.42-50 45 study protocol mind-body-spirit therapy (islamic concept) in this research defined as a religious and spiritual methods based onislamic conceptual approach by having a prayer to (allah ta'la), opening hearts and communicating with allah with an islamic approach to selfhealing, establishing a relationship with the creator to strengthen the heart and lean and trust in allah. mind-body-spirit therapy (islamic concept) consisted of tausiyah (cognitive reconstruction), prayer, dhikr and drinking zam-zam water, provided for 4 weeks with a frequency of twice a week. quality of life scores were evaluated at week 4 after 4 weeks of therapy. 1. tausiyah this technique is designed to reduce negative thoughts and maladaptive behavior, focusing on the ability to manage mindset and psychics that will have an impact on the physical, attitudes and behavior of individuals in addressing their lives. patients are given information and understanding about how to respond to life and their sick condition based on the concept of islam. 2. pray and dhikr perform requests to the highest substance (allah ta'la) by opening hearts and communicating with allah with an islamic approach for self-healing, and establish a relationship with the creator aiming to strengthen the heart, lean and trust god, seek refuge, be humble and show gentleness of heart before him, pleading with him, and praying to god for healing. 3. drink zam-zam water patients started the therapy with a prayer to god (allah ta‘ala). patients can pray with any other prayer that they want. at the end of each therapy, patients drank 50 ml of zamzam water. this systematic and structured mind-body-spirit therapy (islamic concept) is explained in a special handbook (one for patients and one for therapists) and adapted for patients with chronic kidney failure. the handbook is based on a model previously tested in patients with chronic renal failure with hemodialysis (cita, 2016). statistical analysis the data in this study are illustrated by showing the number of subjects, the median of each group, the minimum and maximum of each group and the p-value. the mean and standard deviation values are reported to provide additional information about the characteristics of data distribution, even though the results are not normal. analysis test in this study used wilcoxon test analysis results the sample of this study were patients with chronic renal failure underwent hemodialysis therapy twice a week with a minimum three-months of hemodialysis therapy and minimum age of 18 years old. the characteristics of respondents in this study can be seen in table 1. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.42-50 46 table 1 sociodemography of total population (patients with chronic kidney failure with hemodialysis) characteristics total populasi n = 23 persentase (%) gender male 13 56.52 female 10 43.48 age average (years) 51.5 minimum-maximum (years) (25-67) marital status married 22 95.65 single 1 4.35 education elementary school 4 17.39 middle school 2 8.70 high school 13 56.52 postgraduate 4 17.39 occupation government employee 7 30.43 private employee 6 26.09 entrepreneur 5 21.74 housewife 5 21.74 hemodialysis period 3 month-12 month 9 39.13 1-5 year 14 60.87 table 2 overview of mood score changes before and after mind body spirit therapy (islamic concepts) in patients with chronic kidney failure with hemodialysis mood score after mind body spirit therapy (mbs) n percentage (%) decrease 0 0 steady 7 30.43 increased 16 69.57 23 100 table 3 results of wilcoxon test analysis on the mood of patients with chronic renal failure before and after given mind body spirit therapy (islamic concept) n median (minimummaximum) mean sd ρ mood before mbs therapy 23 3(1-4) 2.9 1.06 0.000 mood after mbs therapy 23 1(1-4) 1.9 1.16 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.42-50 47 socio-demographic data from table 1 shows that in this study the average patient‘s age was 51 years old and 95.6% were married. the majority of patients underwent hemodialysis for more than one year at 60.87% with a frequency of twice a week. table 2 shows that there were changes in mood-score of 23 hemodialysis patients after the intervention of 4 weeks mind-body-spirit (concept of islam) therapy with frequency of 2 times a week ; 69.7% of patients experiencing an increase in mood-score and no changes of mood-score in 30.43% patients. faces test is used to measure the mood of patients. score of 1 is a very pleasant mood condition and a score of 7 reflects very sad mood conditions. table 3 shows that there is an increase in mood conditions in patients after the intervention of mind-bodyspirit (islamic concept) therapy with the average score 2.9 (before the intervention) and 1.7 (after the intervention). the minimum and maximum scores were not changed (the minimum score was 1 and the maximum score was 4). but there was a change in the median value. before the therapy, the median value is 3, and after the therapy, the median value is 1. wilcoxon test results obtained a significance value of 0,000 (p <0,05). it suggests "there are significant differences in mood conditions before the and after the intervention of mind-body-spirit (islamic concept) therapy discussion this study (table 3) shows there is an effect of mind-body-spirit therapy (islamic concept) on mood-score before and after the therapy. mind-body-spirit therapy (islamic concept) is a religious and spiritual methods based onislamic conceptual approach by understanding the aspects of wisdom (tausiah) and given information and understanding about how to respond to life and their sick condition based, prayer, dzikr and drinking zam-zam water on the concept of islam. the key components of spirituality were ‗meaning‘, ‗hope‘, ‗relatedness/connectedness‘, and ‗beliefs/ beliefs systems‘. spirituality has been characterized as the quest for meaning in life, mainly through experiences and expressions of mind, in a unique and dynamic process different for each individual. for many individuals spirituality and religion are important aspects of their existence, constituting a source support contribute to wellbeing and coping with life‘s daily difficulties (fradelos et.al, 2015). prayer will lead to self-confidence, a sense of optimism, bring calm, peace and feel the presence of god almighty so that by remembering, one's faith will increase and there will be a sense of peace, peace in the soul (hawari, 2011). if someone does not open his heart to pray and dhikr, then his heart is always hesitant, the feeling is miserable, his mind is frantic, always restless, his desires become weak (jawas, 2005). when faced with a severe illness, believing the afterlife and that allah is merciful will decrease fear from nothingness (yucel, 2010). spirituality can have an impact on one's coping style that focuses on control of perception (cornah, 2006). there were an increase 69.7% dan steady (30.43%) of mood-score after the therapy. mind-body-spirit (islamic concept) therapy is a spiritual and religious method for patients in addressing a problem, and the illness they experienced. this therapy directs the attitude, gratitude and prohibition of being hopeless about the pain they experienced. in islam, all conditions, happiness and sadness are considered good in the presence of allah ta'ala if we embrace these conditions, being patient and not despairing. this therapy also provides an understanding that the purpose of someone‘s life that will come after death is being in the paradise, so the conditions experienced now in this world is a path for the journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.42-50 48 heaven if we react patiently, thankfully and pleased with the provisions that god gives us. and this will have a good impact that people will have a peace of mind and free from stressful conditions. patients with a lower mood have worse activities of daily living (adl) and qualityof-life (qol) than patients with better mood. patients with a lower mood have got less social support than patients with better mood, including both family support and outside family support. for coping style, patients with a lower mood were more inclined to choose ―acceptance-resignation‖ coping style than patients with better mood, while the result is opposite in ―avoidance‖ coping style. and patients with a better mood have better selfefficacy and ego resiliency than patients with lower mood (xiaodan, 2017). the research conducted by yodchai suggests that religion and spirituality provide powerful coping strategies that can help thai people with ckd overcome the associated distress and difficulties (yodchai, 2017). trusting in god helps them not to become anxious about their illness and what the future may hold. the frequent need to adapt to the changes esrd causes can create a drain on one‘s emotional, physical, and psychological strength, the participants found the use of prayer to be both supportive and strengthening. prayer was the method most used by study participants to assist them in making the necessary modifications in and throughout the lived experience of the illness (darrell, 2016). during illness, patients may be confronted by hopelessness. nevertheless, in islamic creed, god is regarded as the best companion and hope in times of adversity, misfortune and fear for god sees us and looks after us and does not allow the activities of the servants to be in futility; and he is kind and generous towards them (quran 14:49). hopelessness can lead to mental break down. according to the quran, desperation for the mercy of god is considered paganism and a deadly sin (quran, 12:87). it is quoted by the holy prophet muhammad, peace be upon him, that ―whenever you are ill, he heartens you to health and long life. however, this heartening does not affect the will of god (allah); it delights the patient and bring him calmness and relief‖. marzband (2016) reviewed quran and shie‘h‘s narrations (hadiths), and found the concept of spiritual care. the research suggested that spiritual care involves spiritual capacities or skills to help patients in achieving purified life (hayate-tayebeh). this includes providing prayer conditions for patients, giving hope to the patients, helping them to understand the concept of illness, finding hope, nurturing relationships, and caring for patients in end-of-life experiences. spiritual well-being was the strongest predictor of mental health, psychological distress, sleep disturbance, and psychosomatic complaints. poor mental health was associated with lower spiritual well-being (martínez, b, &custódio, r 2014). ebrahimi h, et al. (2014) found a significant relationship between some aspects of quality of life and spiritual well-being. there was a significant positive correlation between spiritual existential aspect of well-being and the dimensions of fatigue, emotional health, social functioning and general health and social performance. limitation the limitations of this study were non-random sampling, sample loss due to the fact that some participants lacked inclusion criteria for the study (high or low age and inability to communicate the response to the questionnaire), and also some patients being unwilling to participate in the study, which all may reduce the generalizability of the results. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.42-50 49 conclusions our results provide further evidence and suggest that mind-body-spirit (islamic concept) therapy is religious and spiritual methods associated with quality of life among hd patients. these findings have clinical implications for the health-care team to improve patient‘s quality of life by encouraging patients to utilize spiritual and religious resources and incorporating psycho-spiritual interventions to minimize religious struggles among hd patients. acknowledgements thanks to the ministry of research, technology, and higher education republic of indonesia for the support for this research (ristekdikti). references american psychological association (apa), living well on dialysis take charge of your emotions, dpc education center, https://www.apa.org/helpcenter/dialysis.pdf chen, c.k., tsai, y.c., hsu, h.j., wu, i.w., sun, c.y., chou, c.c., et al. (2010). depression and suicide risk in hemodialysis patients with chronic renal failure. psychosomatics, 51, 528-528 e526 cita, e.c., wulandari t &istanti yp, (2016). terapi islamic self healing terhadap quality of life pada klien gagal ginjal kronis dengan terapi hemodialisa. muhammadiyah journal of nursing, 43-57 cornah deborah, 2006 the impact of spirituality on mental health a review of the literature mentahl health foundation isbn: 978-1-903645-85-7 www.mentalhealth.org.uk darrell, l 2016, faith that god cares: the experience of spirituality with african american hemodialysis patients, social work & christianity, 43, 2, pp. 189-212, academic search complete, ebscohost, viewed 2 september 2018. ebrahimi, h, ashrafi z, eslampanah g 3 , noruzpur, f 2014 ‗relationship between spiritual well-being and quality of life in hemodialysis patients‘, journal of nursing and midwifery sciences 2014: 1(3): 41-48 fradelos, e, c., tzavella f, koukia e, papathanasiou i v., alikari v, stathoulis j, panoutsopoulos g , zyga s, 2015, ‗ integrating chronic kidney disease patient‘s spirituality in their care: health benefits and research perspectives‘, mater sociomed. 2015 oct; 27(5): 354-358 https://www.ejmanager.com/mnstemps/16/161444047827.pdf hawari, d. (2011). menejemen stress, cemas dan depresi. jakarta : balai penerbit fakultas kedokteran ui. indonesian renal registry, 2015, 9 th report of indonesian renal registry program indonesian renal registry https://www.indonesianrenalregistry.org/data/indonesian%20renal%20regis try%202015.pdf http://www.mentalhealth.org.uk/ https://www.ejmanager.com/mnstemps/16/16-1444047827.pdf https://www.ejmanager.com/mnstemps/16/16-1444047827.pdf journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.42-50 50 jawas, yasid bin abdul qadir, 2005 ‗do‘a&wirid :mengobati guna-guna dan sihir menurut al-quran dan as-sunnah‘ / yazid bin abdul qadir jawas.—jakarta : pustaka imam asy-syafi‘i martínez, b, &custódio, r 2014, 'relationship between mental health and spiritual wellbeing among hemodialysis patients: a correlation study', sao paulo medical journal = revistapaulista de medicina, 132, 1, pp. 23-27, medline with full text, ebscohost, viewed 16 august 2018. marzband,r, hosseini,sm, 2 &hamzehgardeshi, z, 2016 ‗a concept analysis of spiritual care based on islamic sources‘ religions 2016, 7, 61; doi:10.3390/rel7060061 http://www.mdpi.com/journal/religions national kidney foundation, 2015, ‗a to z health guide coping effectively: a guide for patients and their families, https://www.kidney.org/atoz/coping-effectivelyguide-patients-and-their-families puertas, g, patel,v, marshall, t, 2004 are visual measures of mood superior to questionnaire measures in non-western settings? soc psychiatry psychiatr epidemiol 39 : 662–666 snyder mariah, lindquist ruth, 2010 complementary& alternativetherapies in nursing sixth edition springer ublishing company, llc 11 west 42nd street new york, ny 10036 www.springerpub.com e-book isbn: 978-0-8261-2429-6 sunaryo, s. (2018). the influence of therapy do‘a in islam to the cooperative clients skizofrenia cooperative water pathway in public health center karanganyar, gandusari trenggalek, east java. journal of nursing practice, 1(2), 1-6. https://doi.org/10.30994/jnp.v1i2.24 united states renal data system , 2017 usrds annual data report: epidemiology of kidney disease in the united states. national institutes of health, national institute of diabetes and digestive and kidney diseases, bethesda, md, 2017. https://www.usrds.org/2017/view/v1_01.aspx) xiaodan, l, xiaoshi, y, li, y, quan, z, da, s, xinwang, z, tianhua, x, qiang, l, & lining, w 2017, 'prevalence and related factors of depressive symptoms in hemodialysis patients in northern china', bmc psychiatry, 17, pp. 1-7, academic search complete, ebscohost, viewed 2 september 2018. yodchai, k, dunning, t, savage, s, & hutchinson, a 2017, 'the role of religion and spirituality in coping with kidney disease and haemodialysis in thailand', scandinavian journal of caring sciences, 31, 2, pp. 359-367, academic search complete, ebscohost, viewed 2 september 2018. yosep i, 2007 keperawatan jiwa, refika aditama bandung yucel salih (2010) prayer and healing in islam with addendum of 25 remedies for the sick by said nursi, tughra books 345 clifton ave., clifton, nj, 07011, usa http://www.mdpi.com/journal/religions https://www.kidney.org/atoz https://www.kidney.org/atoz/coping-effectively-guide-patients-and-their-families https://www.kidney.org/atoz/coping-effectively-guide-patients-and-their-families https://doi.org/10.30994/jnp.v1i2.24 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.1-7 1 self efficacy of mother working in giving mother milk water with baby growth monika sawitri prihatini, ririn probowati, mamik ratnawati stikes pemkab jombang, east java, indonesia corresponding author: monika.sawitri@yahoo.co.id abstract background: the paradigm change that there is no difference between men and women demands equal rights between women and men. many mothers work as career women, so many women replace breastfeeding with formula milk. based on indonesian government regulations no. 33 of 2012, a mother is obliged to give exclusive breastfeeding to her baby. purpose: this study aimed to determine the relationship between self-efficacy of working mothers in breastfeeding and infant growth. method: the type of correlational analytic research is a cross-sectional approach. the population and sample of working mothers who have babies aged 0-6 months on may 9 to june 6, 2018, at pt mufasufu sejati jaya lestari mps ploso are 30 respondents with a total sampling technique. independent variable self efficacy for working mothers in breastfeeding, the dependent variable for infant growth. the growth instrument uses a standard table of body weight/body length from the ministry of health and a self efficacy questionnaire for mothers to provide breastfeeding. data analysis using chisquare. resultsthe results of the chi-square test analysis at the significance level of α = 0.05 found that ρ <α or 0.048 <0.05, there is a relationship between self-efficacy of mothers working in breastfeeding and growth in infants. conclusion: the head of the agency/company must provide nursing mothers with exclusive breastfeeding by providing a lactation corner so that the mother can milk the milk and store it in the freezer in the refrigerator and take it home to give to the baby while the mother is working so that the baby continues to get milk without formula milk. keywords: maternal self efficacy, breastfeeding, baby growth received july, 25, 2019; revised august 24, 2019; accepted september 13, 2019 how to cite: prihatini, m. s., probowati, r., ratnawati, m. (2019). self efficacy of mother working in giving mother milk water with baby growth. journal of nursing practice, 3(1), 1-7. https://doi.org/10.30994/jnp.v3i1.74 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v3i1.59 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.1-7 2 background the rights of mothers as workers are regulated in law no. 13 of 2003 concerning employment, namely: obtaining resting leave for 1.5 months before and 1.5 months after childbirth (article 82) and female workers whose children are still breastfeeding should be given the opportunity to breastfeed their child if it must be done during work time ( article 83) (nurjanah, 2008). policies that apply in companies often do not support women's rights, with shortened maternity leave and no opportunity for female workers to breastfeed their children during working hours. working mothers can only accompany their babies intensively for 2 (two) months, after which the mother must return to work, and often the mother is forced to stop breastfeeding. table 1. percentage of breastfeeding coverage in jombang regency year percentage 2010 53,4% 2011 79,4% 2012 71,87% 2015 83,3% 2016 81,7% source: district health office jombang mother's milk is the best natural nutrition for babies because it contains energy and substance needs needed during the first six months of a baby's life. the level of breastfeeding can be influenced by several factors. one of them is due to the factor of working mothers. many mothers work as career women. indonesia is a country that absorbs much labor from mothers as well as a country with a very low number of mothers who provide breast milk (prasetyono, 2009). factors that hinder the success of breastfeeding in working mothers are short time off work, lack of workplace support, short break time at work so that the time to milk mother's milk is not enough, there is no room for milking mother's milk, the mother's contradiction between maintaining work performance and production of mother's milk i (idai, 2010). the role of the mother working in the administration of mother's milk i is very determined by the mother's self-efficacy self efficacy is someone's belief about their ability to regulate and decide on certain actions needed to obtain certain results. in general, self-efficacy is a person's assessment of himself or the level of confidence regarding how much his ability to do a particular task (bandura, 1997). people who have low self-efficacy always consider themselves unable to handle any situation while those who have high self-efficacy tend to show more effort than others with low selfefficacy in breastfeeding. child development is influenced by internal and external factors. one of the postnatal factors is nutrition. nutritional elements become the dominant influence in the growth of children, especially at the beginning of life until the age of 12 months. the nutrients needed by babies can be fulfilled by giving mother's milk. mother's milk is the optimal choice as feeding in infants because of the nutritional, hormone, immune factors, growth factors, and anti-inflammatory factors (fitri et al., 2014). health promotion from health workers is expected to improve a person's selfefficacy in the form of verbal persuasion to provide breast milk appropriately and correctly. it is not only the skills that a mother has but the decisions that someone takes journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.1-7 3 are the mother of the skills she has. through this positive attitude, it will eventually be manifested in the form of real behavior in the effort to provide breast milk. the concept of thinking is in line with the formation of behavior preceded by attitudes, while attitudes in precedence of knowledge (hidajaturrokhmah, 2016). objective this study aimed to determine the relationship between self-efficacy of working mothers in breastfeeding and infant growth. methods the type of research used is a correlational analytic cross-sectional approach. the population and sample of the study were all mothers who worked at pt mufasufu sejati jaya lestari mps ploso who had babies aged 0-6 months and breastfed as many as 30 people. the sampling technique used is non-probability sampling with the total sampling method. the independent variable in this study is the mother's self efficacy in breastfeeding. the dependent variable in this study is infant growth. the instrument used was the standard bodyweight/length table from the ministry of health in 2016 and a questionnaire for the mother's self efficacy in providing mother's milk. analysis of bivariate data was carried out on two variables performed by chi-square testing. the participants were assured that their engagement was voluntary, and that anonymity, privacy, and confidentiality of the data were guaranteed. furthermore, they were informed about the purpose and the method of the study before signing a written informed consent. the questionnaires were distributed to eligible participants at the pt mufasufu sejati jaya lestari mps ploso, and respondents were asked to complete and return them in the same time. result a. univariate result table 2. distribution of self-efficacy frequencies from working mothers in breastfeeding). self efficacy f percentage (%) high 12 40 medium 14 46,7 low 4 13,3 total 30 100 based on the table it is known that almost half (46.7%) working mothers have moderate self-efficacy in breastfeeding infants aged 0-6 months. table 3. baby growth frequency distribution based on nutritional status bb/pb f (%) obesity 7 23,3 over weight 13 43,3 normal 10 33,4 total 30 100 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.1-7 4 based on the table, it can be seen that the growth of infants based on nutritional status is almost over weight (43.3%), almost half are 33.4% normal and 23.3% are obesity. b. bivariate result table 4. cross tabulation between mother's self efficacy and baby's growth self efficacy mother growth (nutritional status) obesity overwei ght normal total f % f % f % f % low 1 3,3 1 3,3 2 6,7 4 100 medium 0 0 8 26,7 6 20 14 100 high 6 20 4 13,3 2 6,7 12 100 total 7 23,3 13 43,3 10 33,4 30 100 based on the table shows that working mothers who have moderate self-efficacy in breastfeeding have babies with growth with nutritional status in the category of over wight as much as 26.7% table 5. cross-tabulation between self-efficacy of mothers working in breastfeeding with breastfeeding self efficacy mother giving breast milk exclusive breastfeeding nonexclusive breastfeeding total f % f % f % low 0 0 4 13,3 4 100 medium 5 16,7 9 30 14 100 high 6 20 6 20 12 100 total 11 36,7 19 63,3 30 100 based on the table above shows that mothers who have self-efficacy are giving nonexclusive breastfeeding to their babies as much as 30%. based on the analysis using chi-square test at significance level α = 0.05, it was found that ρ <α or 0.048 <0.05, h1 was accepted and h0 was rejected which means there is a self efficacy relationship between working mothers in breastfeeding and growth in infants 0-6 months at pt mufasufu sejati jaya lestari mps plosobased on the analysis using chi-square test at significance level α = 0.05, it was found that ρ <α or 0.048 <0.05, h1 was accepted and h0 was rejected which means there is a self efficacy relationship between working mothers in breastfeeding and growth in infants 0-6 months at pt mufasufu sejati jaya lestari mps ploso. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.1-7 5 discussion based on the above results show that working mothers who have moderate selfefficacy in breastfeeding have babies with growth with a over weight category as much as 26.7%. based on research conducted at the nanggolo community health center in 2014, it was found that infants who were given exclusive breastfeeding would experience normal growth of 1.62 times greater than non-exclusive breastfed babies (fitri et al., 2014). research carried out at the manado manado puskesmas in 2016 found that more weight babies who received exclusive breastfeeding were lighter than infants who received formula milk until the age of 6 months. exclusive breastfeeding is the right choice that can control the baby's nutritional needs so that the baby's weight tends not to be obese (lutur et al., 2016). in the opinion of mothers, researchers who have moderate self-efficacy towards breastfeeding give their babies with non-exclusive breastfeeding. mothers continue to give breast milk but mixed with formula so that the baby's weight tends to be over weight. mothers give formula milk while working while breast milk is given when the mother is at home. this statement is proven in table 8. based on this table, it shows that mothers who have self-efficacy are giving non-exclusive breastfeeding to their babies as much as 30%. based on the analysis using chi-square test at significance level α = 0.05, it was found that ρ <α or 0.048 <0.05, h1 was accepted and h0 was rejected which means there is a self efficacy relationship between working mothers in breastfeeding and growth in infants 0-6 months at pt mufasufu sejati jaya lestari mps ploso. not only research in indonesia, but a study in baltimore washington also found that infants who were given exclusive breastfeeding were of normal weight and were not obese compared to infants who received non-exclusive breast milk (fitri et al., 2018). bandura's theory of health promotion model consists of components, among others, expectancy value theory, and interaction model theory, which includes the environment, human, and behaviors that influence each other. this theory emphasizes self-direction (self-direction), self-regulation (self-regulation), perception of selfprogress (self-efficacy). this theory suggests that humans have basic abilities, among others, symbolizing namely the process and transformation of experience as a guide for future actions, future thoughts, anticipating events that will emerge and planning actions to achieve quality goals, students from other people's experiences (probowati, 2016) based on table 7 shows that working mothers who have moderate self-efficacy in breastfeeding have babies with growth with a over weight category as much as 26.7%. based on research conducted at the nanggolo community health center in 2014, it was found that infants who were given exclusive breastfeeding would experience normal growth of 1.62 times greater than non-exclusive breastfed babies (fitri et al., 2014). research carried out at the manado manado puskesmas in 2016 found that more weight babies who received exclusive breastfeeding were lighter than infants who received formula milk until the age of 6 months. exclusive breastfeeding is the right choice that can control the baby's nutritional needs so that the baby's weight tends not to be obese (lutur et al., 2016). in the opinion of mothers, researchers who have moderate self-efficacy towards breastfeeding give their babies with non-exclusive breastfeeding. mothers continue to give breast milk but mixed with formula so that the baby's weight tends to be over weight. mothers give formula milk while working while breast milk is given when the mother is at home. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.1-7 6 this statement is proven in table 8. based on this table, it shows that mothers who have self-efficacy are giving non-exclusive breastfeeding to their babies as much as 30%. based on the analysis using chi-square test at significance level α = 0.05, it was found that ρ <α or 0.048 <0.05, h1 was accepted and h0 was rejected which means there is a self efficacy relationship between working mothers in breastfeeding and growth in infants 0-6 months at pt mufasufu sejati jaya lestari mps ploso. not only research in indonesia, but a study in baltimore washington also found that infants who were given exclusive breastfeeding were of normal weight and were not obese compared to infants who received non-exclusive breast milk (fitri et al., 2018). bandura's theory of health promotion model consists of components, among others, expectancy value theory, and interaction model theory, which includes the environment, human, and behaviors that influence each other. this theory emphasizes self-direction (self-direction), self-regulation (self-regulation), perception of selfprogress (self-efficacy). this theory suggests that humans have basic abilities, among others, symbolizing namely the process and transformation of experience as a guide for future actions, future thoughts, anticipating events that will emerge and planning actions to achieve quality goals, students from other people's experiences (probowati, 2016) conclusion there is a relationship between self-efficacy of working mothers in breastfeeding and infant growth. working mothers who have moderate self-efficacy tend to give non-exclusive breastfeeding to infants aged 0-6 months. when mothers at home, babies get breast milk, but when working mothers babies are given formula milk so that babies have growth with nutritional status in the over weight category. references: bandura, a. 1997. self efficacy: the exercise of control. new york. w. h. freeman baron & byrne. 2003. psikologi sosial. jilid 1 edisi kesepuluh. jakarta: erlangga fitri insana dian, dkk. 2014. hubungan pemberian asi dengan tumbuh kembang bayi umur 6 bulan di puskesmas nanggolo. jurnal kesehatan andalus. 3(2) hambawany, e. 2007. hubungan antara self efficacy dan persepsi anak terhadap perhatian orangtua dengan prestasi belajar pada penyandang tuna daksa. skripsi (tidak diterbitkan). fakultas psikologi: universitas muhammadiyah surakarta. hidajaturrokhmah, n., & saputro, h. (2016). pertumbuhan berat badan bayi usia 6 bulan ditinjau dari jenis nutrisi. strada jurnal ilmiah kesehatan, 5(1), 38-45. retrieved from http://strada.ac.id/sjik/index.php/sjik/article/view/102 idai. 2010. indonesia menyusui. jakarta: badan penerbit idai http://strada.ac.id/sjik/index.php/sjik/article/view/102 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.1-7 7 nurjanah.2008. implementasi pasal undang-undang no 13 tahun 2003 tentang hak menyusui pekerja perempuan selama bekerja. jurnal promosi kesehatan indonesia, 3(1). prasetyono. 2009. buku pintar asi eksklusif, pengenalan praktik dan kemanfaatannya. jogjakarta: diva press probowati, ririn. 2016. model keperawatan role attainment ibu bekerja dengan pendekatan self efficacy dalam kompetensi stimulasi pertumbuhan dan perkembangan bayi. surabaya : desertasi soetjiningsih. 2014. tumbuh kembang anak. jakarta: egc yuliarti, nurheti. 2010. keajaiban asi : makanan terbaik untuk kesehatan, kecerdasan dan kelincahan si kecil. yogyakarta journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.72-78 72 the benefits of dates ruthab on blood volume on labor stage 4th agus purnama, mua melawati stikes indonesia maju, jakarta, indonesia corresponding author: purnama.aguz@gmail.com abstract background: birth is a natural process and is a physiological condition in a woman. there are 4 stage/times in labor which are 1st time, 2nd time, 3rd time and 4th time. the effort used to facilitate labor is to make contractions and relaxation effective. dates contain tannins which can shorten bleeding time and high glucose as a good source of energy during labor. purpose: the purpose of this study is to see at the amount of bleeding in the group not given dates and given date ruthab. method: this study using a quasi-experimental method in two different groups with 34 people treated with primigravida with 17 control groups and 17 intervention groups. given treatment for 4 weeks before the estimated delivery and check the blood volume with a measuring cup. result: the results showed a significance value of the results of the t-test, namely: 0,000 for the 4th stage, the value was smaller than the significance level (α) of 0.05, meaning ho was rejected, so it could be decided the hypothesis of the effect of giving wet dates to decreasing blood volume in stage 4th labor can be accepted. conclusion: dates ruthab can be used as supporting therapy in the labor process and has very convincing benefits. keywords: dates ruthab, blood volume, labor stage 4th received july, 29, 2019; revised august 30, 2019; accepted september 22, 2019 how to cite: purnama, a., & melawati, m. (2019). the benefits of dates ruthab on blood volume on labor stage 4th. journal of nursing practice, 3(1), 72-78. https://doi.org/10.30994/jnp.v3i1.67 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v3i1.67 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.72-78 73 background childbirth can be said to be a result of conception of the fetus and age at 37-40 weeks or enough months of pregnancy with spontaneous birth that lasts for 18 hours in mothers who have no labor complications (syaifuddin, 2007). there are four stages of labor, the first time starts from zero opening to complete opening (10 cm), second stage, starting from complete opening until the baby is born, stage iii (release of uri) or birth of the placenta, stage iv (observation), starting from at the birth of the placenta until the first 2 hours post partum. while the four components that influence it are passanger (fetus), passage (maternal pelvis), power (uterine contractions), and psychic (maternal emotional status). if labor begins the interaction of the four components must be interrelated so that spontaneous vaginal birth occurs. at first stage there are 2 phases, the latent phase and the active phase, the active phase of labor is a very heavy and tiring time for a mother, at this time the mother feels severe pain because of the more active uterine activity. in the active phase, strong and continuous contraction (power) is needed for the start of labor. if the uterine contractions weaken this can lead to prolonged labor (kumarawati, 2010). in the first period of labor there is often a delay in opening which is a threat to the life of the mother and baby. this is usually caused by pain, which if not handled quickly will cause the mother's breathing and heart rate to increase so that blood flow and oxygen to the placenta are disrupted. supervision in this phase is a determining point for the mother whether she can undergo a normal delivery or end with an action because of complications (hermawati, 2009). efforts to make mother's labor more effective are made by the occurrence of contractions and reduce the pain felt by the mother during labor, among others, by pharmacological actions and non-pharmacological actions. for pharmacological actions, among others, the use of analgesics, but all these actions have side effects on the mother and fetus. analgesics can enter the placenta and this can cause bad breathing in the fetus and the mother does not use her abdominal muscles when contracting causing long labor. for this reason, more non-pharmacological actions have been developed to reduce pain and stimulate contractions to accelerate labor. this method is considered to be able to create a relaxing effect on the mother who is giving birth by helping to reduce muscle and emotional tension so that it can reduce pain during labor. one of the other non-pharmacological therapies to stimulate the work of the hormone oxytocin to improve the quality of contractions to accelerate the process of labor, is to give dates, on dates containing the hormone oxytocin which can cause uterine contractions. the hormone oxytocin increases during labor. according to prof. dr. ir. ali khomson, ms, dates contain nutrients that are useful for the body. the glucose content is higher than other fruits which are only 20-30%. a high source of sugar is needed by mothers who are giving birth because mothers need a lot of energy. the content of tannin found in dates can also shorten bleeding time (rohrbach, 2009). data from the idhs (indonesian demographic and health survey), in 2012, the mmr (maternal mortality rate) in indonesian got the highest rank in the asean (association of southeast asian nations) which reached 359 per 100 thousand live births. efforts from the government in suppressing mmr are safe motherhood, which considers that every pregnant woman has a risk, even though the condition of maternal health during pregnancy is good. in 2012 the ministry of health launched a expanding maternal and neonatal survival (emas) program in order to reduce the maternal and neonatal mortality journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.72-78 74 rate by 25%. in addition, there is also an increase in comprehensive emergency obstetric and neonatal services in an effort to reduce maternal mortality (kemenkes, 2014). from some of the things mentioned above, the author took a date-giving method to see the effect on improving the quality of contractions in the smooth delivery process, which can reduce the incidence of prolonged labor which can reduce maternal and fetal mortality, while reducing the amount of bleeding postpartum delivery to the mother. objective this study aimed to see at the amount of bleeding in the group not given dates and given date ruthab methods the method in this study is using quasi experiment with a post-test only non equivalent control group design. population in this study are all primigravida mothers with 36 weeks gestational age in rsud x as many as 34 people. the sampling method in this study is the total sample so that the sample in this study amounted to 34 respondents who were divided into the control group and the intervention group. the inclusion criteria in this study are primigravida pregnant women at 36 weeks' gestation and aged between 20 years and 35 years, pregnant women with physiological pregnancy. the place of research was at x hospital with a research period of 4 weeks. the instrument in this study was an observation sheet in the form of a checklist to distinguish respondents who gave dates and those not given dates, then a measuring cup to measure the amount of bleeding of respondents. the process of collecting data in this study begins by providing concentrated information to each respondent by explaining the purpose and process of the research conducted. after the respondent agreed, then for 4 weeks the intervention group was given ruthab dates and monitored until the time of labor began from the first to the 4th time with the measured amount of bleeding from the two groups of research subjects. the participants were assured that their engagement was voluntary, and that anonymity, privacy, and confidentiality of the data were guaranteed. furthermore, they were informed about the purpose and the method of the study before signing a written informed consent. the questionnaires were distributed to eligible participants at the x hospital, and respondents were asked to complete and return them in the same time. results the results of research from univariate data consisting of age, education and employment status are listed in table 1 below table 1. characteristics of respondents variable count precentage age 12-17 years 34 100% 18-40 years 0 0% education no school 0 0% elementary school 0 0% middle school 0 0% high school 22 64,7% journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.72-78 75 college 12 35,3% work no work 23 67,6% work 11 32,4% from the results of the table above, it is found that almost the majority of respondents are at the age of 12-17 years, which means that the respondents are still in their teens, from the education level of the respondents that most of the respondents have the highest level of education, 22 graduates or 64 7%, then from the level of work it was found that most respondents did not work as many as 23 people or 67.6%. the results of the bivariate test on the effect of date ruthab on the amount of bleeding in the iv period are listed in the table below table 2. effect of ruthab dates on blood volume postpartum iv period (n = 34) variabel mean sd se p-value n intervention group 445,2941 57,89 14,04 0,000 17 control group 615,8824 75,42 28,09 17 from the results of table 2 above, the data shows that the average quality of contractions of mothers who did not use wet dates (control group) had contraction or bleeding quality of 615.8824 cc with a standard deviation of 75.42. whereas in the intervention group (the group given wet dates) the quality of contractions or bleeding in the iv period was 415.2941 cc with a standard deviation of 57.89. from the results of the t-test obtained pvalue which is equal to 0,000 means that there is a significant difference in the average quality of contraction when iv using wet dates and those who do not use wet dates. discussion this study is to see the description of the characteristics and effects of date ruthab on blood volume in the iv period of the mother giving birth, from the results of the age characteristics according to notoatmodjo is the age of a person calculated from the moment the person is born until now. from the results of the study it was found that the age of giving birth with primigravida status is between 12-17 years which is as much as 34 which means that 100% are in adolescence, which means that a large proportion of the population in x hospitals have a history of first pregnancy and childbirth first time labor is in that age range. judging from the educational characteristics of respondents with primigravida birth mothers dominated by high school education levels as many as 22 respondents or by 64.7% and the rest have tertiary education with a number of 12 respondents or equal to 35.3%. according to friska (2010) education can be interpreted as someone's guidance on the development of others for an ideal, the higher one's education can be said to be easier to receive information, so that they can think more optimally, this can be interpreted easily someone in an effort to prevent things that are not desirable ie bleeding. from the respondent's job characteristics, it was found that almost the majority of respondents did not work with 23 respondents or 67.6%, while 11 respondents worked or 32.4%. according yuna (2010) that the work of a woman does not have a significant journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.72-78 76 relationship with the process of pregnancy and childbirth, only if the woman works and is pregnant, her level of fatigue is more than the working woman who is not pregnant. from the results of the study obtained data that of 34 respondents who will give birth in the x hospital delivery room, in the intervention group most had an average amount of bleeding of 445cc which was lower than in the control group that is as much as 615cc. this also shows that giving wet dates can control bleeding well, so that bleeding in groups that consume wet dates is less than 500 cc. according to mochtar (2002) the iv stage of labor is monitoring for 2 hours after the placenta is born to observe the mother's condition, especially the danger of post partum bleeding. observations carried out are, the level of awareness of the sufferer, examination of vital signs, uterine contractions, the mother's uterus must be hard and tense, if it is soft then bleeding will occur, immediately look for the cause of bleeding and take management actions, bleeding is still considered normal if not exceeding 500 cc . the results of a study conducted by maria in 2016 were obtained using the mannwhitney test for the time i 0,000, for the second time 0,000 for stage iii 0,000 and for time iv 0,000 which means that there is a significant effect of dates especially on the number of bleeding times iv. the results of the study, the basis of theory and previous research, it can be assumed that with the provision of wet dates it can help the labor process at the time of iv. this is evidenced by the differences in groups given wet dates with groups not given wet dates, where groups given wet dates can further minimize bleeding in the iv period, whereas in groups not given wet dates the amount at the time of iv is above 500 cc. the results of the t test assuming the second variant of the same group (equal variance assumed) with the t test assuming variance with the two groups not equal (equal variance not assumed). to choose which test we use, it can be seen in the test of variance similarity through levene test. see the value of the test result, the p value <alpha (0.05) then the variance is different, and if the value of p> (0.05) then the variant is the same. in the above levene test, the value of p = 0.597 is obtained so that it can be concluded that at alpha 5%, there is no difference in variance (the second variant of the same group). furthermore, the p-value t test is found in the same variance section in the sig column (2 tiled), which is equal to 0,000 meaning that there is a significant difference in the average quality of contraction in the iv using wet dates and those who do not use wet dates. this shows that with the provision of wet dates, it can help the labor process in the fourth stage, namely spending blood no more than 500cc. this is evident in this study, where the wet dates had an average bleeding of 400 cc. according to the journal of obstetrics and gynecology, women who consumed 6 dates every day for 4 weeks before the estimated date of delivery and were associated with cervical ripening, obtained data, underwent spontaneous labor, had the first labor phase faster, used less oxytocin, had a score bishop is better at admission to the hospital, the opening of the cervix is larger, more successful in inducing labor, the membranes are not easily broken, the normal labor rate is higher. iv stage of labor is monitoring for 2 hours after the placenta is born to observe the condition of the mother, especially the danger of post partum bleeding. observations carried out were the level of awareness of the patient, examination of vital signs, blood pressure, pulse, breathing and temperature. uterine contractions, the uterus / uterus of the mother must be hard and tense, if the uterus is soft then bleeding will occur. immediately look for the cause of bleeding and take management measures, bleeding is still considered normal if it does not exceed 500 cc. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.72-78 77 the results of suroso's study (2016) with the results of bivariate t -3.234 while ttable 2.002 so that h0 is rejected which means there is an influence between the consumption of regular date palm extracts against contractions when 1, whereas the amount of bleeding also gets almost the same results where the group given treatment gets bleeding in the iv period of 162.17 ml compared to the control group that is equal to 186.17 ml and based on bivariate analysis h0 was found to be rejected, which means that there is an effect of giving regular dates to iv iv bleeding in primipara. conclusion the results of this study were carried out so that univariate data were obtained where respondents with primigravida in x hospital who experienced the first labor process were mostly teenagers, where the highest level of education was high school graduates, with the majority status not working. after giving ruthab dates to the intervention group there were significant differences in the amount of blood volume at the time of iv between the control group and the intervention group, the results of the bivariate data test showed that dates ruthab could significantly reduce the number of bleeding women giving birth at iv stage. references hermawati (2009). hubungan antara kecemasan pada kehamilan akhir triwulan tiga dengan lama persalinan pada ibu melahirkan anak pertama. http: //repository. ubaya.co.id, diakses tanggal 9-6-2018. kelana, dharma (2015). metodologi penelitian keperawatan. penebit : trans info media, jakarta kemenkes ri (2014). riset kesehatan dasar tahun 2013. jakarta; badan penelitian dan pengembangan kesehatan kementrian kesehatan ri kumarawati, e (2010). pengaruh pemberian pocari sweat terhadap kualitas his persalinan http: //isjd.pdii.lipi.go.id/admin/jurnal/1102529.pdf, diakses tanggal 179-2018. ma. rahayu, dkk (2016). pengaruh pemberian kurma kering (tamr) mulai usia kehamilan 37 mg terhadap kemajuan proses persalinan pada ibu bersalian di rumah bersalinan g bekasi. journal unsika. https://journal.unsika.ac.id/index.php/hsg/article/download/643/961 mochtar (2002). dasar-dasar keperawatan maternitas. jakarta: penerbit buku kedokteran egc notoatmodjo, soekidjo (2006). pendidikan dan perilaku kesehatan. penerbit rineka cipta jakarta notoatmodjo, soekidjo (2012). metodologi penelitian kesehatan. penerbit rineka cipta jakarta https://journal.unsika.ac.id/index.php/hsg/article/download/643/961 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.72-78 78 nursalam (2011). konsep dan penerapan metodologi penelitian ilmu keperawatan. penerbit salemba medika jakarta nursalam (2003). manajemen keperawatan aplikasi dalam praktik keperawatan profesional. penerbit salemba medika jakarta rohrbach, m.s, rolstad, r.a., russell, j.a. (2009). tannin is the major agent present in cotton mill dust responsible for human platelet 5hydroxytryptamine secretion and thromboxane formalium, enviromental research, volume 52, issue 2 saifuddin, a.b (2007). buku acuan nasional pelayanan kesehatan maternal dan neonatal. jakarta: yayasan bina pustaka sarwono prawirohardjo sdki (2012). angka kematian di indonesia mendapat urutan teratas di asean . http: //www.google.co.id/search, diakses tanggal 16-9-2018. sugiyono (2015). metodologi penelitian kesehatan dan teknik analisis data. salemba medika jakarta. suroso, paryono (2016). pengaruh konsumsi sari kurma pada akhir kehamilan terhadap kemajuan persalinan kala i dan jumlah perdarahan saat persalinan pada primipara di wilakyah kerja puskesmas klaten selatan. jurnal terpada ilmu kesehatan. volume 5. no.1. mei 2016, hlm 41-45. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.64-72 64 factors affecting nursing ability to know acute coroner syndrome in emergency installation agus riyadi, karmiati 1 1 dr. iskak hospital tulungagung, east java, indonesia corresponding author : goesaja15@gmail.com abstract background: coronary heart disease is the most cardiovascular disease that causes death in the world. the ability of nurses to recognize acute coronary syndromes is very necessary as part of the emergency services team. purpose : the purpose of this study was to determine the description of the factors that influence the ability of nurses to know acute coronary syndrome in the emergency department of dr. iskak tulungagung. methods : the design of this research is descriptive analytic with a cross sectional approach with the population of all nurses who work in the emergency department of dr. iskak tulungagung. the population is 55 nurses. the sample is all of the population, namely 55 respondents with total sampling sampling techniques. the data that has been collected is processed by a statistical test of multivariate analysis, ordinal regression with significance α = 0.05. result : the results showed that most of the respondents with d3 education were 33 respondents (60.0%), almost all respondents had never attended ecg training in the amount of 50 respondents (90.9%) and almost half of the respondents had a working period of 2-5 year is 25 respondents (45.5%). the results of the regression regression analysis showed that the p-value = 0.855 on the education factor which means that h0 was accepted, the p-value = 0.041 in the training factor which means h1 is received, the p-value = 0.003 on the working period, which means that h1 is accepted conclusion : based on research, education does not affect the ability to recognize acute coronary syndrome. the education obtained will develop according to the increase in the work period and the frequent training that is obtained and practiced directly in real situations. keywords : education, training, length of work, acute coronary syndrome received july, 25, 2018; revised august 24, 2018; accepted september 14, 2018 how to cite: riyadi, a., karmiati, k. (2018). factors affecting nursing ability to know acute coroner syndrome in emergency installation. journal of nursing practice, 2(1), 64-72. https://doi.org/10.30994/jnp.v2i1.45 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v2i1.45 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.64-72 65 background coronary heart disease is the most cardiovascular disease that causes death in the world, which is 7.2 million per year or 41% of cardiovascular diseases (word heart federation, 2010). who data shows that 17 million people die each year from heart and blood vessel disease worldwide. in the united states 1.5 million people have a heart attack and 478,000 people die of coronary heart disease each year (hediyani, 2012). nurses are the most number of health workers in the hospital and most interact with patients, so the ability of nurses who are professional in recognizing acute coronary syndromes is very much needed as part of the emergency services team. according to data from the indonesian ministry of health, based on the doctor's diagnosis data in 2013, the prevalence of coronary heart disease was 0.5% (around 883,447 people), while based on doctor / symptom diagnosis 1.5% (around 2,650,340 people) with an estimated number most patients with coronary heart disease were in the province of east java as many as 375,127 people (infodatin kemenkes ri). in dr. iskak tulungagung, from medical record data since july 2016 until the end of december 2016, there were 149 visits of patients with acute coronary syndrome and thrombolytic therapy was carried out for 55 people in the ed with a 30 minute door to needle target, and 14 primary pci therapy therapists. patients with a door to baloon target of 60 minutes. the initial study of researchers on february 1, 2017, from the results of interviews with 5 nurses in the emergency department of dr. iskak tulungagung hospital, obtained only 2 nurses who could mention the signs and symptoms of angina in acute coronary syndrome, 4 nurses could not do simple interpretation of acute coronary syndrome and 2 nurses who can interpret the results of heart markers. with the number of visits of patients who experienced acute coronary syndrome who went to dr. iskak tulungagung hospital general hospital and in line with the 2015 aha guideline recommendation that the focus of acute coronary syndrome care is emphasized on strengthening pre-hospital services and in the emergency room, the emergency nurse must be truly competent in recognizing acute coronary syndrome, because of an error in detecting the initial symptoms of a heart attack can have fatal consequences, causing permanent death of the heart muscle and death. in addition, from the researchers' preliminary observations starting from mid-december 2016 to mid-january 2017, there were 5 patients with acute coronary syndrome who were supposed to enter a critical room but were put into a semi-critical space which eventually led to delayed management of the right acute coronary syndrome, which of course would reduce successful rescue of heart muscle that has infarction. nurse competence is influenced by the characteristics of nurses (budiharto, 2003). the characteristics in question include; age, gender, education, training and experience (working period). based on the above characteristics, in the er the hospital dr. iskak tulungagung itself has pk 1 nurses, pk 2 nurses, and 3 pk nurses who have varied education, training and work experience. based on the data above, researchers feel the need to dig further and be interested in proposing research with the title of factors that influence the ability of nurses to know acute coronary syndrome in the dr. iskak tulungagung hospital emergency room in hopes of providing input in the form of accurate and accurate research data. so that it can be one of the reference data in preparing plans and strategies for the service of acute coronary syndrome patients in the emergency department of dr iskak tulungagung hospital. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.64-72 66 objective the purpose of this study was to determine the description of the factors that influence the ability of nurses to know acute coronary syndrome in the emergency department of dr. iskak tulungagung. methods this research is a quantitative research with descriptive analytic research with a cross sectional approach with the population of all nurses who work at the emergency department hospital dr. iskak tulungagung. the population is 55 nurses. the sample is the entire population of 55 respondents. the sampling technique used was total sampling technique. the independent variables used in this study were education, training and tenure. the location of the study was carried out at the dr iskak hospital tulungagung hospital on 12-31 july 2017. the research instruments used were observation sheets and questionnaires.. results a. characteristics of respondents age of respondents gender of respondents clinical nurse level of respondents b. variable characteristics independent variable: respondent education 16,4% 69,1% 14,5% < 25 tahun 25-35 tahun > 35 tahun 61,8% 38,2% laki-laki perem puan 78,2% 20,0% 1,8% pk 1 pk 2 pk 3 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.64-72 67 education total persentase (%) d3 33 60,0 s1 22 40,0 total 55 100 electrocardiogram training course total persentase (%) no course 33 90,9 course 22 9,1 total 55 100 respondent's working period lenght work total persentase (%) < 2 years 18 32,7 2-5 years 25 45,5 6-10 years 7 12,7 >10 years 5 9,1 total 55 100 dependent variable: ability to know acute coronary syndrome ability total persentase (%) less 11 20,0 enough 22 40,0 moderate 16 29,1 good 6 10,9 very good 0 0,0 total 55 100 the results of the analysis by ordinal regression test obtained the value of sig. (2-tailed) on the education factor r-square = 0.001, p-value = 0.855> 0.05, then ho was accepted, the working period factor r-square = 0.221, p-value = 0.003 <0.05, then ho is rejected and ecg training factor r-square = 0.073, p-value = 0.041 <0.05, so ho is rejected (the results of the statistical test are attached). based on the results of ordinal regression statistical tests it is known that educational factors are factors that do not affect the ability of nurses to recognize the symptoms of acute coronary syndrome. whereas working period and ecg training factors are factors that influence the ability of nurses to recognize the symptoms of acute coronary syndrome. it is also known that the working period has a p-value = 0.003 which is more significant than the ecg training factor (p-value = 0.041) so that it can be concluded that the working period is the most dominant factor affecting the ability of nurses to recognize the symptoms of acute coronary syndrome in the ed dr. iskak tulungagung hospital discussion effect of education on the ability of nurses to know acute syndrome in the emergency department of dr. iskak tulungagung hospital. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.64-72 68 based on the results of the study it is known that out of 55 respondents, most of them were d3 educated respondents, namely 33 respondents (60.0%), while those with si education were 22 respondents (40.0%). based on the cross tabulation it is known that almost half of the respondents who have d3 education have sufficient ability to recognize acute coronary syndrome, which is 14 respondents (25.5%). likewise for respondents with si education, most of them also have sufficient ability to recognize acute syndrome as many as 8 respondents (14.5%). statistical test was performed using ordinal regression test using spss obtained the sig. (2-tailed) value on the educational factor p-value = 0.855> 0.05, so ho was accepted. ability is a skill that consists of three types of skills to deal with and adjust to new situations quickly and effectively, knowing / using abstract concepts effectively, knowing the relationship and learn quickly (slameto, 2010). the ability / competence of nurses is the biggest variable affecting the performance of nurses. nurse competence is influenced by the characteristics of nurses (budiharto, 2003). the characteristics referred to include education. according to (notoatmodjo (2009), one's education influences the way he views himself and his environment. based on the results of this study it is known that educational factors are factors that do not affect the ability of nurses to recognize acute coronary syndrome. this is actually contrary to budiharto's theory (2013) which states that nurse education is a factor that influences competence. however, it should also be noted that according to notoatmojo (ariwibowo, 2013) that education is a person's process of developing abilities, attitudes, and other forms of behavior in the society in which he lives. which means that the formal education obtained still needs to be developed and honed by experience so that it will produce different levels of competence for each individual. this has led to levels of education level d3 and si in this study will not directly make a person proficient in recognizing acute coronary syndrome, due to the knowledge gained during the study in a general nature only and formal course there will be differences when faced with real situations of heart attack which is full of variations in conditions and patient response. so despite the fact that the respondents are highly educated diii and si nursing, but because it is possible not yet been trained ecg, and has no experience because his tenure is still a little bit, then this will reduce the ability of nurses, because the ability is one element in maturity with regard to knowledge or skills that can be obtained from education, training and experience. it is why even though the respondents had highly educated nursing diii and si but having acute coronary syndrome kemamampuan know less, or it can be said education factor is a factor that does not affect the ability of nurses recognize acute coronary syndrome. effect of training on the ability of nurses to know acute syndrome in the emergency department of iskak tulungagung hospital. based on the results of the research that has been done, it is known that out of 55 respondents, almost all respondents did not take ecg training, amounting to 50 respondents (90.9%), while those who took ecg training were 5 respondents (9.1%). based on cross tabulation data it is known that those who did not take ecg training produced varying values, as many as 11 respondents (20%) received less scores, 16 respondents (29.1%) got a moderate score, almost half of the respondents had enough scores, namely 18 respondents ( 32.7%), and 5 respondents (9.1%) got good grades. whereas respondents who took ecg training received enough scores as many as 4 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.64-72 69 respondents (7.3%) and good grades as much as 1 respondent (1.8%). the results of the analysis by ordinal regression test obtained sig. (2-tailed) value on ecg training factor pvalue = 0.041 <0.05, so ho was rejected, which means that ecg training factor is a factor that influences the ability of nurses to recognize acute coronary syndrome in rsd dr. iskak tulungagung. the ability / competence of nurses is the biggest variable affecting the performance of nurses. nurse's competence is influenced by the characteristics of nurses. the characteristics in question include; age, gender, education, training and experience / tenure (budiharto, 2003). training as a short-term education process that uses systematic and organized methods and procedures (sumantri 2000: 2). the trainees will learn practical knowledge and skills for specific purposes. while hariandja (2007: 169) explained that training was emphasized on increasing the ability to do specific work. based on the results of the above studies it is known that ecg training factors are factors that influence the ability of nurses to recognize acute coronary syndrome. this is because the symptoms of acute coronary syndrome are emergency conditions that require immediate early detection so that relief can be done immediately before experiencing more severe damage to the heart muscle or death. training is needed to improve the ability of nurses to recognize acute syndrome in accordance with cardiovascular emergencies that are always developing. based on history, physical examination, electrocardiogram (ecg) examination, and examination of cardiac markers, acute coronary syndrome was divided into stemi, nstemi, and uap. to be able to diagnose and differentiate which stemi, nstemi, and uap are the most important are from ecg recordings. therefore, wherever possible, ecg recordings are made within 10 minutes of the arrival of the patient in the emergency room. ecg examination should be repeated every time angina complaints arise again. but unfortunately, based on the results of this study it is known that almost all respondents stated that they had never received ekg training. this is something that is vital and needs to get attention from the hospital management to increase the hr of nurses, especially in the emergency department to hold ecg training so that nurses are able to recognize and detect acute coronary syndrome correctly and quickly. effect of working period on the ability of nurses to know acute syndrome in the emergency department of dr iskak tulungagung hospital. based on the results of the study, it is known that out of 55 respondents, almost half of the respondents had a working period of 2-5 years, amounting to 25 respondents (45.5%). based on cross tabulation it is known that almost half of the respondents have sufficient ability to recognize acute coronary syndrome and experienced by respondents who have a working period of 2-5 years, namely 9 respondents (16.4%). while most of the nurses who have a working period of <2 years get less value, namely 7 respondents (12.7%). work imposes different demands on actors to use intellectual abilities, meaning that the more demands for information processing in the work, the more intelligence and general verbal abilities needed to be able to complete the work successfully. while physical ability is the ability to carry out tasks that demand stamina, skills, strength and similar characteristics (slameto, 2010). the ability / competence of nurses is the biggest variable affecting the performance of nurses. nurse competence is influenced by the characteristics of nurses, including experience / working period (budiharto, 2003). journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.64-72 70 working period is a measure of the length of time or time taken by a person to be able to understand the task of a job and has been carried out properly (ranupandojo: 2002). based on the results of the study obtained results that the working period / experience of nurses affect the ability of nurses to recognize acute coronary syndrome. when viewed from the tabulation, it is known that respondents with a working period of <2 years have abilities that are less familiar with acute coronary syndrome, while respondents who have had work experience for 2-5 years have sufficient ability to recognize acute coronary syndrome. this shows that at a work period of 2 <years, respondents are still relatively new and do not have sufficient ability if they have to be faced with a serious situation of heart attack. whereas those who have 2-5 years of service can get acquainted with acute coronary syndrome, this is in line with the launching of an acute coronary syndrome network program at rsud dr. iskak tulungagung as a referral center for cases of acute coronary syndrome that must be supported by competent personnel and able to recognize the symptoms of the syndrome acute coronary therapy so that reperfusion therapy can be done immediately. it also shows that during the 2-5 year work period, nurses are in a developing stage towards better performance, so that they try to compete healthily to show their best ability in recognizing acute coronary syndrome, which eventually will get recognition and can be extended. analyze the factors that influence the ability of nurses to recognize acute syndrome in the emergency department of rsud dr. iskak tulungagung. statistical test was performed using ordinal regression test using spss. the results of the analysis by ordinal regression test obtained the value of sig. (2-tailed) on the educational factor p-value = 0.855> 0.05, then ho was accepted, the working period factor p-value = 0.003 <0.05, then ho was rejected and the factor ecg training p-value = 0.041 <0.05, so ho is rejected. based on the results of ordinal regression statistical tests it is known that educational factors are factors that do not affect the ability of nurses to know acute coronary syndrome. whereas working period factors and ecg training factors are factors that influence the ability of nurses to recognize acute coronary syndrome. it is also known that the working period has a p-value = 0.003 which is more significant than the ecg training factor (p-value = 0.041) so that it can be concluded that the working period is the most dominant factor affecting the ability of nurses to know acute coronary syndrome in the emergency department of dr. iskak tulungagung . coronary heart disease is the most cardiovascular disease that causes death in the world, which is 7.2 million per year or 41% of cardiovascular diseases (word heart federation, 2010). nurses are the most number of health workers in the hospital and most interact with patients, so the ability of nurses who are professional in recognizing the symptoms of acute coronary syndromes is very much needed as part of the emergency services team (hediyani, 2012). nurse competence is influenced by the characteristics of nurses (budiharto, 2003). the results of this study indicate that educational factors are factors that do not affect the ability to recognize the symptoms of acute coronary syndromes, long working factors and training factors on ecg are factors that influence the ability of nurses to know acute coronary syndrome in the emergency department of dr. iskak tulungagung. it is also known that the working period factor is the most dominant factor that influences the ability journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.64-72 71 of nurses to know acute coronary syndrome in the emergency department of dr. iskak tulungagung hospital. ecg training is one of the factors that influence the ability of nurses to recognize acute coronary syndrome, because by following ecg training activities can increase the knowledge of respondents. coupled with the existence of a work period of 2-5 years which is a period in which respondents have high motivation and morale. this is in accordance with the statement of nursalam, 2012, which states that past experience influences a person's behavior and actions, so that a person will be motivated because of past experience as a response in behavior patterns. therefore, in this study, the results of the working period factor is the most dominant factor that influences the ability of nurses to recognize acute coronary syndrome in the emergency department of dr. iskak tulungagung hospital. conclusion there is no influence of education factors on the ability of nurses to recognize the symptoms of acute syndrome in the ed. iskak tulungagung hospital (p-value = 0,855). working period factors and ecg training factors are factors that influence the ability of nurses to recognize acute coronary syndromes, and working period factors are the most dominant factors influencing them. references american heart association. (2015). guidelines update for cardiopulmonary resuscitation (cpr)and emergency cardovascular care (ecc). aha and american college of cardiology foundation ariwibowo. (2013). hubungan antara umur, tingkat pendidikan, pengetahuan sikap terhadap praktik safety riding awwareness pada pengendara ojek sepeda motor di kecamatan banyumanik. jurnal kesehatan masyarakat vol. 2 nomor 1. budiharto, (2003). karakeristik perawat. jakarta : universitas indonesia gunarto, g., setiyani, d., iswahyudi, p., & hildania, h. (2018). nursing role in the implementation of emergency patients with interruption of the cardiovascular systemat the review of nurse knowledge in aisyiyah hospital ponorogo. journal of nursing practice, 1(2), 41-46. https://doi.org/10.30994/jnp.v1i2.32 hediyani, novie. (2012). penyakit jantung koroner. jakarta hidayat, a. a. (2014). metode penelitian keperawatan dan teknis analisis data. jakarta : salemba medika karmiati, k., & sutrisno, s. (2018). description of ecg recycle and coronary angiography in coronary heart disease patients in dr iskak hospital. journal of nursing practice, 1(2), 26-32. https://doi.org/10.30994/jnp.v1i2.30 kumar, dkk. (2007). buku ajar patologi robbins. jakarta : egc notoadmojo, s. (2010). ilmu perilaku kesehatan. jakarta : rineka cipta notoatmodjo, soekidjo. (2009). pendidikan dan perilaku kesehatan. jakarta : rineka cipta notoadmojo, s. (2007). pengantar pendidikan dan ilmu penelitian kesehatan. yogyakarta andi offset. https://doi.org/10.30994/jnp.v1i2.32 https://doi.org/10.30994/jnp.v1i2.30 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.64-72 72 perhimpunan dokter spesialis kardiovaskular indonesia. (2016). buku ajar kursus bantuan hidup jantung lanjut,acls. jakarta : perki perhimpunan dokter spesialis kardiovaskular indonesia. (2015). pedoman tata laksana sindrom koroner akut. jakarta : centra communications. r.i., pusat data dan informasi kementerian kesehatan, (2014) situasi kesehatan jantung (http//www.depkes.go.id/folder/view/01/structure-publikasi-pusdatin-infodatin.html.jakarta). diakses 7 desember 2016 riyadi, sugeng. (2007). keperawatan kesehatan masyarakat. jakarta : salemba medika robbins sp, dan judge. (2007). perilaku organisasi. jakarta : salemba empat sjaharuddin harun, dkk. (2006). buku ajar penyakit dalam jilid 3. jakarta. pusat penerbitan ilmu penyakit dalam fakultas kedokteran universitas indonesia slameto. (2010). belajar dan faktor – faktor yang mempengaruhinya. jakarta : rineka cipta http://www.depkes.go.id/folder/view/01/structure-publikasi-pusdatin-info-datin.html.jakarta http://www.depkes.go.id/folder/view/01/structure-publikasi-pusdatin-info-datin.html.jakarta journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.145-154 145 mother's behavior in breastfeeding after the covid-19 pandemic: a cross sectional study reni yuli astutik1*, nining istighosah2, suci anggraeni3, devy putri nursanti4, eri puji kumalasari5 1,2,4,5 department of midwifery, institut ilmu kesehatan strada indonesia 3 department of nursing, institut ilmu kesehatan strada indonesia *corresponding author: dealovanining@gmail.com abstract background: research related to the implementation of breastfeeding guidelines after the covid-19 pandemic in healthy breastfeeding mothers is still minimal, even though the mother's behavior in implementing breastfeeding guidelines correctly can ensure the safety of breastfeeding. purpose: this study aims describe the behavior of mothers in breastfeeding during and after covid-19 pandemic. methods: this study used a cross-sectional design. the sample in this study were breastfeeding mothers who had babies aged less than 6 months who met the inclusion criteria and obtained a total of 94 respondents. the research instrument used a questionnaire. mother's behavior in breastfeeding is categorized into good, moderate and sufficient categories. data analysis used the wilcoxon signed ranks test to compare behavior during and after the covid19 pandemic. results: during the pandemic, the behavior of mothers in the moderate category was more than the good or sufficient category, which was 42.6%. meanwhile, after the pandemic, there was no maternal behavior in the sufficient category, while the good category was more than the moderate category, which was 71.3%. the wilcoxon rank test results obtained pvalue=0.000, there was a significant difference between the behavior of mothers in breastfeeding during and after the covid-19 pandemic. conclusion: the covid-19 pandemic period for breastfeeding mothers is an external stimulus, it is hoped that mothers can make changes to the right breastfeeding pattern in accordance with health protocols as an effort to control and prevent the spread of covid-19 during the breastfeeding process, because the benefits of breastfeeding far exceed the potential for covid-19 transmission. keywords: after the pandemic, behavior, breastfeeding mothers, covid-19, during the pandemic received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.363 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:dealovanining@gmail.com https://doi.org/10.30994/jnp.v6i2.368 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.145-154 146 background the spread of the sars-cov-2 corona virus as a pandemic was declared by the world health organization (who) on march 11, 2020.(ghebreyesus, 2020) during the covid-19 pandemic, breast milk (asi) must still be given to infants on the grounds that breast milk is a source of good nutrition and can protect infants from infectious diseases.(spatz & froh, 2021) in fact, current evidence suggests that the corona virus is not transmitted through breast milk, the possible risks during the covid-19 pandemic are less than the benefits of breastfeeding and even breastfeeding can protect infants and mothers.(lubbe et al., 2020) this statement is in accordance with the recommendation of the who that breast milk be given to newborns up to the age of 6 months without other food or liquids, except vitamins, minerals, and drugs that have been permitted for medical reasons.(who, 2018) the situation of the covid-19 pandemic it is hoped that what has happened in indonesia will not scare mothers or stop breastfeeding. in fact, the government has taken various measures to stop the spread of the corona virus. one of the efforts to prevent the spread of covid-19 is urging the public to maintain a physical distance of at least one meter from other people. however, this actually makes breastfeeding mothers afraid to breastfeed their babies. the covid-19 pandemic has also disrupted access to essential services such as breastfeeding counseling in hospitals, health clinics, and home visits by health workers as well as visits by nursing mothers at the baby love hospital.(hull et al., 2020) the reduced frequency of visits by postpartum and breastfeeding mothers to health services to gain access to examinations and education about breastfeeding, thus affecting the mindset and behavior of breastfeeding mothers during the covid-19 pandemic. several studies stated that most breastfeeding mothers felt that covid-19 had a negative impact because of the need to stay at home (50.8%), not receiving visits from relatives (52.1%), the need to cancel attendance in support groups, (72.8%). %) unable to go to health facilities (70.6%), and excessive time to focus on breastfeeding.(brown & shenker, 2020)(pacheco et al., 2021) this situation increases the interest of breastfeeding mothers in receiving information during breastfeeding.(pacheco et al., 2021). in indonesia, the integrated service post program which functions to provide services to mothers and toddlers is also experiencing obstacles. the results of a survey conducted by the ministry of health of 43% did not carry out face-to-face integrated service post during the pandemic, but through telecounseling(ministry of health of the republic of indonesia, 2020) so that information related to breastfeeding and breastfeeding guidelines during the covid19 pandemic could still be provided. providing correct information regarding breastfeeding during the covid-19 pandemic is one of the responsibilities of health workers, including midwives. as research states that antenatal and postnatal support, including the provision of information to the mother positively affects the success of breastfeeding(mcfadden et al., 2017; rollins et al., 2016). in kediri regency, midwives continue to provide information about breastfeeding during the covid-19 pandemic through whatsapp. information related to breastfeeding guidelines during the covid-19 pandemic, including always washing hands before and after breastfeeding, using masks, cleaning touched surfaces with disinfectant, applying coughing and sneezing etiquette (unicef, 2020) has been socialized by midwives to nursing mothers with the aim that mothers can breastfeed safely follow health protocols. however, the implementation of breastfeeding guidelines during the covid-19 pandemic is a challenge for breastfeeding mothers, especially for healthy breastfeeding mothers. even with the enactment of social restrictions, it causes increased stress during isolation for breastfeeding mothers(davenport et al., 2020; snyder & worlton, 2021) the condition of people in indonesia who are accustomed to socializing must change to being https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.145-154 147 individuals who stay at home due to the advice from the government to avoid crowds and not to leave the house, thus limiting themselves to receive visits from relatives after having a baby. on the other hand, the covid-19 pandemic also benefits breastfeeding mothers because mothers can focus on breastfeeding their babies without being disturbed by visits from relatives. after the pandemic, breastfeeding continues to apply health protocols. research related to the implementation of breastfeeding guidelines during and after the covid-19 pandemic in healthy breastfeeding mothers is still minimal, even though the mother's behavior in implementing breastfeeding guidelines correctly will be able to ensure the safety of breastfeeding by mothers to babies. thus, the objectives of this study are 1) to describe the behavior of mothers in breastfeeding during and after the covid-19 pandemic; 2) analyze differences in the mother's behavior in breastfeeding during and after the covid-19 pandemic. methods this study used a cross-sectional design. the choice of this design is to describe the existence of a unique event at one time in a responsive and exploratory manner. in the covid19 pandemic situation, an exploratory design approach is considered the most appropriate.(reiter, 2017). the research was conducted in october december 2021 in kediri regency. the process of collecting data online via google form. the informed consent given includes the purpose of the research, the reward for being a respondent, namely being able to consult for free regarding breastfeeding and infant growth and development. this research has received a certificate of ethical conduct from the ethics commission of the institute for research and community service karya husada kediri health science reference number 378/ec/ lppm/stikes/kh/vii/2021. breastfeeding mothers who gave birth in januari 2021 were assisted and given information regarding the importance of breastfeeding and breastfeeding guidelines during the covid-19 pandemic. the sample in this study were breastfeeding mothers who had babies aged less than 6 months who met the inclusion criteria. the inclusion criteria in this study were: https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.145-154 148 1. mothers who are willing to be respondents 2. mothers who gave birth normally 3. mothers who initiate early breastfeeding 4. mothers who only give breast milk to babies 5. breastfeeding mothers who lives at home with her husband the flow of data collection can be seen in the chart below: the research instrument used a questionnaire in the form of closed questions consisting of demographic data about the characteristics of the respondents, including age, occupation, income, parity and education. specific data on the behavior of mothers in breastfeeding their babies during and after the covid-19 pandemic, which includes the use of hand sanitizers or washing hands with soap before breastfeeding; breastfeeding using a mask; when coughing/sneezing cover mouth and nose with tissue or arm; cleaning touched surfaces with a disinfectant; using hand sanitizer or washing hands with soap after breastfeeding. mother's behavior in breastfeeding is categorized on a likert scale with a rating of 1 = never, 2 = sometimes, 3 = often, 4 = always. the score obtained from the total score obtained from the statement items in behavior was then categorized into good behavior (score 19-28), sufficient (score 10-18) and less (score < 9). the collected data were analyzed using the statistical package for the social sciences (spss), version 21.0. this study uses descriptive statistics (e.g., numbers and percentages) and analytical statistics. data analysis used the wilcoxon signed ranks test to compare behavior before and during the covid-19 pandemic. the reason for using the wilcoxon signed rank test is because the sample data is not normally distributed, the two samples are paired groups and the samples are ordinal scale. initially, there were 118 breastfeeding mothers who were willing to be respondents in this study. after being selected based on inclusion criteria and excluded samples who did not live at home with their husbands (n=6), gave birth to sc (n=8), imd was not performed for reasons of mother and baby (n=10) so that a sample was obtained (n=94). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.145-154 149 results characteristics of respondents table 1. characteristics of respondents characteristics f % p-value age <0.001 < 20 year 2 2,1 20-35 year 78 83 > 35 year 14 14,9 working <0.001 no 56 59,6 yes 38 40,4 family income <0.001 < district minimum income 79 84 > district minimum income 15 16 education level <0.001 low 20 21,3 middle 64 68,1 high 10 10,6 parity <0.001 primiparous 34 36,2 multiparous 60 63,8 total 94 100 table 1 shows data that the majority of respondents are aged 20-35 years (83%), 59.6% of respondents do not work, respondents who have family incomes below the minimum wage are 84%, respondents with secondary education are 68.1% and respondents are multiparous more than primiparous, namely 63.8%. mother's behavior in breastfeeding during and after the covid-19 pandemic table 2. overview of mother's behavior in breastfeeding during and after the covid-19 pandemic mother's behavior during the covid-19 pandemic after the covid-19 pandemic p-value never rarely sometimes often always never rarely sometimes often always use of hand sanitizer/ wash hands with soap before breastfeeding 9 (9,6%) 4 3 (45,7%) 1 6 (17%) 23 (24,5%) 3 (3,2%) 0 (0%) 0 (0%) 11 (11,7%) 20 (21,3%) 63 (67,0%) 0.02 breastfeeding with a mask 22 (23,4%) 28 (29,8%) 18 (19,1%) 26 (27,7%) 0 (0%) 0 (0%) 2 (2,1%) 13 (13,8%) 29 (30,9%) 50 (53,2%) 0.04 when coughing/ sneezing, cover your mouth and nose with a tissue or your arm 54 (57,4%) 26 (27,7%) 10 (10,6%) 3 (3,2%) 3 (3,2%) 0 (0%) 0 (0%) 24 (25,5%) 24 (25,5%) 46 (48,9%) 0.01 cleaning touched surfaces with disinfectant 1 (1,1%) 40 (42,6%) 28 (29,8%) 25 (26,6%) 0 (0%) 0 (0%) 0 (0%) 12 (12,8%) 24 (25,5%) 58 (61,7%) 0.01 https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.145-154 150 use of hand sanitizer/ wash hands with soap after breastfeeding 37 (39,4%) 17 (18,1%) 14 (14,9%) 24 (25,5%) 2 (2,1%) 0 (0%) 3 (3,2%) 23 (24,5%) 17 (18,1%) 51 (54,3%) 0.04 the description of mother's behavior in breastfeeding during and after the covid-19 pandemic is depicted in table 2. mother's behavior in breastfeeding before the covid-19 pandemic in the use of hand sanitizer/washing hands with soap before breastfeeding is in the rare category (45.7%), a total of 29, 8% of mothers rarely breastfeed using masks, some 57.4% when coughing/sneezing mothers do not cover their mouth and nose with a tissue or arm. the behavior of mothers before breastfeeding by cleaning touched surfaces using disinfectants is classified as rare category, namely 42.6% and 39.4% mothers never use hand sanitizer/wash hands with soap after breastfeeding. during the covid-19 pandemic, 67% of mothers always use hand sanitizer/wash hands with soap before breastfeeding. mothers who always use masks when breastfeeding babies are more than those who don't use masks, namely 53.2%. a total of 48.9% of mothers who breastfeed their babies cover their mouth and nose using a tissue or arm when coughing/sneezing. a total of 61.7% of mothers cleaned the touched surface using a disinfectant before breastfeeding. the number of breastfeeding mothers who always use hand sanitizer/wash their hands with soap after breastfeeding is higher than mothers who do not use hand sanitizer/wash their hands, which is 54.3%. the differences of mother's behavior in breastfeeding during and after the covid-19 pandemic table 3. the differences of mother's behavior in breastfeeding during and after the covid19 pandemic. mother's behavior in breastfeeding during pandemic f(%) after pandemic f(%) good 29(30,8%) 67 (71,3%) moderate 40 (42,6%) 27 (28,7%) sufficient 25 (26,6%) 0 total 94 94 p value = 0.000 table 3 illustrates the differences in maternal behavior in breastfeeding during and after the covid-19 pandemic. mother's behavior in breastfeeding is categorized into good, moderate and sufficient categories. during the pandemic, the behavior of mothers in the moderate category was quite a lot more than the good or sufficient category, which was 42.6%. meanwhile, after the pandemic there was no mother’s behavior in the sufficient category, while the good category was more than the moderate category, which was 71.3%. the wilcoxon rank test results obtained the asymp value. sig(2-tailed) obtained p value <0.05 so it can be concluded that there is a significant difference between the behavior of mothers in breastfeeding before and during the covid-19 pandemic. discussion the purpose of this study was to compare the behavior of mothers in breastfeeding their babies during and after the covid-19 pandemic. the results of the study also describe how the behavior of breastfeeding mothers during and after the covid-19 pandemic, which includes the use of hand sanitizers or washing hands with soap before breastfeeding; breastfeeding using https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.145-154 151 a mask; when coughing/sneezing, cover mouth and nose with tissue or arm; cleaning touched surfaces with a disinfectant; using hand sanitizer or washing hands with soap after breastfeeding. overview of mother's behavior in breastfeeding during and after the covid-19 pandemic most of the behavior of mothers in breastfeeding during the covid-19 pandemic in the use of hand sanitizers/washing hands with soap before breastfeeding was in the rare category while after breastfeeding was in the newer category. in fact, good hand washing can prevent infection. (luangasanatip et al., 2015). when breastfeeding a baby, mothers rarely use masks. this behavior is probably because the use of a mask makes the mother unable to breathe freely because the nose and mouth are covered by the mask. the results of a systematic review stated that the behavior of using masks in the community was still low.(bin-reza et al., 2012) the possibility of using masks on mothers before the covid-19 pandemic was carried out by breastfeeding mothers who were sick with flu, cold or cough. as research states that personal protective equipment to help reduce the risk of exposure to the influenza virus by using a mask.(bin-reza et al., 2012) likewise, the behavior of breastfeeding mothers when sneezing/coughing covers with a tissue or arm is included in the rare category. whereas when coughing/sneezing, germs and viruses can come out of the respiratory tract so that they can be transmitted to other people. when coughing/sneezing, it is recommended to cover your mouth and nose with a tissue or a mask. dispose of used tissues and masks and perform hand hygiene after contact with respiratory secretions. if a tissue is not available, then cough or sneeze into the elbow or sleeve and not in the hands.(shrivastava & rambiharilal shrivastava, 2019) the behavior of the mother before breastfeeding by cleaning the touched surface using a disinfectant is in the rare category. this behavior is rarely carried out by breastfeeding mothers, possibly because exposure to the virus before the covid-19 pandemic has not frightened the public. after the covid-19 pandemic, most mothers always use hand sanitizer/wash hands with soap before and after breastfeeding. during the covid-19 pandemic, hand hygiene is necessary by washing hands with soap for 40-60 seconds by rubbing all surfaces of the hands, rinsing hands and drying thoroughly with disposable towels and using towels to turn off the tap or by rubbing hands using disinfectant for 20-30 seconds to all areas of the hands, then rub hands and wait for them to dry. (shrivastava & rambiharilal shrivastava, 2019) hand sanitizer can be used before breastfeeding, but if your hands look dirty you need to wash them with soap and water. this study shows that during the pandemic, mothers who always use masks when breastfeeding babies are more than those who don't use masks. the use of masks, especially during a pandemic, can protect mothers and babies from exposure to the virus. in fact, during the covid-19 pandemic, unicef recommends the use of masks when breastfeeding.(unicef, 2020) the use of disposable masks, especially when the mother has the flu, cough or cold, must cover her nose and mouth. in terms of mother's behavior when coughing/sneezing, breastfeeding mothers covered their mouths and noses with tissue or arms more than those who did not. even most breastfeeding mothers also clean the touched surfaces using a disinfectant before breastfeeding. research says that the coronavirus can survive for about three days on plastic and stainless steel surfaces. viruses can also survive for an entire day on cardboard and can only survive for only about four hours on copper surfaces. (suman et al., 2020). differences of mother's behavior in breastfeeding during and after the covid-19 pandemic the results of data analysis using the wilcoxon rank test showed pvalue=0.000, there were differences in the behavior of mothers in breastfeeding their babies during and after the https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.145-154 152 covid-19 pandemic. in this study, the most behavioral differences were found in behavior when sneezing/coughing using a tissue or the inside of the arm. during the pandemic, the behavior of mothers who always used a tissue or inner arm when coughing was only 4.3%, then after the pandemic it became 48.9%. this behavior is likely because the mother is aware that the covid-19 virus can be transmitted through airborne transmission. (marchiori, 2020; yuen et al., 2020) it is even mentioned that the covid-19 virus can survive in the air for up to 3 hours. respondents who always use masks while breastfeeding have increased during the covid-19 pandemic, by 25.5%. there are still respondents who have never used a mask while breastfeeding (2.1%) possibly because the use of a mask seems to be an obstacle in physical contact with the baby while breastfeeding. this raises the opinion that wearing a mask has become a visual factor that strengthens physical strength as a public health measure indicating that after the pandemic all respondents had cleaned the surface they touched before. this respondent's behavior is based on the respondent's awareness of the dangers posed by viruses, especially those attached to surface areas. thus, it can be said that each indicator of mother's behavior in breastfeeding her baby is different between during and after the covid-19 pandemic. this difference in behavior is because mothers have received information related to breastfeeding guidelines during the covid-19 pandemic. if it is related to the characteristics of the respondents, most of the respondents do not work so they have a lot of time to absorb information from outside. in terms of education, most of the respondents have secondary education, so that the researcher assumes that it is easier to absorb the information provided. providing information from outside is a cognitive component that can influence human behavior. changes in the mother's behavior in breastfeeding that are more towards the application of breastfeeding guidelines during the covid-19 pandemic can be said to be a form of a person's response or reaction to a stimulus or an external stimulus. (alghamdi & badr, 2022; chien et al., 2022; kilic et al., 2021; martinelli et al., 2021; pandey et al., 2021). breastfeeding mothers who are faced with the current covid-19 pandemic are a stimulus, it is hoped that mothers can make changes to appropriate breastfeeding patterns in accordance with health protocols as an effort to control and prevent the spread of covid-19 during the breastfeeding process, because the benefits of breastfeeding far exceed the potential for transmission covid-19. the covid-19 pandemic condition will make breastfeeding mothers take steps to control and prevent the risk of spreading covid-19 to babies during the breastfeeding process. even though breastfeeding mothers are in good health or not infected with covid-19, mothers need to pay attention to infection prevention and control measures. future research is expected to use a prospective design so that breastfeeding behavior after the pandemic can be described in detail. conclusion differences in the mother's behavior in breastfeeding her baby before and during the covid-19 pandemic could be due to mothers having received accurate information about breastfeeding guidelines during the covid-19 pandemic. this difference proves that information related to breastfeeding guidelines during the pandemic is not only given to breastfeeding mothers who are positive for covid-19, but also to healthy breastfeeding mothers. the need for support and the role of various parties, especially families so that mothers can be consistent in breastfeeding by applying the correct breastfeeding guidelines. references alghamdi, s., & badr, h. 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(2020). providing breastfeeding support during the covid-19 pandemic: concerns of mothers who contacted the australian breastfeeding association. breastfeeding review, 28(3), 25–35. https://doi.org/10.1101/2020.07.18.20152256. kilic, t., kilic, s., berber, n. k., gunduz, a., & ersoy, y. (2021). investigation of sarscov-2 rna in milk produced by women with covid-19 and follow-up of their infants: a preliminary study. in international journal of clinical practice (vol. 75, issue 7). https://doi.org/10.1111/ijcp.14175. luangasanatip, n., hongsuwan, m., limmathurotsakul, d., lubell, y., lee, a. s., harbarth, s., day, n. p. j., graves, n., & cooper, b. s. (2015). comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis. in bmj (online) (vol. 351). https://doi.org/10.1136/bmj.h3728. lubbe, w., botha, e., niela-vilen, h., & reimers, p. 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(2019). a cross sectional study to assess the awareness and practice about cough etiquettes among respiratory symptomatic patients in tamil nadu. international journal of community medicine and public health, 6(10), 4248. https://doi.org/10.18203/2394-6040.ijcmph20194165. snyder, k., & worlton, g. (2021). social support during covid-19: perspectives of breastfeeding mothers. in breastfeeding medicine (vol. 16, issue 1, pp. 39–45). https://doi.org/10.1089/bfm.2020.0200. spatz, d. l., & froh, e. b. (2021). birth and breastfeeding in the hospital setting during the covid-19 pandemic. in mcn. the american journal of maternal child nursing (vol. 46, issue 1, pp. 30–35). https://doi.org/10.1097/nmc.0000000000000672. suman, r., javaid, m., haleem, a., vaishya, r., bahl, s., & nandan, d. (2020). sustainability of coronavirus on different surfaces. in journal of clinical and experimental hepatology. http://www.embase.com/search/results?subaction=viewrecord&from=export&id=l20 05949921%0ahttp://dx.doi.org/10.1016/j.jceh.2020.04.020. unicef. (2020). breastfeeding during coronavirus (covid-19) unicef indonesia. https://www.unicef.org/indonesia/stories/breastfeeding-during-coronavirus-covid-19. who. (2018). reducing stunting in children. in equity considerations for achieving the global nutrition targets 2025. https://apps.who.int/iris/bitstream/handle/10665/260202/9789241513647eng.pdf?sequence=1. yuen, k. s., ye, z. w., fung, s. y., chan, c. p., & jin, d. y. (2020). sars-cov-2 and covid-19: the most important research questions. in cell and bioscience (vol. 10, issue 1). https://doi.org/10.1186/s13578-020-00404-4. https://thejnp.org/ journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.7 16 relationship strategy family coping with quality of life in elderly post stroke dodik limansyah, junaiti sahar, sukihananto 1 1 stikes yarsi pontianak, kalimantan barat, indonesia corresponding author : dodik.limansyah@yahoo.com abstract background: stroke is the highest cause of death in urban areas, one of the regions in indonesia with stroke exceeds the national rate is the city of pontianak. purpose : this study aims to determine the relationship of family coping strategies to the quality of life of elderly post-stroke in the city of pontianak. methods : analytical research design correlation with cross sectional approach. sampling in total sampling with respondents amounted to 58 respondents. the sample of this study was post-stroke elderly and family members as caregiver or primary outpatient who treated elderly with post stroke. result : the results of multiple linear regression analysis or anova test (f test) with p value = 0.001 (<0.05) indicating that there is a significant relationship between social support, reframing, seeking and receiving, passive income and income with the quality of life of the elderly post stroke. conclusion : social support is a dominant element of coping strategy. the role of community nurses is needed to support family caregivers in providing social support to post-stroke elderly. keywords : coping strategies, stroke, whoqol-bref received july, 30, 2018; revised august 2, 2018; accepted september 12, 2018 how to cite: limansyah, d., sahar, j., sukihananto, s. (2018). relationship strategy family coping with quality of life in elderly post stroke. journal of nursing practice, 2(1), 7-16. https://doi.org/10.30994/jnp.v2i1.37 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v2i1.37 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.7 16 8 background vulnerability is a weakness to health problems (shi & steven, 2010, allender, 2014). vulnerable populations are in a group of adverse health risks, susceptibility is associated with an increased risk of morbidity and mortality. vulnerable characteristics are characteristic of populations at risk of declining health status both physically, psychologically and socioeconomically (ajmc, 2006). stroke is one of the diseases suffered by many elderly, currently stroke is one of the many diseases found mainly at the age of 45 years and over (riskesdas, 2007). elderly with a stroke in rehabilitation or continuing care at home or community is highly dependent on family members, the family as a cargiver should have both physical and emotional resilience in carrying out rehabilitation. chaiyawat (2012) stated the initial effectiveness of home rehabilitation programs during the first 6 months post stroke period leads to improvements and functions that will reduce disability and improve quality of life. the prevalence of national stroke is 0.8% of the total population of indonesia. this figure has not been seen from other variables such as regional type, if seen from the spread based on the type of regional prevalence of stroke nationally in urban areas is 0.9% and in rural 0.78% of the total population. one area in indonesia with stroke exceeds the national rate of pontianak with a prevalence of 1.4%. this prevalence exceeds the national prevalence rate of 0.8%. (ministry of health, 2007). the task of treating patients stroke in a long time will increase the burden experienced by caregiver family. this condition is exacerbated by a lack of caregiver knowledge in treating patients at home. the burden experienced by caregivers occurs due to several reasons such as feeling the task of caring for patients as a difficult task, unclear about the treatment of stroke patients, barriers in social relations during caring for patients and the feeling that patients should be helped maximally in self-care. caregiver plays an important role in post-stroke rehabilitation of patients especially when undergoing rehabilitation at home. darlington et al, (2007) in his research says that coping is a very powerful factor that affects the quality of life (qol) of post-stroke patients. given the importance of caregiver coping in post-stroke rehabilitation, the patient's output is strongly influenced by caregiver coping strategies. coping family (f-cope) strategy according to mccubbin (1991) in friedman (2010) is divided internally and externally, internal coping such as family coping pattern, family resource derived from family resources consisting of confidence in problem solving (confidence in problem solving ), arranging family problems (reframing family problems), and family passivity or inactive or passive family behavior. koping consists of problemsolving efforts faced by individuals with demands that are highly relevant to well-being, but burdensome to one's source (lazarus, averill, & opton, 1974) in friedman (2010). the gap between several facts about stroke such as increased prevalence of cases, the biggest cause of death, inadequate rehabilitation of in-house patients where this is influenced by coping and family coping strategies as caregivers who provide home care. for that family as caregiver need to maintain koping and family coping strategies to improve the quality of life of elderly, especially elderly with post stroke. objective this study aims to determine the relationship of family coping strategies to the quality of life of elderly post-stroke in the city of pontianak. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.7 16 9 methods the design of this research is descriptive correlation with cross sectional approach method (point time approach). the measurement of this study measures the variables of family coping strategies including social support, reframing, searching and receiving efforts, passive acceptance and income confounding variables with the quality of life of elderly post-stroke patients at the same time. the population in this study were all post-stroke elderly people aged 60 years or older and family cargiver as main offender who live in pontianak city area. sample in this research is all elderly stroke post-care hospital that aged 60 years or more residing in pontianak city area, the amount of sample in this research as much 58 responder. sampling method used in this research is total sampling technique, that is sample determination technique by taking all member of population as respondent or sample. results table 1 the relationship between family coping strategies and the quality of life (qol) of poststroke elderly people in pontianak (n = 58) independent variable dependent variable r value p value family coping strategy quality of life 0,293 0,026 social support quality of life 0,376 0,004 reframing quality of life 0,252 0,056 spiritual support quality of life -0,300 0,022 family businesses seek and receive help quality of life 0,165 0,216 passive appraiasal quality of life -0,217 0,102 pearson correlation test result (p value ≤0,05) which indicate that family coping strategy significantly correlated with quality of life of elderly post-stroke. the analysis of correlation between social support variable with quality of life of elderly post stroke with pearson correlation test resulted in probability value 0,004 (p value ≤ 0,05) indicating that family social support significantly correlated with quality of life of elderly post stroke. analysis of the relationship between reframing variables and the quality of life of elderly post-stroke. the pearson correlation test yielded a probability value of 0.056 (p value ≥ 0.05) indicating that reframing did not significantly correlate with post-stroke survival elderly. the analysis of the relationship between the variables of family effort seeking and receiving help shows that spiritual support is not significantly related to the quality of life of elderly post-stroke, while passive acceptance is not significantly associated with poststroke survival of elderly. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.7 16 10 table 2 late linear regression model double relationship of family coping strategy with poststroke life quality of elderly in pontianak (n = 58) no model koefisien b p value r square (r 2 ) 1. constants 13,199 0,549 2. social support 1,013 0,001 0,312 3. reframing 0,507 0,14 4. efforts to find and receive help 0,827 0,121 5. passive acceptance 0,258 0,481 6. family income -1.6e,006 0,088 the final model shows that the independent variables that enter the linear regression model are social support, reframing, effort seeking and receiving passive help and acceptance as well as the confounding variable that is family income. r square value shows the value of 0.312 means that the regression model obtained can explain 31.2% variation of the dependent variable quality of life of the elderly. in the table anova f test results show that the value of p = 0.001 means at alpha 5% can state that the regression model fit (fit) with existing data. dependent and independent variables can be used to predict the elderly's quality of life variables. based on the value of coefficient b in table 2 it can be determined multiple linear regression model as follows: y=13,199+1,013x1+0,507x2+0,827x3+0,258x4-0,0000016x5 kualitas hidup lansia = 13,199 +1,013 dukungan sosial + 0,507 reframing + 0,827 usaha mencari dan menerima pertolongan + 0,258 penerimaan pasif–0,0000016 pendapatan keluarga. the most influential variable in this research is social support variable, because the value of p = 0.001 with the largest value of b coefficient is 1.013, where every increase of 1 score of social support value, then the elderly quality of life value will increase by 1.013 where the relationship of social support variable with the quality of life together with other variables produce the number 1,013 ie, reframing variables, effort seeking and receiving help, passive acceptance and family income discussion results analysis on quality of life of post-stroke elderly in pontianak city showed that mean of quality of life of post-stroke elderly in town of pontianak is equal to 76,29 (sd 5,651), result of mean interval estimate of quality of life quality of post-stroke elderly in population pontianak is between 74.81 to 77.78. the whoqol-bref questionnaire is divided into 4 domains: physical domain, psychology, social relations, and environment. conversion results from 4 domain average quality of life of elderly post stroke for physical domain 46,41 (sd 9,19). journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.7 16 11 the mean comparison of quality of life of chiu et al (2006) study conducted in taiwan using whoqol-bref instrument in acute stroke patients with n = 199 mean age = 72 average physical health 15.1 (sd 2.7), psychology 13, 9 (sd 2.5), average of social relationship 14,2 (sd 19,6), and environment 13,7 (sd 2,1). this shows that the average quality of life of post-stroke elderly people in pontianak is still above the average quality of life of acute stroke population in taiwan. based on the analysis of the researchers, this difference may be due to the age of respondents in taiwan average 72 years and this research is done in acute stroke, and ethnicity or social culture factor also can influence health status where pontianak city consists of various tribes and culture. ethnic factors play an important role in the maintenance of family health (stuart and laraia, 2005). edwards and o'connell's study (2003) was performed on chronic stroke in australia using whoqol-bref instrument with n = 74 mean age = 58.35 average physical health 60.5 (sd 21.2), psychology 59.8 (sd 21,5), average social relation 62.1 (sd 25,4), and environment 67,9 (sd 19,1). this shows that the average quality of stroke chronicles higher than the average post-stroke elderly in the city of pontianak. this difference is due to the research of o'connel performed on chronic strokes and performed in developed countries so that resources and care facilities for stroke patients are different, and in general post-chronic stroke has been dating and have a more effective coping. differences between caregiver caring for post-stroke patients between 1 month and 6 months where coping ability (cargiver coping ability) over 6 months is more effective which can affect quality of life (puymbroeck, 2005). chaiyawat (2012) stated the initial effectiveness of home rehabilitation programs during the first 6 months post stroke period leads to improvements and functions that will reduce disability and improve quality of life. this quality of life evaluation instrument has been applied internationally and crossculturally and has tested its validity and reliability. jennifer et.al (2009) in her study stated that the strongest predictors of stroke patients were their initial perception of hrqol and the effect of caregiver depression during post-stroke rehabilitation that may affect the quality of life in stroke patients. sutikno (2011) states that quality elderly life is functional condition of elderly at optimal condition, so that they can enjoy their old age with full meaning, happy and useful. the family relationship with the highest elderly was 79.3% for children, this was in agreement with his research wu, et al, (2009) which stated that after post hospitalization 85-90% of stroke patients treated by family members at home, including about 10-15% treated by nurses who work at home. the family continues to take responsibility for stroke patients. kaakinen et al. (2010) in allender (2014) also defines families as two or more individuals dependent on one another in emotional, physical, and economic support. his research, saban and hogan (2012), which states that cargivers who have a family relationship and female sex are more caring for their loved stroke patients and more quickly adapt to changes that occur and further improve the effectiveness in providing treatment for stroke patients. confounding income variable when tested model in multivariate, giving influence to other independent variable more than 10%. from the meaning of the coefficient beta states that any increase of 1 rupiah in family income, then the elderly quality of life will decrease by 0,0000016 after controlled social support, reframing, searching and receiving passive help and acceptance. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.7 16 12 the results are inversely proportional to the theory that income or economic factors affect quality of life. parker (2012) states that resources in this regard are the costs required for checks during rehabilitation to improve the quality of life of clients post-stroke. (flores & tomany-korman, 2008; hausmann, jeong, bost, & ibrahim, 2008; allender, 2014) access of the poor to health services becomes a gap to obtain quality services. (stuart and laraia, 2005) argue that economic factors are a crucial risk in seeking help in using in-house facilities, with low socioeconomic families experiencing difficulties in using health facilities such as money, goods or services that can be purchased. the higher the available resources, the family coping strategy will be stronger.francisco (2009) states that physical and psychosocial well-being is influenced by their clients and caregivers. based on the analysis researchers can be assumed that the relationship of blood or family has a high emotional relationship and have a commitment between caregiver with elderly post stroke so it will cause a great sense of responsibility. revenue in theory greatly affects the health status where clients can access health facilities. the result of bivariate test shows that family coping strategy in pontianak is significantly related to the quality of life of elderly post stroke. family coping strategies are divided into 5 subvariables (ie mccubbin, olson & larsen, 1991; walsh, 2998; friedman 2010); social support, reframing, spiritual support, seeking and receiving help, and passive acceptance. coping strategies are done effectively stressor no longer cause pressure psychologically, or physically but will be a stimulant that spurs achievement and physical and mental condition better. based on respondents' answers that most respondents are trying to try to solve the problem as soon as possible. darlington (2007) in his research stated that coping strategy is the most important determinant affecting quality of life, and he also states that coping has a big effect after 5 months of discharge. social support resulted in a p value of 0.004 from bivariate test results indicating that soial support has a very significant relationship with the quality of life of elderly poststroke. the end result of the multiple linear regression model states that every increase of 1 score of social support value then the quality of life number will increase 1.013 which means that the relationship of social support variable with quality of life together with reframing variables of effort seeking and receiving help, passive acceptance and family income . research conducted by grant (2007) which states that social support and emotional focus is a component that contributes to cargiver self-adjustment in problem solving. families utilizing social support systems in family social networks are a very important external family coping strategy that functions as a social, psychological, and behavioral function. dayapoglu (2010) also stated that quality of life score has positive impact and has significant relation with social support from family scale and aspect of life quality variable such as functional status, welfare, perception to general health and general life quality. liu (2005) in his research stated that social support including family support is an effective factor in solving problems with chronic diseases that can improve health status in improving quality of life. this is supported by respondents' answers mostly answered that they shared difficulties with their immediate family, asked for advice, discussed problems with their neighbors and asked the close family about how they felt about the problem, so that the elderly received massive social support from the family that could improve quality of life. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.7 16 13 the reframing variable with quality yielded a value (p value> 0.05) indicating that reframing did not significantly correlate with post-stroke survival of the elderly (clarke et al, 2010) in his research suggesting that short-runs to risk managment have implications for well being ( welfare) of individuals and is recommended for comprehensive assessment so that they know what they need. reframing is especially necessary in times of cryicitis or in acute stroke, which will improve the effectiveness of solving health problems especially in post-stroke elderly people who are attacked between 3-6 months. if this can be done then the quality of life of elderly post-stroke will increase. this is supported by the responses of respondents who mostly stated that they have the strength or ability to solve the problem. results analysis of spiritual support with quality of life in the city of pontianak (p value <0.05) indicates that spiritual support is significantly related to the quality of life of elderly post-stroke. spiritual trust is the individual and family religion is the core of all koping and family adaptation. confidence is a major force in increasing family resilience in family coping strategies (mccubbin, olson & larsen, 1991; walsh, 2998; friedman 2010). based on the above results, the spiritual support provided by the family in this case caregiver will increase the sense of comfort and safe in the elderly post stroke especially in the acute phase, because it will improve the psychosocial well being which will ultimately improve the quality of life of elderly post-stroke. this is supported by respondents' answers, most of whom claimed they were following religious activities in the mosque / church, asking for advice from religious leaders and believing in god's greatness. based on the calculation in modeling the change of coefficient value b on each independent variable of effort seek and receive help turns out there is value that change more than 10%, that is equal to (25,41%), it can be concluded that business variable seek and accept has a meaningful relationship with the quality of life. from the results of coefficient b on this variable states that every 1 digit increase in business variables seek and receive help then the quality of life will rise by 0.827 conclusion based on the results of research on the relationship of family coping strategies to the quality of life of post-stroke elderly in the city of pontianak, obtained the following conclusions: 1. characteristics of post-stroke elderly in the city of pontianak on average 65 years old, stroke less than 6 months, most categories of male sex, and low-educated. the characteristics of the families caring for the post-stroke elderly in pontainak are mostly female and have a family relationship as and the mean age after 33 years 2. quality of life post-stroke elderly in the city of pontianak an average of 76.29. conversion results from 4 domains mean the elderly's quality of life for social relations domains had the highest mean value. 3. family coping strategies have a significant relationship with the quality of life of elderly post stroke in general in the city of pontianak. 4. social support given is to tell the family difficulty with close family, friends or neighbors. 5. reframing given to elderly post-stroke families is that they have the ability to solve problems, the family has the power to solve problems, and show others that the family is strong and steadfast in the face of problems. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.7 16 14 6. spiritual support is given to follow the study activity in the mosque or other places of worship, participate in religious activities, seek advice from religious leaders, and believe in the greatness of god. 7. attempt to seek and receive help given to seek advice from other families who have similar problems, ask for help from puskesmas, ask for explanations and advice from doctors, ask for help and consult the experts. 8. family income in the city of pontianak is the only confounding variable that affects independent and dependent variables. references adientya, g & handayani, f.(2012). stres pada kejadian stroke. jurnal nursing studies. vol. 1. hal 183 – 188. anonim (2014). vulbarable population; who are they. website: http://www.ajmc.com/publications/diunduh tanggal 20 februari 2014 anonim (2014). health policy vulbarable population. website: http://www.urban.org/health_policy/vulnerable_populations index.cfm. diunduh tanggal 23 februari 2014. anderson, e. t., & mcfarlane, j. m. 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(2009). feeling sad and useless’: an investigation intopersonal journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.7 16 15 acceptance of dwasability and its association with depression following stroke. clinical rehabilitation 2010; 24: 556-564. ekawati sutikno (2011). hubungan antara fungsi keluarga dan kualitas hidup lansia. jurnal kedokteran indonesia, vol. 2/no. 1/januari/2011. fransesco, jose egido (2009). quality of life after stroke: the importance of a good recovery: journal stroke cerebrovasc dwas; 27:204–214 gunilla gosman-hedstrom, lwasbeth claesson,chrwastian blomstrand (2008), consequences of severity at stroke onset for health-related quality of life (hrql) and informal care: a 1-year follow-up in elderly stroke survivors. archives of gerontology and geriatrics 47 79–91. jennifer, et. all. (2009). cargiver characterwastics predict stroke quality of life at 4 months and 1 year.reaserch in nursing & health: 32, 592-605. joan s. grant, et. all. (2006). social support, social problem-solving abilities, and adjusment of family cargiver of stroke survivor. arch phys rehabilitation vol 87. marieke van puymbroeck, maude r. rittman (2005) quality-of-life predictors for caregivers at 1 and 6 months poststroke: results of path analyses. journal of rehabilitation research & developmentvolume 42, number 6, pages 747–760 maurer, f. a., & smith, c. m. (2005). community/public health nursing practice: health for families and populations. philadelphia: elsevier saunders. mccubin, h. mccubbin & thompson, a (1991) family assassment inventories for research and practice, madwason: university of winconsin, madwason. miller, c. a. (2012). nursing for wellness in older adults: theory and practice. sixth edition. philadelphia: j.b lippincott company. muslihati, i., lisandy, y., kasanah, r., & winarko, h. (2018). effect of education media video on improve stroke prevention behavior in continued age in wiyurejo pujon malang. journal of nursing practice, 1(2), 12-17. https://doi.org/10.30994/jnp.v1i2.28 pakaratee chaiyawata, kongkiat kulkantrakornb (2012). effectiveness of home rehabilitation program for waschemic stroke upon dwasability and quality of life: a randomized controlled trial. clinical neurology and neurosurgery 114 866– 870 riskesdas (2007). profil kesehatan indonesia. jakarta riskesdas (2007). profil kesehatan kalimantan barat . jakarta rosalyn j. pawlak (2006) reasons persons with stroke seek health care services after dwascharge home. master of science in nursing. university of ohio. (tidak dipublikasi) susan ky chow (2007) coping and caring: support for family caregivers of stroke survivors. journal compilation blackwell publwashing ltd. doi: 10.1111/j.13652702.2006.01711.x. townsend, m.c. (2009). psychiatric mental health nursing.sixth edition : concepts of care in evidence-based practice. philadephia. f.a. davwas company https://doi.org/10.30994/jnp.v1i2.28 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.2 no.1. october 2018. page.7 16 16 the internet stroke center. 2011. stroke statwastics. http://www.strokecenter.org/. diunduh tanggal 22 februari 2014 unfpa & help age international. (2012). ageing in the twenty-first century: a celebration and a challenge. new york united states cencus beureu. (2012). us department of commerce. www.cencus.gov. diakses tanggal 10 februari 2013, pukul 10.15 vicki stemmons mercer, et. all. step test scores are related measures of activity and participation in the first 6 months after stroke. psysical therapy vol 89. who (2004). who quality of life bref. geneva: world health organization journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.87-95 87 relationship response time handling stroke patients with anxiety of patients family in emergency room hendratmo lasaka, alfian fawzi, aprin rusmawati, agusta dian ellina* institute of health science strada indonesia, east java indonesia corresponding author: agustadian85@gmail.com abstract background: response time that is done to stroke patients when taken to hospital causes anxiety problem for the patient's family, this is due to family concerns about the health condition of family members who are waiting for the queue of action. purpose: this study aimed to know the relationship response time of stroke patients with anxiety in the patient's family in the emergency room. method: this research design was a correlational analytic with cross sectional approach. the population were all families of stroke patients in the emergency room of luwuk regional hospital averagely 35 patients per month, with accidental sampling technique obtained sampleas many as 33 respondents. the independent variable was response time with the dependent variable anxiety. data collection using a questionnaire. data analysis using spearman rank test on α = 0.05. result:the results showed that most respondents received response time in the right category, as many as 21 respondents (63.6%) and most respondents had an anxiety level in the moderate category, as many as 17 respondents (51.5%).analysis results spearman rank obtained p-value (0,000) <α (0.05) then h0 is rejected and h1 is accepted, which means there is a relationship between response time handling of stroke patients with anxiety in the patient's family in the emergency room conclution: the role of nurses is crucial in raising anxiety level in both patients and their families while in the emergency room. fast and appropriate services and no less important communication with the family is an important factor in providing certainty and educating in handling patients while in the emergency room so that families are not too worried about the situation that is happening. keywords: response time, stroke patients, anxiety. received july, 29, 2019; revised august 30, 2019; accepted september 22, 2019 how to cite: lasaka, h., fawzi, a., rusmawati, a., & ellina, a.d. (2019). relationship response time handling stroke patients with anxiety of patients family in emergency room. journal of nursing practice, 3(1), 87-95. https://doi.org/10.30994/jnp.v3i1.69 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v3i1.69 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.87-95 88 background stroke is a condition in which brain dysfunction occurs due to blood supply to the brain experiencing problems that occur suddenly (fast), and last for 24 hours so that biochemical reactions occur that cause cells in the brain to become dead (wiwit, 2010). according to thedefinition world health organization (who), stroke is a clinical sign that develops rapidly due to focal (or global) brain disorders with symptoms that last for 24 hours or more and can cause death without any other obvious cause other than vascular (harsono, 2009). to minimize the risk of brain damage, response time is the most important factor in early stroke management. the time period for handling a stroke is 3 hours from the the initial symptoms, more than three hour period is too dangerous for action. the part of the brain that does not get blood intake becomes damaged, if forced to take action to launch a blockage it is very risky to cause more severe bleeding in the brain (persistent, 2012). response time that is done to stroke patients when brought to the hospital raises its own anxiety problem for the patient's family, this is due to family concerns about the health condition of family members who are waiting for the queue of action (tumbuan, 2015). the phenomenon that often occurs related to response time is the patient's family does not know the problem of triage in the emergency room so that the patient's family sometimes thinks that the treatment is not fast and can cause anxiety for his family's critical health. anxiety itself is related to underlying health problems for a large number of people, in some cases anxiety is the first sign and symptom or indicator that someone has a medical disease (musliha, 2015) in 2017 data from the world health organization (who) shows as many as 15.1 million per year worldwide have a stroke (who, 2017). the indonesian stroke foundation (yastroki, 2017) states that indonesia in 2017 was the country with the largest number of stroke sufferers in asia, reaching 3.3 million people consisting of new and old sufferers. in indonesia stroke is the number three deadly disease after heart disease and cancer. about 3.85% of elderly people have a stroke and 12.9% at a younger age. every year an estimated 500 thousand people in indonesia suffer a stroke. of this amount, one third can recover, another third have mild to moderate functional impairment, and the remaining third have severe functional impairment which requires the sufferer to continue lying in bed. according to pambudi (2008), 78% of families of stroke patients experience anxiety related to the patient's health condition. the results of a preliminary study conducted on february 14, 2018 in the emergency room of luwuk regional hospital are known to have an average number of 31 stroke patients per month. observations made on 5 stroke patients known response time in 3 patients about 5 minutes, when an interview with the patient's family obtained answers that 2 of 3 family members said they were worried about the patient's condition because when they arrived the patient still had to wait, for them time 5 minutes was very long, while 1 other family member of the patient said he was grateful because the patient had been treated with not too long to wait even though he had been nervous and had cold sweat waiting for the patient to be treated. the other 2 stroke patients received response time within 12 minutes and 15 minutes, when asked about the feelings of the family obtained information that the two families who delivered the patient claimed to be very anxious even one of the families had to go back and forth to the toilet because of panic queues at the er long. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.87-95 89 stroke occurs when blood flow to the brain is disrupted. the disorder causes the blood supply to the brain decrease or stop. the human brain need of blood supply, because in the blood there are nutrients and oxygen for the brain. the brain that does not get blood supply will have an impact on paralysis so that it burdens the family but can also cause death. (wardhana, 2011). the condition of stroke patients who are not treated immediately can encourage damage to the brain resulting in decreased functional organ of the motion causing disruption in carrying out the daily activities of patients, even in some cases causing dependence, this has an impact on the emergence of anxiety in the family of stroke patients associated with patient recovery and the emergence of additional burdens on the family (ritarwan, 2013). the phenomenon that often occurs in emergency rooms related to response time is patient and family anxiety about emergency treatment. because most patients do not know about the problem triage in the emergency room so the patient's family sometimes thinks that the handling is not fast, causing anxiety for the health of family members (putri, 2016). the level of anxiety in the patient's family is not only influenced by the response time of nurse, but seen from the patient's worrisome condition so that the family still feels anxious and the lack of knowledge in the patient's family about emergency treatment makes the family more anxious. the success of response time is very dependent on the speed available and the quality of assistance to save lives or prevent defects from the scene, on the way to hospital help (hasan, 2012). many post-stroke sufferers become disabled enough to cause disruption in their activities if not treated immediately. this condition raises anxiety for his family because of the uncertainty of the future of this patient himself especially if the patient does not immediately get treatment (pudiastuti, 2011). nurses in carrying out the nursing process in stroke patients tend to only focus on patients and pay less attention to the family even though the family has an important role to help the nursing process, so nurses need to help prevent anxiety in the family by providing information that can be understood by the family. according to festy (2012), nurses need to involve the family in the initial care process of stroke patients so that the family is able to support the implementation of care measures properly. objectives this study aimed to know the relationship between response time handling stroke patients with anxiety in the patient's family in the emergency room of luwuk regional hospital methods design design of research used in this research was correlation analytic research which is a research that aims to find out the relationship between two or more variables with the process of data retrieval that only done once for each research variable (notoatmodjo, 2009). the approach used is cross sectional research that is independent variables and the dependent variable is measured simultaneously and carried out briefly or once (nursalam, 2008). journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.87-95 90 population, sample and sampling the population in this study were all families of stroke patients in the emergency room of luwuk regional hospital. using an accidental sampling technique as many as 33 respondents was obtained. research variables the independent variable in this study was response time, while the dependent variable was anxiety. the instrument used in this study is the observation sheet and questionnaire which is the type of primary data data analysis the statistical test used in this study is spearman rank test a level of deviation of 5% (α = 0.05). ethical considerations the participants were assured that their engagement was voluntary, and that anonymity, privacy, and confidentiality of the data were guaranteed. furthermore, they were informed about the purpose and the method of the study before signing a written informed consent. the questionnaires were distributed to eligible participants at the luwuk regional hospital, and respondents were asked to complete and return them in the same time. results response time for stroke patients in the emergency room of luwuk hospital. response time treating patients with stroke in luwuk hospital emergency room are as follows: tabel 1 variablecharacteristics of response time handlingstroke patients in hospitals emergency room luwuk may 9 june 9, 2018 no response time frequency% 1 exactly 21 63.6 2 notright 12 36, 4 total 33 100.0% based on table 4.1 it is known that most respondents get response time the appropriate category, which is 21 respondents (63.6%). anxiety in the family of stroke patients in the emergency room of luwuk hospital. anxiety in stroke family in luwuk hospital emergency room is as follows: tabel 2 variable characteristics of anxiety in stroke patient family in luwuk hospital emergency room may 9 june 9 2018 no anxiety frequency % 1 normal 0 0.0 2 mild 14 42.4 3 moderate 17 51.5 4 weight 2 6.1 total 33 100.0% journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.87-95 91 based on table 4.2 it is known that the majority of respondents have an anxiety level in the moderate category, namely 17 respondents (51.5%). data analysis hypothesis testing is done using thecorrelation test spearman rank obtained the following: tabel 1 resultsanalysis results of relationship response time handling of stroke patients with anxiety in patients' families in the emergency room of luwuk regional general hospital may 9 june 9 2018 variable correlation coefficient sig. (2-tailed) response time anxiety 0.678** 0,000 n 33 33 the results of the analysis using thetest spearman rank show p-value = 0,000 < = 0.05 then h0 is rejected and h1 is accepted, which means there is a relationship between response time handling stroke patients with anxiety for patients' families in luwuk regional hospital emergency room. based on the correlation coefficient of 0.678, it can be interpreted that the closeness of the relationship between the variable response time handling stroke patients with anxiety in the family patients in the strong category, 67.8% response time handling stroke patients associated with anxiety in the family received while the remaining 33.2% caused by other factors not examined in this study. discussion a. response time handling stroke patients in the emergency room of luwuk regional hospital response time handling of stroke patients in the emergency room of the luwuk regional hospital is known that most patients get response time in the right category, namely 21 patients (63.6%) and almost half of patients get a response time in the inappropriate category were 12 patients (36.4%). based on the characteristics of the respondents it is known that almost half of the respondents have basic education, namely 16 respondents (49%). response time is the speed in handling patients, calculated from the time the patient arrived until treatment was carried out (suhartati et al. 2011). a good response time for patients is ≤ 5 minutes. (ministry of health republic of indonesia, 2009). service response time can be calculated in a matter of minutes and is greatly influenced by various matters both regarding the number of personnel and other supporting components such as laboratory, radiology, pharmacy and administration services. response time is said to be on time or not late if the time required does not exceed the average standard time available (haryatun and sudaryanto, 2008). according to long (2016) nursing intervention given in the emergency room to save lives is done when the patient's physiological state is threatened, such actions include giving emergency medication, performing cardiopulmonary resuscitation. a lifesaving medical treatment can bring anxiety, because there is a threat to bodily integrity (araujo, 2014). journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.87-95 92 the results showed that the majority of patients received response time in the right category, but the number of patients who received response time in the incorrect category was still quite a lot, the condition was at risk of reducing the success rate of healing in stroke patients. time is a very important factor in the management of emergencies, it is important that therapy can follow a sequence in accordance with the order of urgency of the existing situation. the success of response time depends on the speed available and the quality of assistance to save lives or prevent severity. the critical time for handling stroke patients, especially ischemic stroke is 3 hours since the attack occurred. very short time is used to correct the blockage that occurs in the brain, but if more than 3 hours the patient has not received medical treatment, the patient will experience severe brain damage and result in extensive paralysis and cognitive impairment, there for is needed response time a fast possible to reduce the number of physical disabilities due to stroke. emergency management system in stroke patients in the er is adjusted to the patient's condition which is divided into 4 zones. in general, the patient's family does not know the zone division system so that the handling system in the er is in line with the queue of patients who enter. the triage system applied in the er has gone through an appropriate selection so that the health and lives of patients can be saved. however, based on observations it can be seen that there are some patients who do not get response time in accordance with the provisions of the triage due to lack of medical staff and equipment in the er and the large number of patients who are currently queuing to be immediately treated in the er. therefore, delivering clear information to the patient's family is important enough to prevent excessive anxiety in the family which can also have an impact on the decline in community satisfaction with the hospital. b. anxiety in the family of stroke patients in the emergency room of luwuk regional hospital anxiety in the families of stroke patients in the emergency room of the luwuk regional hospital is known that the majority of respondents have an anxiety level in the medium category, namely 17 respondents (51.5%). based on the cross tabulation it is known that respondents aged 36-45 years have anxiety levels in the mild category, which is 9 respondents (27.3%). anxiety is an uncomfortable feeling or vague worry accompanied by an autonomic response (the source is often not specific or unknown to the individual); feelings of fear caused by anticipation of danger. this is a sign of vigilance that warns individuals of danger and enables individuals to act in the face of threats. (nanda international, 2013). anxiety itself is related to the underlying health problems for a large number of people, in some cases anxiety is the first sign and symptom or indicator that a person has a medical disease (musliha, 2015). according to yulishati (2011) emergency nursing services are services provided to patients to cope with emergency conditions and also provide nursing care to overcome anxiety in patients / families. the results showed that the majority of patients' families experienced anxiety in the moderate category. anxiety experienced by the patient's family in the emergency room is usually related to the patient's condition, the hope of recovery, and medical action to be given. families also experience anxiety when they feel the service they journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.87-95 93 are receiving is slow so that concerns arise if the patient's condition can worsen. besides family anxiety can also arise due to lack of information received by the family from the hospital, especially related to the patient's condition and the priority system applied to the er. a nurse who provides information about emergency response time to patients or the patient's family, will have a positive impact, one of which is the family can understand the patient's condition and procedures that must be carried out by the hospital so that it can provide certainty to the family about the time of handling patients in the end can reduce anxiety. in terms of gender it is known that respondents with moderate anxiety tend to be more common in female respondents. related to anxiety in men and women, women are more anxious about their disabilities compared to men. men are more active and logical while women are more sensitive than men. they also tend to be able to think more rationally compared to women who have a tendency to think emotionally. therefore, women are easier to feel anxious when getting stressor anxiety in emergency room. c. relationship between response time handling of stroke patients with anxiety in the patient's family in the emergency room of luwuk regional hospital. the results showed that p-value = 0,000 < = 0.05 then h0 was rejected and h1 was accepted, which means there was a relationship between response time in handling stroke patients with anxiety in the patient's family in the emergency room of luwuk regional hospital. based on the correlation coefficient of 0.678, it can be interpreted that the closeness of the relationship between the variable response time handling stroke patients with anxiety in the family patients in the strong category, 67.8% response time handling stroke patients associated with anxiety in the family received while the remaining 33.2% caused by other factors not examined in this study. individuals that are classified as normal sometimes experience anxiety that appears, so that it can be witnessed in the appearance of physical and mental symptoms. physical symptoms include cold fingers, faster heart rate, cold sweats, dizziness, decreased appetite, poor sleep, chest tightness. mental symptoms are: fear of being overwritten by danger, unable to focus attention, not peaceful, wanting to escape from reality (siti sundari, 2014). the results showed that there was a significant relationship between response time and family anxiety in stroke patients. patients who come to the emergency room will experience a triage or priority selection process first. patients will get services according to their conditions (green, yellow, red or black). the time spent by the family while waiting for patients to enter the emergency room is synonymous with boredom, anxiety, stress and even suffering. reactions that can occur in anxious families include the release of cold sweat, trembling feelings of wanting to urinate over and over and running without a clear purpose. the inappropriate response time of patients in the emergency room at the time of the study was due to the lack of nurses in the emergency room compared to the number of patients who came in, as well as several patients who arrived at the same time in the emergency department so nurses had to prioritize the most emergency problems. the inaccuracy caused the patient and family to have to wait longer to get treatment with uncomfortable conditions due to confusion and fatigue, causing journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.87-95 94 increased family anxiety while waiting for treatment in the er. this is supported by the results of cross tabulation which shows that patients who get response time the right category, families experience anxiety in the mild category. under these circumstances, the role of nurses is very important because in addition to having the main role in the emergency department, the role of nurses is crucial in the emergence of anxiety levels both in patients and their families while in the er. fast and appropriate services and no less important communication with the family is an important factor in providing certainty and educating in handling patients while in the er so that families are not too worried about the situation that is happening. in addition, the main fact that must be improved is the quality of services in the er that needs to be improved through efforts to improve human resources, facilities, procedures, services and other technical aspects. conclusions most respondents get response time in the right category, which is 21 respondents (63.6%) and most respondents had an anxiety level in the moderate category, namely 17 respondents (51.5%). there is a relationship between response time handling of stroke patients with anxiety in the patient's family in the emergency room of luwuk regional hospital (p-value = 0,000 < =0.05) references bethesda, 2014. melanjutkan hidup pasca stroke. http://www.strokebethesda.com/index2.php?option=com_content&do_pdf=1& id=229. tanggal 7 februari, jam 10.30 wib. capernito, lynda j, 2015. diagnosa keperawatan aplikasi pada praktik klinis. jakarta : egc festy, p. 2012. peran keluarga dalam pelaksanaan rehabilitasi medik pada pasien stroke. jurnal penelitian fakultas ilmu kesehatan universitas muhammadiyah surabaya. hadari, 2016. instrumen penelitian bidang social. yogyakarta. gajah mada university press. hamsyah, a, 2014. warta pengendalian penyakit tidak menular. jakarta: depkes ri. hawari, dadang, 2011. manajemen stres cemas & depresi. jakarta : fakultas kedokteran universitas indonesia. junaidi, isakandar, 2011. stroke: waspada ancamannya. yogyakarta: andi. pambudi, h. 2016.. studi fenomologis kecemasan keluarga pada pasien stroke yang dirawat di ruang hnd santo lukas rs santa elisabeth semarang. artikel penelitian fakultas kedokteran undip. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.87-95 95 pudiastuti, r.d, 2015. penyakit pemicu stroke. yogyakarta: nuha medika ramaiah, s, 2015. kecemasan bagaimana mengatasi penyebabnya. jakarta: pustaka popular obor. ritarwan, k, 2013. pengaruh suhu tubuh terhadap outcome penderita stroke yang di rawat di rsup h. adam malik medan. jurnal penelitian fakultas kesehatan universitas sumetera utara. setiadi, 2015. keperawatan keluarga. jakarta: egc. stuart, g.w, 2016. buku saku keperawatan jiwa. jakarta: egc. sugiyono, 2010. statistika untuk penelitian. bandung : alfabeta. who. 2017, prevalence of stroke and transient ischaemic attack in the elderly population. http://www.who.int/infobase/report. tanggal 2 februari 2013, jam 09.00 wib. wihastuti, t.a, 2013. hubungan antara dukungan keluarga dengan tingkat kecemasan pada pasien pre operasi appendictomy di ruang flamboyan rsud tarakan pemerintah provinsi kalimantan timur. artikel penelitian fakultas keperawatan brawijaya. wright & leahey, 2012. nursing and familles ; a guide to family assessment and intervension. phyladelphia. davis company. yastroki. 2011. masyarakat perlu disadarkan untuk penanggulangan stroke. http://www.yastroki.or.id/read.php?id=349. tanggal 22 februari 2018, jam 08.00 wib yunitasari, p. 2012. hubungan jenis cva dengan kecemasan keluarga pasien cva di rssa kota malang. jurnal penelitian fk um malang journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.39-49 39 application of clean and healthy living behavior (phbs) from the household knowledge and attitude study ronasari mahaji putri, yanti rosdiana, aprilia choirun nisa faculty of health sciences, tribhuwana university tunggadewi, malang, indonesia corresponding author: putrirona@gmail.com abstract background: the behavior of clean and healthy life (phbs) is an obligation to be carried out by everyone. phbs is an effort to maintain the health of themselves and their families. the phbs coaching program has been running for approximately 18 years, but its success is far from expected. it is necessary to explore the factors underlying the failure to implement phbs. mothers as educators in the family, have an obligation not only to implement phbs for themselves, but also educate their children to conduct clean and healthy lifestyle. purpose: this study aimed to determine the application of clean and healthy behavior (phbs) from the study of knowledge and attitudes of housewives in the household setting. method: this research is a descriptive study with a cross sectional approach, involving 39 housewives in rt 03 rw 06 tlogomas malang. the sample is taken in total side. the independent variable is the knowledge and attitudes of housewives, while the dependent variable is clean and healthy living behavior. instrument to explore knowledge, attitudes and behavior using a questionnaire. data analysis using the spearman rank test. result: the results showed that as many as 43.6% of housewives were well informed, 76.9% of housewives had good attitudes, and as many as 69.2% of mothers had good phbs. statistical tests show there is no relationship between knowledge with phbs (p value 0.792), and there is a relationship between attitudes and phbs of housewives (pvalue 0.007). conclusion: the application of clean and healthy lifestyle is not related to knowledge, but is related to the attitude of housewives in rt 03 rw 06 tlogomas malang. keyword : mother, implementation, clean and healthy behavior, knowledge, household received july, 29, 2019; revised august 30, 2019; accepted september 22, 2019 how to cite: putri, r.m., rosdiana, y., & nisa, a.c. (2019). application of clean and healthy living behavior (phbs) from the household knowledge and attitude study. journal of nursing practice, 3(1), 39-49. https://doi.org/10.30994/jnp.v3i1.64 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v3i1.64 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.33-49 40 background family is the smallest unit of a society. various efforts will certainly always be carried out by the family, including in terms of health, with the aim that family life can live a healthy and happy life. clean and healthy life behavior (phbs) is an obligation to be carried out by everyone. phbs is an effort to maintain the health of themselves and their families. rahmawati (2012) revealed that phbs is an effort to make family members want and be able to act clean and healthy lives and play an active role in the movement of healthy living. the efforts carried out and expected from this clean and healthy lifestyle are in accordance with the health development mission in the range of 2015-2019, namely the indonesia program through improving health status, nutritional status with various efforts carried out and by empowering communities and supporting financial protection and providing health services evenly (indonesia, 2014). the phbs coaching program has been running for approximately 18 years, but its success is far from expected (dinas kesehatan lumajang, 2015). there are still many housewives who have phbs less. data shows that in east java 48.3% have good households, but this figure is still far from the 70% target (indonesia, 2014). data (kemenkes, 2018), it is known that from 38 regencies / cities in east java, 33 districts / cities were found with phbs policies reaching 86.84%; 9 regencies / cities from 38 districts / cities have implemented at least 5 themes of the community life movement campaign. the implementation of phbs in the household is not only the responsibility of the household, but the importance of each family member making this phbs effort. noncompliance of one family member in carrying out phbs indirectly will cause the emergence of infectious and non-infectious diseases. can be said so, because family members who do not run phbs will be at risk for experiencing greater disease than family members who implement phbs. with one family member suffering from illness, it will facilitate the transmission of the disease in one family. if the phbs business is carried out perfectly (in 10 indicators), it will reduce the incidence of undesirable diseases more or less. from the description above, it can be said that the beh(hidayat, ts dan faudia, 2011)avior of clean and healthy living is a way to prevent the entry of diseases into the body. slamet (2002) confirming that the implementation of phbs in a family or individual that is less likely to cause the body to contract the disease according to his lifestyle, also concluded that the level of poor health causes nutritional problems for individuals or families. agree with research (hidayat, ts dan faudia, 2011), that healthy environmental sanitation is related to the nutritional status of children under five (bb / u). mothers as educators in the family, have an obligation not only to implement phbs for themselves, but also educate their children to conduct clean and healthy lifestyle. various activities carried out by the mother, really took the attention and energy of housewives. starting from housework to caring for children and husbands, the point is to complete the work in the house. the busyness of housewives will increase without any help from other people (domestic helpers). housewives can easily experience stress if they do not have a good coping mechanism. in accordance with the putri,kak., sudhana (2013) who concluded that there was a difference in stress between housewives without help compared to mothers who used helpers (pvalue=0,00). as a result, if the mother experiences stress, the mother cannot carry out and complete household work, including not being able to do phbs. phbs housewives can run well, if the mother has good knowledge and attitude about the implementation of phbs. this study aims to determine the relationship between knowledge, attitudes and hygiene behavior in housewives rt 03 rw 06 malang tlogomas journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.33-49 41 objective this study aimed to determine the application of clean and healthy behavior (phbs) from the study of knowledge and attitudes of housewives in the household setting. methods this research is a descriptive study with a cross sectional approach, involving 39 housewives in rt 03 rw 06 tlogomas malang. the sample is taken in total population. the independent variable is the knowledge and attitudes of housewives, while the dependent variable is clean and healthy living behavior. instrument to explore knowledge, attitudes and behavior using a questionnaire. data analysis using the spearman rank test. the participants were assured that their engagement was voluntary, and that anonymity, privacy, and confidentiality of the data were guaranteed. furthermore, they were informed about the purpose and the method of the study before signing a written informed consent. the questionnaires were distributed to eligible participants at the tlogomas malang, and respondents were asked to complete and return them in the same time results tabel 1 frequency distribution of respondents based on characteristics of housewives in rt 03 rw 06 tlogomas malang age (years) total % 26-35 10 25,6 36-45 19 48,7 46-55 5 12,8 56-65 3 7,7 65 and above 2 5,1 mother’s work total % work 9 23,1 not work 30 76,9 mother’s education elementary scholl 10 25,6 junior hig scholl 9 23,1 high school 16 41 s1 4 10,3 family income < 2 jt 25 64,1 >2jt 14 35,9 get counseling yes 22 56,4 no 17 43,6 jamkesmas ownership yes 26 66,7 no 13 33,3 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.33-49 42 based on table 1 it is known that as many as 48.7 respondents aged 36-45 years; 76.9% of mothers do not work; 41% of mothers have high school education; 35.9% of mothers have family income> 2 million; 56.4% of mothers get counseling about phbs; as many as 25.6 mothers have elementary education; 66.7% had leadership in jamkesmas. from table 2, it is known that most housewives have phbs knowledge in sufficient categories, namely 17 people (43.6%). tabel 2 respondent frequency distribution based on knowledge of housewives about the application of clean and healthy behavior (phbs) in rw 06 tlogomas malang criteria total % well 14 35,9 enough 17 43,6 less 8 20,5 total 39 100 tabel 3. respondents' frequency distribution based on the attitudes of housewives about the application of healthy and healthy life behavior (phbs) in rw 06 tlogomas malang criteria total % well 30 76,9 enough 3 7,7 less 6 15,4 total 39 100 from table 3 it is known that most housewives have a good attitude about phbs, which is 30 people (76.9%). tabel 4. respondents 'frequency distribution based on housewives' behavior about the application of healthy and healthy life behavior (phbs) in rw 06 tlogomas malang criteria total % well 27 69,2 enough 4 10,3 less 8 20,5 total 39 100 from table 4 it is known that most housewives have good behavior about phbs, which is 27 people (69.2%). journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.33-49 43 table 5. cross tabulation of knowledge and behavior of housewives regarding the application of healthy and behavior (phbs) in rw 06 tlogomas malang knowledge perilaku total well enough less well 9 2 3 14 enough 14 2 1 17 less 4 0 4 8 total 27 4 8 39 from table 5 it is known that housewives who have sufficient knowledge will have an impact on good behavior by 14 people; and knowledgeable mothers will have an impact on phbs behavior that is less than 3 people. table 6. cross tabulation of attitudes and behavior of housewives about the application of healthy and behavior (phbs) in rw 06 tlogomas malang behavior total attitude well enough less well 23 3 4 30 enough 2 1 0 3 less 2 0 4 6 total 27 4 8 39 from table 6 it is known that mothers who have a good attitude, will behave well as many as 23 respondents; however, mothers who behave well also cause the formation of phbs behavior that is less than 4 people. the results of statistical tests using rank spearman to examine the relationship of knowledge with phbs behavior obtained p value 0.792 (above 0.05). it was concluded that there was no relationship between knowledge with phbs behavior in housewives; and the results of statistical tests to examine the relationship of attitude to phbs behavior obtained p value 0.007 (below 0.05). it was concluded that there was a relationship between attitudes and phbs behavior in housewives discussion knowledge phbs most housewives have enough phbs knowledge in the category. the data illustrates that the majority of mothers have sufficient understanding of clean and healthy living behaviors. if peeled out of 10 household indicators the value of knowledge is low in most mothers, namely the benefits of hand washing , consumption of vegetables and fruit, 3m benefits, the impact of smoking and latrines. while in other indicators, housewives already have good knowledge. mother's phbs knowledge in the category is enough due to many factors, one of which is education. most housewives have high school education. however, the next highest order is dominated by mothers with elementary school education (sd). the level of high school education can be categorized in higher education. by having higher education, journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.33-49 44 housewives will usually have better knowledge, especially phbs compared to loweducated mothers. elementary education is included in low education, where in this level a child does not have a good understanding, so it is more difficult to be able to receive information about something. although education is not the same as knowledge, however notoadmodjo(2007) view that education has a close relationship with knowledge. and this education is important as a basis for developing oneself. the higher a person's education, the easier it will be for someone to receive information and develop this information. and knowledge is important in shaping one's actions. from this analysis, it can be said that education contributes to phbs behavior. effendy j., (2008) states there is a relationship between education and phbs. in accordance with timisela (2007) who found that education level was the dominant factor in phbs. mother's knowledge about phbs is also influenced by age. most housewives are 3645 years old. age 36-45 is a category of mature age, which is very likely to influence the maturity of thinking and determine behavior that is considered better. age also determines maturity in thinking and acting. in accordance with the (suriyani, 2009); gita s.p,etc.(2018), which reveals that age has an influence on clean and healthy lifestyle. increasing age will make thinking more mature to behave something. various studies support the opinions of researchers. iskriyanti (2002) revealed that age will have an influence in the learning process, and become a factor that describes one's social, physical and psychological. the same harwinta (2008) which mentions there is a link between age and phbs. the results of the reinforcement research above are not in line with wantiyah (2004) who did not find a meaningful relationship between age and behavior, which is good behavior obtained at a younger age; maulana (2009) explained that age is a variable that is less correlated with behavior because it is considered more influenced by one's attitude. sufficient knowledge is also influenced by work factors. most of them are housewives. this profession is very possible to have a limited community environment, and allegedly has limited information as well. the community is limited, and the frequency is more at home than outside the home, making researchers believe that the information obtained is also limited. sesuai dengan notoatmodjo (2010) which states that the work environment contributes to experience and knowledge. nevertheless a housewife can be said to be someone who has more exposure in 10 indicators compared to other family members. however, it cannot be said that someone who is exposed to more with various phbs activities will have good knowledge. high exposure has an impact on experience in these behaviors. sufficient knowledge is also influenced by the availability of media in the household. half of the respondents (51.2%) have 2 media, namely television and handphone (cellphone). if seen from the ownership of these 2 media, it allows respondents to be able to find more information about phbs. also included in this phbs. housewives can actually get a variety of healthy information from the media they have at home. various media can be used to find information in a broad scope, namely radio, television, magazines and newspapers and the internet. however, this researcher's opinion needs to be reviewed by looking at the interest in the show / type of spectacle for housewives. the interest in health information through the media, will more or less have a good impact on the knowledge of housewives. rahayu (2010) mentioning that interest is a form of one's interest in something. if interest about something, is not in someone, it will become a barrier for someone to get information, especially phbs. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.33-49 45 phbs attitude most housewives have a good attitude about phbs. this data shows that the majority of mothers already have a good understanding of phbs, so that this understanding forms a good attitude / perception about phbs. respondents showed good attitude and supported from 10 indicators. from the percentage of mothers with more than 70% of mothers having a good attitude on each phbs indicator. the results of this study are in accordance with azrimaidaliza, karina,n., (2012) who also found that most rt mothers had a good attitude about phbs. research timisela (2007)) found attitude as the dominant factor in the formation of phbs. as well as zahara (2001); (yaslina, y., etc. 2018) who also found a positive association with maternal phbs in family settings. another study revealed that there was a relationship between family characteristics, knowledge of the family head, attitudes of the head of the family, utilization of information services and health services for phbs rt applied with phbs rt (khairiyati, l., rahman, f., udin, a., & anhar, 2019). from this kind attitude, ideally it should also form good behavior. support theory from notoatmodjo (2012) yang menyampaikan bahwa sikap mewujukan suatu bentuk perilaku. positive attitudes about maternal phbs are in a good category, due to one of them experiences. the experience of housewives here, which is meant is the experience of mothers in doing 10 indicators. researchers think that mother supports positively in carrying out 10 phbs indicators is possible because various phbs activities have long been run and can be said to be the results of education from mother's parents when they were small. so that it appears as a daily habit. because it has become a habit, it will be more inclined to have a positive attitude about this phbs. attitude is a response to a stimulus that appears. this attitude cannot be seen directly, but also determines the formation of behavior. notoatmodjo (2010) argues that attitude as a closed reaction (can be positive / negative) to a stimulus, which cannot be seen directly but can be interpreted from closed behavior. behavior most housewives have good behavior about phbs. this data shows that the majority of mothers have implemented 10 phbs indicators. if examined from each indicator, it is known that out of the 10 indicators only 5 indicators meet the average value, which is above 70% of mothers doing the activity. the five indicators are labor assisted by medical personnel, bringing toddlers once a month to posyandu, giving exclusive breastfeeding, washing hands before and after activities, and using clean water for household needs. while the other indicators are still below 70% of mothers who do it. means that there is still homework that must be completed in the household setting in the study. phbs must always be done in the household setting. given that by carrying out this phbs action although it is considered trivial but has a big impact on the health of the self and the surrounding community. of the 10 indicators there are several indicators that are risky if not done will cause infectious diseases. dinkes (2009), states that there are several indicators that play a role in the spread of infectious diseases caused by climate change namely "using clean water, washing hands with soap and clean water, using healthy toilets, removing larvae at home once a week. the clean and healthy behavior of good housewives in the household is one of the health determinants. with housewives implementing indicators specifically indicators that allow the transmission of disease, the incidence of diarrhea, dengue fever which often occurs in the data community is minimized. opinion of this researcher agrees with dinkes (2009); journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.33-49 46 raksanagara (2015) which revealed that with the mother doing the phbs indicator related to infectious diseases, various seasonal diseases that occur would be reduced. he also said that the incidence of dengue fever would be lower, and diarrhea if maternal phb increased. behavior and environment as the main factors detreminan infectious diseases. the results also showed that there was a correlation between clean and healthy living behavior with the incidence of diarrhea (r = -0.70), free numbers of larvae (r = -0,600 and dengue fever (r = -0,20). relationship of knowledge, attitude with clean and healthy behavior bivariate tests show that there is no relationship between knowledge and phbs and there is a relationship between attitudes and phbs of housewives. this data shows that in this study phbs was not related to knowledge. the researcher believes that knowledge is not the dominant factor that influences phbs. the results of this study contradict the theory which reveals that knowledge plays an important role in the formation of phbs. notoatmodjo, (2012) said that knowledge is the key to behavior, and also knowledge as a result of learning from one's sensory observations. the incompatibility of the results of the research with the theory is possible because the respondents in knowing the phbs are still in the stage of knowing they have not yet reached the stage of understanding "why this behavior should be done" so that it has not impacted the behavior of housewives. the researcher also believes that the behavior of clean and healthy living by housewives is possible to be a hereditary routine. this routine makes housewives undergo 10 indicators but have not arrived at the application stage. notoatmodjo (2010) that knowledge is the key to behavior, and also knowledge as a result of learning from one's sensory observations. the incompatibility of the results of the research with the theory is possible because the respondents in knowing the phbs are still in the stage of knowing they have not yet reached the stage of understanding "why this behavior should be done" so that it has not impacted the behavior of housewives. the researcher also believes that the behavior of clean and healthy living by housewives is possible to be a hereditary routine. this routine makes housewives undergo 10 indicators but have not arrived at the application stage. he also said that the level of knowledge from the stage of know, understand, application, analysis, synthesis and evaluation of phbs. researchers argue that someone will experience behavioral changes if they have a minimum level of knowledge of "understanding" level. someone who has knowledge, may not be able to apply it in behavior if there is no understanding stage. if studied from the level of education, respondents who have knowledge of the less category come from mothers who have elementary education level. in theory, the results of this study are appropriate, because this knowledge is the result of learning through the five senses. with low education, the mother has not yet been able to fully understand the information obtained. the higher education someone will be able to understand and develop information well. in addition there are also many factors that affect knowledge, which will have an impact on phbs. wawan, a dan dewi (2010) revealed the age, education, social culture and environment also formed phbs. clean and healthy life behavior (phbs) is a group of behaviors as learning outcomes so that it has an impact on the ability to help themselves and their families in the health field(depkes, 2006). the results of this study are in line with saibaka, y.e., tucuman, aat., rumayar, (2016) who examined the relationship between knowledge and attitudes with household journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.33-49 47 phbs in pusksesmas wawonasa, manado city, with the results there was no relationship between knowledge and phbs (p value 0.916). the results of this study contradict the research which found that there was a relationship between knowledge and attitudes with the implementation of phbs in the household, namely in the study suriyani (2009); artini (2010); azrimaidaliza, karina,n.(2012); (r. damayanti, etc. 2017); tumiwa (2015). the results of statistical tests also show that there is a relationship between attitudes and phbs. this data shows that attitudes are more dominant in influencing clean and healthy behavior. attitude is said to be a response to an event. someone will be healthy, if you have minimal knowledge at the stage of understanding the importance of something done. so here, researchers believe that attitudes are a determinant of whether or not a behavior is carried out, including in a clean and healthy lifestyle. including in conducting an assessment of something especially in matters relating to health. agree with ramdaniati (2008) which states that attitude is related to phbs. becker also argued that attitude as one of the domains in health behavior. as an opinion / assessment in relation to health care, attitudes to infectious and non-infectious diseases or other factors that affect human health, as well as attitudes to various existing health service facilities. the results of the statistical tests contradict some of the results of the research, namely azrimaidaliza, karina,n., (2012) who found a connection of knowledge, attitudes with the implementation of phbs mothers in households. this study also produced information that most rt mothers had a good attitude about phbs. likewise with kusumawati, y., astuti, d., (2008) also explained that there was a relationship between environmental health knowledge and clean and healthy lifestyle. likewise with resminawati (2010) which explains the relationship between the knowledge of the head of the family and the phbs of the head of the family but this is not in accordance with the results of the research of a well-informed mother who will have an impact on the phbs behavior that is lacking conclusion the application of clean and healthy lifestyle is not related to knowledge, but is related to the attitude of housewives in rt 03 rw 06 tlogomas malang. references artini, n. n. 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(2015). hubungan antara faktor predisposing, enabling, dan reinforcing dengan perilaku hidup bersih dan sehat tatanan rumah tangga di kecamatan remboken kabupaten minahasa, (online). retrieved from http://jkesmasfkm.unsrat.ac.id/wpcontent/uploads/2015/06/1-fix-fini-tumiwa.pdf wantiyah. (2004). gambaran perilaku hidup bersih dan sehat (phbs) di rw iv kelurahan terban wilayah kerja puskesmas gondosuman ii yogyakarta. program studi ilmu keperawatan fakultas kedokteran ugm. wawan, a dan dewi, m. (2010). teori dan pengukuran pengetahuan , sikap dan perilaku manusia. yogyakarta: nuha medika. yaslina, y., andini, b., & nofriadi, n. (2018). hubungan sikap dan motivasi dengan penerapan perilaku hidup bersih dan sehat (phbs)pada keluarga di wilayah kerja puskesmas gulai bancah kota bukittinggi tahun 2018. jurnal kesehatan perintis (perintis’s health journal), 1(65–72). retrieved from https://doi.org/10.33653/jkp.v5i1.97 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.22-32 22 relationship between family support and self care agency with the quality of living type ii diabetes patients in prolanis patients ferawati, mei fitria kurniati stikes insan cendikia husada, bojonegoro, east java, indonesia corresponding author: ferasacepu1@gmail.com abstract background: diabetes mellitus is a chronic disease characterized by high blood sugar level and is caused by an increase in glucose levels due to a progressive decrease in insulin secretion caused by insulin resistance. the ability of diabetic patients to do appropriate and succesful self-care habits is closely related to morbidity and mortality and significantly affect productivity and quality of life. purpose: this study aimed to determine the correlation between family support and self care agency with quality of life of diabetes mellitus patient type 2. method: this study uses analitycal methods, namely research that explores how and why health phenomena occur with a cross-sectional approach. result: the results of the spearman-rho test that the p-value in te sig (2-tailed) column 0.123 is more than the level of significance α 0,05 ( 0,000 < 0,05 ) so it can be concluded that h0 is accepted and h1 is rejected. conclusion: there is no relationship between self care agency and the quality of life of people with type 2 diabetes mellitus in prolanic patients. keywords: diabetes mellitus, self care, quality of life received july, 28, 2019; revised august 28, 2019; accepted september 20, 2019 how to cite: ferawati., & kurniati, m.f. (2019). relationship between family support and self care agency with the quality of living type ii diabetes patients in prolanis patients. journal of nursing practice, 3(1), 22-32. https://doi.org/10.30994/jnp.v3i1.62 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v3i1.62 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.22-32 23 background diabetes mellitus (dm) is a chronic disease characterized by blood sugar levels (blood glucose) that exceeds normal values and is caused by an increase in glucose levels due to a decrease in progressive insulin secretion caused by insulin resistance. dm consists of two types, namely type 1 dm and type 2 dm. compared to other types of dm, the number of patients with type ii dm is about 90% higher. the number of dm patients is increasing exponentially as the result of the changes in lifestyle in this era (suyono, 2009: 3-15). international diabetes federation (idf) (2015) mentioned that there are 415 million people in the world with dm and predicted that in the next 2040 the trend will continue to increase to 642 million. dm prevalence in indonesia is around 10 million people; which make indonesia in 7th place out of 10 countries with the highest dm in the world based on the survey conducted. in indonesia, there are 17 provinces with higher dm prevalences than the national average (5.7%). according to the data, east java province has 1.0% dm prevalence. in east java capital city, surabaya in 2009, there were 15,961 dm patients, and then in 2010 the number increased to 21,729 patients and to 26,613 in 2011. whereas in bojonegoro, based on data from the bojonegoro health office, the number of dm patients in 2016 is 27,875. out of that number, from the results of the preliminary study, there were 35 on chronic disease management program (cdmp) dm patients in dander health center. family is pivotal to individual growth and development; thus family becomes one of the most important aspects of nursing. through the family nursing care approach, family nurses can modify family environment, facilitate the achievement of the family development tasks, maintain the family structure and function and help the family adapt to the stressors so they can overcome health problems independently (friedman, 1998 in muhtar 2016). family support could be in the form of information, instrumental, emotional and appreciation support. research conducted by flynn et al., (2013) in wachyu f.a (2016) explained that family support will help to increase knowledge about hypertension and provide motivation to achieve goals of hypertension self care. the main aim of dm treatment is to prevent and minimize both acute and chronic complication (ayele, k., tesfa, b., abebe, l., tilahun, t., girma, e, 2012). complications of dm can be controlled, prevented and inhibited by controlling blood sugar levels through diabetes management activity with non-pharmacological and pharmacological approach (waspadji, s, 2009). the goal of dm treatment will be successful if the management of diabetes is carried out based on the patient's ability to start and act independently through self-care activity (asselstine, r.t.m, 2011 in rantung, 2015) the ability of dm patients to practice appropriate and successful self-care habits is closely related to morbidity and mortality and significantly affects productivity and quality of life (ayele, et al., 2012 in rantung, 2015). nurses as part of health workers play an important role in changing the behavior of patients and families to establish balance and independence in self-care activities. dorothea e. orem (1971) in tomey & alligood (2010) argued that everyone has the ability to fulfill their basic needs independently. the role of the nurse is as an agent who assists clients in returning their roles as a self-care agent. nurses as educators and counselors provide assistance in the form of supportive-educative systems by educating the patients to be able to perform care independently and improve patient compliance in treatment (muhtar, 2016). dm patients need time to adapt well to lifestyle changes. prevention and management strategy are very important in monitoring dm. maximum monitoring and management of dm will have a positive effect on health, especially on the quality of life and journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.22-32 24 life expectancy (sikdar, k. c., wang, p. p., macdonald, d., & gadag, v. g, 2010). the recent finding obtained in the rantung research (2015) was that most respondents did not carry out self-care activity optimally, since, on average, the respondents were satisfied with their quality of life. there was a relationship between self-care activity, gender and depression with the respondents quality of life. furthermore, there was no relationship between age, education level, income, and duration of suffering from dm with the quality of life. one of the functions of the family is as a health care function to maintain the condition of family members in order to have high productivity continously. this function becomes the primal task of the family in the health sector (suprajitno, 2004). families are expected to be able to meet primary health needs in order to protect and prevent diseases that families may experience. families as a small unit consisting of several family members need help from nurses to gain information about health, especially if the family is experiencing health problems. more specifically, family support is very important thing in the elderly selfcare management. this is in line with orem's theory which stated that family support is a basic factor that influences one's self care agency to make decision in implementing self care (nwinee, 2011; schnall, 2005 in f.a wahcyu, 2016) it is stated that family duties in the health sector included being aware of family health problems, deciding appropriate actions for families, caring for families with health problems, modifying the family environment to ensure family health and utilizing nearby health care facilities for families. for this reason, researchers are interested in raising the issue about the relationship of family support and self care agency with the quality of life of diabetes mellitus patient type 2 on cdmp in dander health center. objective this study aimed to determine the correlation between family support and self care agency with the quality of life of diabetes mellitus patient type 2 on cdmp in dander health center, which futher is expected to help dm patients to improve their quality of life. method this research is a quantitative research using a correlational description research design, a research that explains whether there is a correlation between independent variables and dependent variables through testing hypotheses (nursalam, 2016: 162). this study used analytical methods explores how and why health phenomena occur. then analyzing the correlation dynamics between phenomena or between risk factors and effect factors was conducted (nursalam, 2016: 163). it was continued until the conclusion was made by using a statistical test to analyze the data obtained. the research approach used in this study is cross-sectional, a study to observe the dynamics of correlation between risk factors and effects by approaching, observing or collecting data at one particular time (point time approach). it means that each research subject is only observed once only and measurement is made based on character status or subject variables at the time of investigation (notoadmodjo, 2012: 37). the design of this study aims to reveal the correlation between family support and self care agency with the quality of life of diabetes mellitus patient type 2 on cdmp in dander health center. the population in this study were dm patients who participated on cdmp in dander health center. meanwhile the sample in this study were dm patients who attended cdmp journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.22-32 25 activities in dander heatlh care using the non-probability sampling sampling technique with the accidental sampling method. the inclusion criteria in this study were dm patients who followed cdmp in dander, bojonegoro health center and those who were willing to be respondents in the study. the location of this study is dander health center. dander health center is a health center located in dander area which is located on the right side of the road addressed at jl. raya dander temayang no. 08 kab. bojonegoro, east java. the participants were assured that their engagement was voluntary, and that anonymity, privacy, and confidentiality of the data were guaranteed. furthermore, they were informed about the purpose and the method of the study before signing a written informed consent. the questionnaires were distributed to eligible participants at the dander health center, and respondents were asked to complete and return them in the same time result table 4.1 shows that as many as 32 respondents most of them are female, 24 respondents (75%). table 4.1 respondent frequency distribution based on gender no gender frequency percentage % 1 male 8 25 2 female 24 75 total 32 100 source : january questionnaire 2019 table 4.2 shows that out of 32 respondents most of them worked as a housewife which is 10 respondents (31.2%). table 4.2 respondent frequency distribution based on occupation no occupation frequency percentage % 1 housewife 10 31,2 2 merchant 8 25 3 farmer 6 18,8 4 retiree 8 25 total 32 100 source: january questionnaire 2019 table 4.3 shows that the majority of respondents had good family support which is 23 respondents (71.9%). table 4.3 frequency distribution based on family support no family support frequency percentage % 1 good 23 71,9 2 average 7 21,9 3 poor 2 6,2 total 23 100 source: january questionnaire 2019 table 4.4 shows that the average self care agency value is 2445.69. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.22-32 26 table 4.4 frequency distribution based on the self care agency variable n min max mean±sd self care agency 15 2101 2873 2445.69±188.643 source: january questionnaire 2019 table 4.5 shows that the majority (22 respondents/68.8%) of respondents had poor quality of life which table 4.5 frequency distribution based on quality of life no family support frequency percentage % 1 average 10 31,2 2 poor 22 68,8 total 32 100 source: january questionnaire 2019 the results of cross tabulation in table 4.6 found that most of the respondents who had good family support with average quality of life were 5 respondents (21.7%) and poor quality of life were 18 respondents (78.3%). families that had average family support with average quality of life are 5 respondents (71.4%) and poor quality of life are 2 respondents (28.6%). while families that had poor family support with poor quality of life were 2 respondents (100%). table 4.6 cross tabulation of the correlation between family support and the quality of life of diabetes mellitus patient type 2 on cdmp in dander health center. family support quality of life average poor total n % n % n % good 5 21,7 18 78,3 30 100 average 5 71,4 2 28,6 7 100 poor 0 0 2 100 2 100 total 10 31,2 22 68,8 32 100 based on the results of rho speraman test, it was shown that the results of the p-value in the sig column (2 tailed) obtained a value of 0.123 higher than the level of significant α 0.05 (0,000 <0.05) so that it can be concluded that h0 was accepted and h1 was rejected. this means that there is no correlation between family support and quality of life of diabetes mellitus patient type 2 on cdmp in dander health center. furthermore, the spearman correlation value of -0,279 shows that the direction of the negative correlation had a very weak correlation. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.22-32 27 table 4.7 the result of the correlation between family support and quality of life of diabetes mellitus patient type 2 on cdmp in dander health center. correlations family support quality of life spearman's rho family support correlation coefficient 1.000 -.279 sig. (2-tailed) . .123 n 32 32 quality of life correlation coefficient -.279 1.000 sig. (2-tailed) .123 . n 32 32 based on the results of the spearman rho test, it is shown that the results of the p-value in the sig column (2 tailed) obtained a value of 0.751 higher than the level of significant α 0.05 (0,000 <0.05) so that it can be concluded that h0 was accepted and h1 was rejected. it means that there is no correlation between self care agency and the quality of life of diabetes mellitus patient type 2 on cdmp in dander health center. the spearman correlation value of 0.058 indicates that the direction of positive correlation had a very weak correlation. table 4.8 the result of the correlation between self care agency and quality of life of diabetes mellitus patient type 2 on cdmp in dander health center correlations self care agency kualitas hidup spearman's rho self care agency correlation coefficient 1.000 .058 sig. (2-tailed) . .751 n 32 32 quality of life correlation coefficient .058 1.000 sig. (2-tailed) .751 . n 32 32 discussion the characteristics of respondents who have diabetes mellitus the factor that influences the results of this study is gender. based on table 4.1 shows that the majority of respondents are female which are 75% or 24 respondents, whereas male respondents only 25% or 4 male respondents. according to caplan and sadock (2005) in demak & suherman (2016), anxiety occurs more in women. women have a high level of anxiety because of the result of excessive autonomic nerve reactions with an increase in the sympathetic system, norepineprine, as well as cotalamin release, and there is an abnormal disorder of serotonergic regulation. this shows that gender will also affect the quality of life of the elderly who have diabetes mellitus in dealing with the problem. based on table 4.2, it shows that from 32 respondents most of them work as housewives (10 respondents /31.2%). the other data shows that there are respondents who work as merchant and retirees as many as 8 respondents or 25%, and as farmers 6 respondents or 18.8%. according to the results ansori and martiana’s research in 2017, it stated that the employment relationship is a work condition factor which is related to the occurrence of work stress. it means that the type of work done by a person also affects the journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.22-32 28 quality of life. meanwhile the study was conducted by zainuddin, et al (2015) in mirza (2017) was done to diabetes mellitus patients to see whether stress affects quality of life or not. the research obtained significant and negative results on stress variables, the lower the stress, the higher the quality of life, on the contrary the higher the quality of life, the lower the quality of life. in this study, the majority of cdmp respondents with diabetes mellitus worked as housewives. the demand as a housewife makes someone have to work harder since they have to deal with both their husbands and children. being a housewife is required to always be able to meet the needs of all family members, which ultimately makes the burden of housewives a little heavy. according to brunner and suddarth (2013), one of the factors causing diabetes mellitus is stress. this factor will damage beta cells in the body so that it will lead to insulin insufficiency. so it is not surprising if women who work as a housewife tend to have diabetes mellitus type 2 more. moreover, women are more susceptible to stress than men, and also the majority of respondents in this study are women with a profession as housewives. nursing action carried out by dorothea oreme was with independent nursing which means that the implementation of activity is initiated and carried out by the individual to meet the needs to maintain life, health, and well-being according to health conditions (oren, 1980 in maryani, 2014). that act of independence is expected to help people with diabetes mellitus to recover and be healthy. the healing process of diabetes mellitus requires patience and extra discipline because blood sugar levels can go up and down at any time if the patient does not maintain their diet properly. for this reason it is necessary to modify the environment of the nurse to the family and the patient's environment so that the patient can control the sugar content independently. family support toward diabetes mellitus type 2 patient. meanwhile in table 4.3 the characteristics of family support show that the majority of respondents had good family support which is 23 respondents (71.9%). other data said that 21.9% received sufficient support and 6.2% respondents received less support. based on these data, it can be concluded that diabetes mellitus type 2 patients had received good support from the family. in khairani's (2014) in kuntjoro (2002) study stated that emotional support allows someone to get emotional closeness; thus it creates a sense of security for the recipient. people who receive this kind of emotional support will feel calm, safe and comfortable which is indicated by a calm and happy attitude. this source of support is most often gained from spouses or families, close friends as well as relatives. according to brunner & suddarth (2002) in taluta, et al (2014), diabetes mellitus will also cause some psychological impacts such as anxiety, anger, grieving, shame, guilt, hopelessness, depression, loneliness, helplessness ,additionally the patients can also be passive, dependent, uncomfortable, confused and suffered. therefore, they really need support from their closest people. the support from the closest people such as family, will build an adaptive coping mechanism so that the recovery and healing process can be controlled properly. family support is beneficial for a development towards a healthy personality without any disturbance (kuntjoro, 2002 in cahyoputro, 2008). this is in line with the views of oreme in the independent nursing paradigm, with overall physical, mental, psychological, and social integration along with a various degrees of independent nursing ability, the level of well-being and health of individuals will increase well. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.22-32 29 the support from the closest family will make dm type 2 patients feel comfortable, assured to be cared for and loved so they can deal with the problems better. family support is very important in dealing with uncontrollable circumstances. dorothea oreme teaches nurses to also play a role as a supporter for the patients so that the patients can continue their lives independently. also, they can encourage the patients’ family to always provide good support in order to make the patients be able to carry out their activities independently. furthermore, the respondents with the average quality of life are 31.2% or 10 respondents while the respondents with the poor the quality of life are 22 respondents or 68.8%. one of the tasks in oreme's self care nursing model is to modify the environment that can support health (maryani, 2014). by making modification to the environment, the quality of family life will be better. the majority of the quality of life of the respondents in this study was poor, this is because the family had not been able to modify the environment such as utilizing health facilities around the respondent's environment. table 4.6 shows that from 32 respondents, who have diabetes mellitus, there are 5 respondents (21.7%) who had good family support with average quality of life and 18 respondents (78.3%) had poor quality of life. one of the ways to avoid loneliness is with the support of family and people around him. the result of this study, streghtened by hayati (2010) in khairani (2014) research, found that family support is the most important element in solving loneliness problem. family support is also able to provide a sense of confidence and motivation toward the patients and thus the quality of life will increase. the correlation between family support and the quality of life of diabetes mellitus patient type 2 on cdmp in dander health center according to the world health organization (who, 2004 in chusmeywati, 2016), quality of life is an individual's perception of value and concept in their relationship to achieve expectations. in this study, table 4.7 shows the correlation between the relationship between the self care agency and the quality of life of diabetes mellitus patient type 2 on cdmp in dander health center, based on the results of the rho series test, it is indicated that the p-value in the sig column (2 tailed) is 0.123 higher than the level of significant α 0.05 (0,000 <0.05) so that it can be concluded that h0 was accepted and h1 was rejected. this means that there is no correlation between family support and quality of life of diabetes mellitus patient type 2 on cdmp in dander health center. the spearman correlation value of -0,279 shows that the direction of the negative correlation had a very weak correlation. that result contradicts the study conducted by alvita (2016) regarding to the correlation of family support and the diabetes mellitus care of the elderly at home, the study found that there was a correlation between emotional support, award support, information, and instrumental with diabetes care in elderly with a value of p <0.05. in her research, alvita (2016) stated that the support given by the family to the elderly could increase the motivation of the elderly in performing dm care so that nurses needed to increase family participation in looking after the elderly who had dm especially by providing emotional support. in addition, alvita’s study is also in line with the results of research conducted by yusra (2010) regarding to the relationship of family support with the quality of life of dm type 2 internal polyclinic of fatmawati general hospital, jakarta, which stated that there was a correlation between family support in terms of four dimensions (emotional, appreciation, instrumental, and information) with quality of life. according to bomar (2004) in yusra (2010), reward is a support or assistance from the family in the form of providing feedback and appreciation by showing a positive journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.22-32 30 response, such as encouragement or approval of someone's ideas or feelings. similar to this statement, in the independent oreme nursing model there are three categories of nursing assistance given to individuals, namely wholly compensatory (full assistance), partially compensatory (partial assistance), and supportive-educative (educational support). if analyzed from the three assistances, it can be concluded that in order to achieve independent health, the help or support of the closest people is needed. the closest people can be from family, friends, even from nurses. in the theory of self care, support becomes one of the important things because when an individual gets a problem, he/she is unable to solve the problem independently without the support of the closest person. quality of life is a functional psychological capacity and social health as well as individual well-being. quality of life is influenced by physical health, psychological conditions, the level of dependence on social relations, and the relationship of patients to the surrounding environment. he also explained that family support given to dm ii patients can be viewed from four dimensions, namely: emotional dimensions, appreciation, instrumental, and participation (skevington et al., 2004 in nuraisyah et al., 2017). in this study, it was found that there was no correlation between family support and diabetes mellitus type 2 patients in dander health center, which proved that there was no significant influence between physical health, psychological conditions, level of dependence on social relations, and patients relationships with the surrounding environment because in the results of this study there was no significant correlation between family support and patients quality of life. the correlation between family support and quality of life of diabetes mellitus patient type 2 on cdmp in dander health center. according to orem, dorothea et al (2001) in ramawati, dian., et al (2012) self care is an activity and initiative by an individual in fulfilling and maintaining life, health and well-being. patients with diabetes mellitus will experience a psychological impact that will later result in despair to depression because of the long healing process and the effect of complications caused by it. in a study conducted by sari (2017), oreme argues that knowledge is what makes individual can perform his/her own self-care. self-awareness is the factor that determines the quality of life the most for people with dm. when nurses are able to optimalize dm patients’ knowledge, their obedience, self care agency and self-care activities will also increase. the factors that influence the behavior of self care according to the middle range theory of chronic illness are experience and skills, motivation, belief and cultural value, habits, functional, cognitive abilities, social support, facilities, and confidence including: self efficacy, self esteem. from the results of this study, it was found that between self care agency and quality of life of the dm type 2 patients in the dander health care were not correlated. in addition, based on the results of the spearman rho test, it was shown that the results of the p-value in the sig column (2 tailed) obtained a value of 0.751 higher than the level of significant α 0.05 (0,000 <0.05) so that it can be concluded that h0 was accepted and h1 was rejected. the spearman correlation value of 0.058 indicates that the direction of positive correlation had a very weak correlation. from these results it can be concluded that quality of life of diabetes mellitus patient type 2 on cdmp in dander health center has no correlation with the self care agency. this might be influenced by gender, employment, and family support of respondents in the dander health center. meanwhile, riegel suggested that self care behavior itself is influenced by experience and skills, motivation, belief and cultural value, confidence, habits, journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.22-32 31 functional and cognitive abilities, social support, and facilities (barbara, 2012 in ismatika & sholeha, 2017). in contrast from the results of a research conducted by chaidir, et al (2017) which concluded that there was a correlation between self care and the quality of life of patients with diabetes mellitus in tigo baleh health center which was directly proportional and had an average level of correlation, in which there were factors that influence the correlation of self care and the quality of life. it was known that the two results obtained were significant value (2-tailed) and the value of the correlation coefficient. significant value (2-tailed) between self care quality of life for patients with diabetes mellitus in tigo baleh health center, which is 0.001 (<0.05). it means that there was a significant correlation between self-care and quality of life of diabetes mellitus patients in tigo baleh health center. the difference in results from the research conducted by chaidir, et al (2017) with the results of this study may be influenced by the characteristics of different respondents in the study. conclusion from the results of the study it can be concluded that there is no correlation between self care agency with the quality life of diabetes mellitus patient type 2 on cdmp in dander health center.. based on the results of spearman rho test, it is shown that the results of the p-value in the sig column (2 tailed) obtained a value of 0.751 higher than the level of significant α 0.05 (0,000 <0.05) so it can be concluded that h0 was accepted and h1 was rejected. the spearman correlation value of 0.058 indicates that the direction of positive correlation has a very weak correlation. reference alligood,m.r., tomey, a.m. 2010. nursing theorists and their work. mosby alligood, martha raile. 2006. nursing theory: utilization and application. elsevier-mosby brunner dan sudarth.2013. keperawatanmedikalbedah.edisi 12.jakarta.egc. alvita, galia wardha. 2016. hubungan dukungan keluarga dengan perawatan diabetes mellitus pada lansia di rumah, kelurahan cisalak pasar kota depok. issn : 22528865 vol. 2, no, 4-maret, 2016. ansori&martiana. 2017. hubungan faktor karakteristik individu dan kondisi pekerjaan terhadap stres kerja pada perawat gigi. the indonesian journal of public health, vol. 12 no. 1, juli 2017: 75–84. cahyoputro, damar. hubungan antara faktor jenis kelamin dan dukungan sosialdengan tingkat kecemasan pada lansia di desaluwang, gatak, sukoharjo. naskah publikasi fakultas ilmu kesehatan universitas muhammadiyah surakarta. chaidir, dkk. 2017. hubungan self care dengan kualitas hidup pasien diabetes melitus. journal endurance 2(2) june 2017 (132-144). chusmeywati, vitta. 2016. hubungan dukungan keluarga terhadap kualitas hidup penderita diabetes melitus di rs pku muhammadiyah yogyakarta unit ii. naskah publikasi fakultas kedokteran dan ilmu kesehatan universitas muhammadiyah yogyakarta. damayanti. 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(2014). dasar-dasar metodologi penelitian klinis. edisi ke3. sagung seto. jakarta sari, ni putu wulan purnama. 2017. nursing agency untuk meningkatkan kepatuhan, selfcare agency (sca) dan aktivitas perawatan diri pada penderita diabetes mellitus (dm). jurnal ners lentera, vol. 5, no. 1, maret 2017. siokal, brajakson dkk. 2017. falsafah dan teori dalam keperawatan. jakarta : cv trans info media suhardingsih, av. sri., mahfoed, moh. hasan.,hargono, rahmat., nursalam. peningkatan self-care agency pasien dengan stroke iskemik setelah penerapan self-care regulation model jurnal ners vol. 7 no. 1 april 2012: 13–23. suprajitno. 2004. asuhan keperawatan keluarga aplikasi dalam praktik. jakarta : egc. utami, d.t., karim, d., agrina. 2014. faktor–faktor yang mempengaruhi kualitas hidup pasien diabetes mellitus dengan ulkus diabetikum. jom psik volume 1 nomor 1 oktober 2014. taluta, dkk. 2014. hubungan tingkat kecemasan dengan mekanisme koping pada penderita diabetes melitus tipe ii di poliklinik penyakit dalam rumah sakit umum daerah tobelo kabupaten halmahera utara. ejournal keperawatan (e-kp) volume 2. nomor 1. februari 2014. yusra, aini. 2011. hubungan antara dukungan keluarga dengan kualitas hidup pasien diabetes mellitus tipe 2 di poliklinik penyakit dalam rsup fatmawati jakarta. naskah publikasi fakultas keperawatan universitas indonesia : depok. journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.230-243 230 discharge planning to improve readiness transition care inpatient cerebrovaskuler accident: a literature review apriyani puji hastuti1*, nursalam1, fitri chandra kuspita1, lina ema purwanti1, domingos soares1, misutarno1, karyo1, ismuntania1, ratna roesardhyati2 1 department of nursing, universitas airlangga, surabaya, indonesia 2 department of nursing, institute technology, science and health, rs dr. soepraoen malang *corresponding author: apriyani.puji@itsk-soepraoen.ac.id abstract conclusion: review of discharge planning can be influenced by several factors: individual characteristics (clients' potential with special needs early, motivation), family factors (social resources, home environment), and health care system (teaching home care skills with community/ hospital professionals. these factors will affect the implementation of discharge planning in health services which is hospital accreditation. keywords: care, cerebrovascular accident, discharge planning, readiness received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.327 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. background: effective and continuity discharge planning is vital in care continuity and integrated care. continuity discharge planning can reduce avoidable hospital readmission, and fulfillment improves the quality of care. prevention efforts to prevent the re-attacks and readmission because of this cva attack should be started early before the patients return home from the hospital. purpose: this research aims to review the effect of discharge planning on the readiness of returning home in cva patients. methods: we included english materials published between science direct, pubmed, research gate, and google scholar that were used to find studies on discharge planning, readiness, and transitional care between 20162021. results: discharge planning is carried out in three-stage, inpatient admission and intra-hospital when the patient is about to be discharged from the hospital. in the first stage, the nurse explains patient admission, regulation, and management when the patient enters the hospital. the second stage is when the patient is hospitalized, which consists of nurses providing education about medication, environment, health, outpatient referral, and diet. while the last stage is when the patient will be discharged, the nurse explains the control, medication, and nutrition schedule at home. post-stroke rehabilitation and recovery is a chronic process. https://thejnp.org/ mailto:apriyani.puji@itsk-soepraoen.ac.id https://doi.org/10.30994/jnp.v6i2.300 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.230-243 231 background discharge planning is a systematic process in various disease cases, one of which is stroke or cva (cerebro vascular accident). in implementing discharge planning, multiple problems are still encountered, where nurses' knowledge about discharge planning is still very lacking, and discharge planning is still not implemented in its entirety (asmuji et al., 2018). discharge planning is an effort to educate patients and their families from the time they enter the hospital until they leave it to prepare their families to provide follow-up care at home (camicia et al., 2021). the goals of discharge planning include increasing the patient's readiness to leave the hospital and self-management at home (camicia et al., 2019). this systematic planning process starts from when the patient enters until he leaves the hospital. however, there are still many cva patients who experience relapse with complaints of the same disease. the discharge planning instrument used to prepare the patient to go home has not yet achieved its goals (griffiths et al., 2014). the effectiveness of the discharge planning instrument that was not found to be applied to cva patients who had been discharged from the hospital had not been carried out optimally and was well developed. the low level of family readiness in terms of knowledge and skills on how to care for patients at home is due to the implementation of discharge planning is limited to the routine performance of new patient admissions when entering the hospital or only providing information on recontrol that is carried out before leaving the hospital, resulting from failure in the program, home care planning (hsieh et al., 2017). cva is the third leading cause of death, with a mortality rate of 18-37% in the first attack, 62% in the second attack, and so on. as many as 2 million people survive cva infarction with a disability, of whom 40% require assistance with activities of daily living. previous research stated that 64% of nurses carried out discharge planning; 56% of the data were not based on structured planning and assessment of patient needs (asmuji et al., 2018). the nurse did not have time to provide health education because of the many nurses' actions and factors from the patients who were in a hurry to go home. in addition, studies conducted previously with discharge planning were associated with a prolonged length of stay, rehospitalization frequency, and decreased patient quality of life (hughes et al., 2018; serfontein et al., 2020). several factors that cause the recurrence of some cva patients include patients who are less disciplined in continued treatment at home, lack of family knowledge in carrying out follow-up care for cva patients, and nurses' lack of explanation of the continuity of care for stroke patients after returning from the hospital through discharge planning (dai et al., 2017). implementation of discharge planning in hospitals that are not carried out continuously when the patient arrives while in the hospital and preparing to go home is the cause of the high incidence of recurrent cva patients. the discharge planning, which should have been ongoing from the patient's admission to the patient's discharge, was not carried out correctly. discharge planning that was carried out did not reach the target as a medium for prevention, rehabilitation, and preparing patients and families regarding matters that must be considered at home, including a referral system for further treatment. the patient's and family's knowledge is not optimal, causing the family to bring the patient back to the hospital when the next attack occurs. in addition, the discharge planning implementation is carried out when the patient is about to leave the hospital, the discharge planning operational procedure does not provide overall guidance from the discharge planning process itself. finally, the procurement of the discharge planning format from the hospital management often experiences delays in its provision. this study aims to review discharge planning to improve readiness for transition care in a cerebrovascular accident. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.230-243 232 methods as shown in table 1, this investigation followed the preferred reporting items for systematic review and meta-analysis protocols (prisma-p) 2015 checklist. data sources and searches the database searched from science direct, pubmed, research gate, and google scholar provides studies on identifying discharge planning, the readiness of care, and transitional care determined from 20162021. in addition, we checked the reference lists of all included papers and conducted a systematic evaluation of the literature. study selection an inclusion criterion was used to select the studies. selected inclusion criteria were open access, cross-sectional, pre-experiment, experiment and randomized control trial, qualitative study with mother as a respondent, full-text articles, using english language, and study protocols. we included quantitative and qualitative papers that described intervention efforts. we considered studies that reported on discharge planning to improve care readiness as an outcome. data collection and analysis two writers independently examined the titles and abstracts of the obtained records to find potentially eligible studies. data extraction all citations were imported into the mendeley desktop program from an electronic database. to select potentially relevant research, reviewers independently assessed the titles and abstracts of each study found through a literature search. for additional investigation, the complete text of the remaining studies was collected. in this article, the authors carry out a systematic review of relevant data using the keywords "instrument" and "discharge planning" and "readiness of care" and "cerebrovascular accident." the same two reviewers collected the first author's name, year of publication, sample size, study design, trial duration, and participants’ general characteristics. # of records identified through database searching, n= 2260 # of additional records identified through other sources, n = 0 # of records after duplicates removed, n = 538 # of records screened, n = 538 # of records excluded, due to non-elderly participant, irrelevant studies, study protocol # of full-text articles assessed for eligibility, n = 34 # of records excluded, n = 9; due to out of asian country and the outcome preceptorship # of studies included in qualitative synthesis, n = 25 # of studies included in quantitative synthesis (metaanalysis), n = 8 s c re e n in g e li g ib il it y id e n ti fi c a ti o n https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.230-243 233 figure 1. preferred reporting items for systematic reviews and meta-analysis (prisma) flowchart study characteristics data were extracted from each study that needed the requirements. the extracted data included the characteristics of the study, parts of an age-friendly health system, activity in daily living, attributes of the results, and a summary of the results. the standard protocol for selecting studies is suggested in the systematic review method guide, prisma. the steps taken are: 1. removal of duplication 2. examination independently of titles, abstracts, and keywords and delete citations that were not relevant according to the inclusion criteria, 3. if the title and abstract are likely to follow the inclusion criteria and the objectives of the systematic review, the next step was the selection of journals with full text. 4. the final step was the selection of articles authors and years study design, sample, variable, instrument, analysis the outcome of the analysis of factors summary of result (camicia et al., 2021) design: a qualitative study sample: 20 stroke caregivers variable: uncertainty, anticipation, instrument: paths analysis: analyze data using thematic analysis. commitment, physical ability, resources need, prognosis, management strategies, need for self-care path-s item aided caregivers in recognizing potential issues and concerns about stroke and the caregiving role. caregivers experienced uncertainty about the long-term stroke prognosis, which provoked anticipation and cues to action to begin addressing their situation. uncertainty: 1. living in uncertainty and effect on the relationship (commitment strength of association) 2. uncertainty about physical ability to sustain caregiver role (capacity: preexisting factors (health problem) 3. uncertainty about the ability to fulfill other roles and responsibilities (capacity: preexisting factors/different roles and responsibilities) 4. uncertainty about resource needs (capacity: resources (internal/ external, informal/ formal, financial) 5. uncertainty about the long-term implication of stroke https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.230-243 234 (capacity: ability to sustain; power: crisis response) 6. uncertainty about prognosis/ recovery (long-term implication stroke: prognosis, long-term implication stroke: insight) anticipation 1. anticipating management strategies (capacity: resources and ability. to sustain) 2. predicting choices that will need to be made (commitment: willingness) 3. anticipating a need for self-care (capacity: ability to maintain) (nurjono et al., 2019) design: ethnographic research sample:169 individuals work in the health, social, and voluntary care sectors. variable: care processes, services, and organization instrument: this combined over 180 hours of observations of discharge processes and knowledgesharing activities in various care settings and qualitative interviews analysis: analysis of content identified interventions and practices that support knowledge sharing and collaboration in the processes of discharge planning and care transition 1. hospital discharge is a complex system involving dynamic and multidirectional patterns of knowledge sharing between multiple groups. 2. discharge planning and care transitions develop through linked 'situations' or knowledgesharing opportunities. 3. variations in these situations include the range of actors, forms of knowledge sharing, media and resources used, and the broader culture and organization of discharge. 4. patient safety is associated with hospital discharge, as participants and stakeholders perceive. there is related to falls, medicines, infection, clinical procedures, equipment, timing and scheduling of discharge, and communication. (lutz et al., 2017) design: a quantitative study sample: patient handovers between 1. to provide insight into hospital discharge problems and underlying causes and to give 1. ineffective discharge is related to factors at the level of the individual care provider, the patient, the relationship between providers, and the organizational https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.230-243 235 acute care hospitals and primary care in five countries, i.e., the netherlands, spain, poland, sweden, and italy variable: patient discharge and reducing hospital readmissions, intervention mapping instrument: analysis: the analysis was based on primary data from 26 focus group interviews and 321 individual interviews with patients and relatives and involved hospital and community care providers. an overview of solutions that guide providers and policymakers in improving hospital discharge. 2. to provide a comprehensive guiding framework for providers and policymakers to improve patient handover from hospital to primary care. and technical support for care providers 2. providers can reduce hospital readmission rates and adverse events by focusing on high-quality discharge information, well-coordinated care, and direct and timely communication with their colleagues. 3. patients, or their carers, should participate in the discharge process and be well aware of their health status and treatment. 4. assessment by hospital care providers of whether discharge information is accurate and understood by patients and their community counterparts are essential for overcoming identified barriers to effective discharge. (serfontein et al., 2020) design: qualitative research variable: health services administration, mental health services, patient discharge analysis: analysis concept 1. to bring clarity to the concept of discharge planning within a mental healthcare context 2. to ensure a safe transition of mental health patients from hospital to community settings, greater attention is being given to discharge planning. 3. to facilitate the evaluation of discharge planning and its meaning in the mental health 1. however, the lack of consistency in processes, care delivery models, and patient outcomes examined makes it difficult to conclude the quality and impact of discharge planning. 2. while preliminary efforts have been made to evaluate aspects of discharge planning, including the guideline, transition between inpatient mental health settings and community or care home settings by the national institute for health and care excellence (nice 2016), our ability to comprehensively evaluate discharge planning and compare disparate processes has been hampered by persistent conceptual confusion relating to https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.230-243 236 what, precisely, discharge planning comprises. 3. clarifying the concept of discharge planning is necessary to facilitate improved standards and evidence-informed evaluation methods for discharge planning processes in mental health care. (hu et al., 2020) design: prospective cohort study. sample: patients admitted at the general internal medicine wards of the tertiary referral hospital in turin, italy variable: brass index, discharge planning instrument: simplified brass index analysis: auc 1. discharged at home without complications, including all patients discharged at home with a length of stay (los) lower than the 90th percentile of drgspecific los observed in piedmont region hospitals. 2. complex discharge, including all alive patients not discharged at home or patients, discharged at home with a los more significant than the 90th percentile of drg-specific los observed in piedmont region hospitals in the same year. 3. dead in hospital. among 6044 patients in the study's first phase, 63% were discharged home without complications, 31% had complex discharge, and 6% died during the hospital stay. compared with the original index, the auc of the simplified brass index was 0.71 vs. 0.70 for complex discharge and 0.83 vs. 0.80 for hospital mortality. in the validation set (3325 patients), the simplified brass index discriminates the outcome categories with an auc of 0.69 and 0.81 for complex discharge and hospital mortality, respectively. (provencher et al., 2020) d: a quantitative study s: 400 hospitalized older patients. v: independence in adls, participation in life roles, number of rehospitalizations and physical characteristics, psychological characteristics, social characteristics. analyses revealed significant interaction effects for intervention by cognitive status for unplanned rehospitalization (p = 0.003) and ed presentations (p = 0.021) at 3 months. within the at-risk subgroup of mild cognitively impaired, the home intervention significantly reduced unplanned https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.230-243 237 late-life disability index, i: questioners a: descriptive statistics hospitalizations (p = 0.027), but the effect did not reach significance in ed visits. while the effect of home differed according to support received from family for participation in life roles (p = 0.019), the participation observed in home patients with no support was not significantly improved. (gholizadeh et al., 2018) d: a qualitative study s: 51 participants, including health policymakers, hospital and health managers, faculty members, nurses, practitioners, community medicine specialists, and other professionals of the ministry of health and medical education (mohme). v: implementation requirements, patient discharge planning, health systems. i: interview and fgd guideline. a: thematic and framework analyses method health reforms levels, recruitments, behavior, organization, payment, financing, and regulation (themes). according to the control knobs (health reforms levels), recruitments of effective hospital discharge planning were divided into four areas, behavior (of policymakers, service providers, recipient's services), organization, payment and financing, and regulation (themes), in which there were 3, 7, 2 and 3 sub-themes respectively. based on the findings of the interviews, they were categorized into the following main themes: behavior (policymakers, providers, and patients), organizational change, financing, payment system, and rules and regulations. (sakai et al., 2016) d: cross-sectional survey s: 624 ward nurses v: teaching homecare skills with community/hospital professionals, identifying clients' potential needs early in the discharge process, teaching homecare skills with community/hospital professionals, identifying clients' potential needs early in the discharge process, introducing social resources, identifying initially, 55 items were collected. examination of the floor effect, item-total, good– poor analyses, and exploratory factor analysis yielded a fourfactor model with 24 items ('teaching home-care skills with community/hospital professionals,' 'identifying clients' potential needs early in the discharge process,' https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.230-243 238 introducing social resources, identifying client/family wishes, and building consensus for discharge. i: questionnaire a: extreme skewness, good– poor (g-p) analysis, item-total (i-t). client/family wishes, and building consensus for discharge 'introducing social resources' and 'identifying client/family wishes and building consensus for discharge'). the four-factor structure was supported by confirmatory factor analysis. the dpwn correlated with scales ascertaining similar concepts, supporting concurrent validity. internal consistency and test-retest reliability were generally satisfactory. (emes et al., 2019) d: a case study s: 88 patients v: efficacy, efficiency, effectiveness, ethicality, and elegance. i: questionnaire a: statistically analysis proactivity, effective communication, keeping the process moving, this initiative saw a 20% reduction in the total length of stay for 88 patients in three wards where the spring form was used, while 248 patients in five control wards saw no significant change in the complete length of stay in the same period. these initiatives have reduced the total length of stay by 67%, from 55.8 days to 18.6 days for the patients studied. results the identified themes regarding discharge readiness are presented. articles recognized the importance of functional outcomes as a predictor of discharge destination, length of stay, readmission, and barriers and facilitators to discharges as essential to discharge planning in a patient with a cerebrovascular accident. factors as predictors of length of stay are age, functional status at patient admission, and time from access to injury, all significantly influencing applicable quality of discharge planning. in older patients, an early discharge to a familiar environment is more beneficial for a patient. besides that, a shorter stay for younger people was advantageous; they needed outpatient services. discharge planning determined the predictors of length of stay for a stroke patient at the point of admission and identified a patient's motor function at the entrance as well as their socioeconomic status and family structure, all influencing the length of stay in a patient with cerebrovascular accident. gender was not a significant factor in predicting length of stay, but age was substantial. moreover, comorbid and therapy have no predictive power. environmental factors are divided into categories support and relationship; product and technology; services, systems, and policies as facilitators; and physical geography as a barrier. finding across these studies suggest that they influence readiness for discharge from rehabilitation. from this study, the implementation of discharge planning can be influenced by several factors: individual characteristics (clients' potential with special needs early, motivation), family factors (social resources, home environment), and health care system (teaching home https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.230-243 239 care skills with community/ hospital professionals. these factors will affect the implementation of discharge planning in health services which is hospital accreditation. discharge planning is carried out in three-stage, inpatient admission, and intra-hospital when the patient is about to be discharged from the hospital. in the first stage, the nurse explains patient admission, regulation, and management when the patient enters the hospital. the second stage is when the patient is hospitalized, which consists of nurses providing education about medication, environment, health, outpatient referral, and diet. while the last stage is when the patient will be discharged, the nurse explains the control, medication, and nutrition schedule at home. post-stroke rehabilitation and recovery is a chronic process. the implementation of discharge planning is expected to improve the quality of life in cva patients and readmission into hospital in 90 days, improve the ability to activity daily living in a patient with cerebrovascular, and improve patient satisfaction as a standard of patient center care. one strategy to overcome the challenges of transitional care in stroke patients for clients and families is to provide and support the patient. patient survivors and keepers often report receipt with quality and quantity of information provided to patient and family or caregivers and the desire to receive higher quality information about the cerebrovascular accident. many interventions have been designed to educate patients during hospitalization. however, it is recognized that this is not a suitable time to absorb information effectively. besides, nurses and patients cannot be overcome only through a hospital approach. patients’ and their family's readiness for discharge planning is based on clinical reasoning and patient assessment. this review has been identified from the perspective of all stakeholders (patients, careers, allied health staff, medical teams, and organizational managers). these studies suggest that patients place as ready for discharge planning. they likely require support to adjust to their new impairment because in a cerebrovascular accident, patient immobilization. identifying a patient as prepared for discharge requires the patient to have a certain level of functional independence and have met their rehabilitation outcome. this review also identified that much of the research had been performed mainly with the cerebrovascular population, with occasional articles on the spinal cord and musculoskeletal patient population. this means that most conclusions are drawn about the patient's physical and cognitive impairment readiness to go home. we recognize that not all people can identify readiness indicators. however, the breadth of the clinical caseload in studies representative of demographics of hospitalized patients and rehabilitation settings for this diagnostic group and findings from reviews. therefore, it is very relevant to inpatient rehabilitation services internationally. discussion the initial screening and assessment are essential to differentiate patients with different risks and complexities in care needs for discharge planning. the initial screening and assessment specified that discharge planning should be classified as simple or complex at the point of patient admission (petitgout, 2015). emergency department, active medical disease, drugs, and need of a referral. however, it does not contain the functional, cognitive status, and mobility factors due to the unavailability of this data in the clinical management electronic system. thus, our framework has proposed seven other items such as social support, care support, the activity of daily living, functional status, mobility status, mental status, and fall history to supplement the tool, and these risk screening items were well accepted by the participants in the study the risk of prediction of readmission in patients aged 60 or above. it includes the essential 13 specific risk factors: age, https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.230-243 240 gender, living situation, functional status, cognitive status, behavior pattern, mobility, sensory deficit, number of the previous admission, number of the last admission through the accident & emergency department, active medical disease, drugs, and need of a referral. however, it does not contain the functional, cognitive status, and mobility factors due to the unavailability of this data in the clinical management electronic system. thus, our framework has proposed seven other items, such as social support, care support, the activity of daily living, functional status, mobility status, mental status, and fall history, to supplement the tool. the participants in the study well accepted these risk screening items. the implementation of discharge planning with this traditional model does not involve much multidisciplinary, and nurses do not do much assessment, intervention, and education, as well as evaluate the readiness of patients and families to return home. the weakness of this model is that patients and families do not understand the instructions for self-care at home, and the tendency of patients to return to the hospital is higher. structured discharge planning can improve the smooth transition of patient care from hospital to home. inadequate discharge planning significantly contributes to the decline in quality of care and the inefficiency of wasteful healthcare costs. when the patient is discharged from the hospital, the patient will receive various information about how to perform maintenance at home independently, which medications to take, the symptoms of complications to watch out for, and who health workers can be contacted if they have problems with home care (petitgout, 2015). readiness for discharge in this study was assessed using the readiness for hospital discharge scale (rhds). the rhds questionnaire includes 21 question items that measure the patient's perception of readiness to go home from the hospital, which consists of four discharge readiness factors: personal status, knowledge, coping abilities, and support. emotional status is defined as the patient's physical-emotional statement immediately before discharge. knowledge is defined as the perception of the adequacy of the information needed to respond to the same problems and problems in the post-hospitalized period. coping ability refers to the patient's perceived ability to self-manage personal care and health needs after discharge. expected support is the emotional and instrumental assistance that is expected to be available after the patient is discharged from the hospital and is well supported transitioning to home-based care (alemayehu et al., 2021). structured discharge planning can improve care transition patients from hospital to house. discharge planning that doesn't adequate is the main contributor to a decrease in the quality of care and health care cost inefficiencies wasteful. when the patient is discharged from in the hospital, the patient will receive various information about how to perform care at home independently, the medication to be taken, symptoms of complications that should be watched out for, and who the health workers can be contacted if they experience problems with home care (petitgout, 2015). providing adequate information for patients and their families during hospitalization can positively impact patients and families to help themselves during the healing process at home. insufficient and unclear information will have adverse effects, such as errors when taking drugs, poor diet, or neglecting activities after returning from the hospital. proper health education during hospitalization is critical in improving the ability to manage the disease because, with good management, acute and chronic complications of diabetes can be avoided. discharge planning that has not been optimal has an impact on the patient. the effect is an increase in the number of readmissions, and in the end, the patient will bear the financing for hospitalization costs. the patient's relapse or re-treatment condition is sure to the patient, his family, and the hospital. the state of this patient's recurrence is undoubtedly very harmful to the patient, family, and the hospital. customers will gradually abandon hospitals that https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.230-243 241 experience this condition. several studies examined the impact of less than discharge planning implementation. the role of nurses in hospitals is to work as professional health service providers because nurses act as case managers and patient care practitioners. before going home, the nurse provides services in the form of pre-discharge care, namely discharge planning stroke, by providing information and teaching families about how the patient helps to move from bed to chair, assists in dressing, bathing, and washing, and how to give medicine correctly, when to take medication for home control the patient's behavior can be changed by giving discharge planning, namely through the information provided to the patient so that it becomes a stimulus that can increase knowledge and influence awareness to behave as expected. stroke patients have different abilities and responses to the given stimulus, so the patient's behavior and ability to perform self-care are also other. the results obtained through the provision of distributed planning can provide many benefits for stroke patients in the short and long term. short-term include being able to control blood pressure, lifestyle modifications (physical activity, diet, smoking habits), and control of mental status (depression and anxiety) are shortterm outcomes. meanwhile, from the long-term psychological rate (confidence and coping), health service facilities (control) should be utilized. expected from the long-term effect is the prevention of recurrent stroke. the process of discharge planning are: 1) in the early entry: the observation of health conditions and health problems, the approximate length of treatment, the doctor/nurse who is in charge of the treatment, the estimated cost of care, the orientation of spaces and facilities; 2) during the treatment: diseases and nursing problems faced by the patients, the required supporting examination, doctor therapy and nursing interventions conducted; 3) before leaving the hospital: the treatment of stroke patients at home, the drugs are still consumed at home, the diet during the patients are at home, the introduction of the critical condition of the patients, and time to check up. while in the control group, the materials of discharge planning included the time to check up, the way to take medicine and some lifestyle changes that must be done. thus giving the discharge planning at the beginning of admission to hospitalized, during the treatment, and by the time before the patients leave the hospital is very effective in improving the patient's readiness because there is a two-way communication effectively between the giver of discharge planning and patient that gives a chance to the patient to participate in the problemsolving process so that the goals of discharge planning can be achieved. conclusion the results of this literature review answer the research question that discharge planning positively affects stroke patients' quality of life through lifestyle changes, motivation, family support, and knowledge of stroke patients. then, it can conclude that discharge planning is effective for changes in training, quality of life, motivation, family support, and knowledge of stroke patients. discharge planning at the beginning of admission to hospitalized, during the treatment, and by the time before the patients leave the hospital is very effective in improving the patient's readiness because there is a two-way communication effectively between the giver of discharge planning and the patient that gives a chance to the patient to participate in the problem-solving process. therefore, the use of discharge planning can be recommended as an intervention that can be developed to help nurses provide good nursing care. references alemayehu, m., tinsae, f., haileslassie, k., seid, o., gebregziabher, g., yebyo, h., gonah, l., mutambara, j., nash, k. l., blythe, j. l., cvitanovic, c., fulton, e. a., halpern, b. s., milner-gulland, e. j., addison, p. f. e., pecl, g. t., watson, r. a., blanchard, j. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 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(2017). stroke severity may predict causes of readmission within one year in patients with first ischemic stroke event. journal of the neurological sciences, 372, 21–27. https://doi.org/10.1016/j.jns.2016.11.026. hu, r., gu, b., tan, q., xiao, k. z., li, x., cao, x., song, t., & jiang, x. (2020). the effects of a transitional care program on discharge readiness, transitional care quality, health services utilization and satisfaction among chinese kidney transplant recipients: a randomized controlled trial. international journal of nursing studies, 110. https://doi.org/10.1016/j.ijnurstu.2020.103700. hughes, a. k., woodward, a. t., fritz, m. c., & reeves, m. j. (2018). improving stroke transitions: development and implementation of a social work case management intervention. social work in health care, 57(2), 95–108. https://doi.org/10.1080/00981389.2017.1401027. lutz, b. j., young, m. e., creasy, k. r., martz, c., eisenbrandt, l., brunny, j. n., & cook, c. (2017). improving stroke caregiver readiness for transition from inpatient rehabilitation to home. gerontologist, 57(5), 880–889. https://doi.org/10.1093/geront/gnw135. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.230-243 243 nurjono, m., shrestha, p., ang, i. y. h., shiraz, f., yoong, j. s. y., toh, s. a. e. s., & vrijhoef, h. j. m. (2019). implementation fidelity of a strategy to integrate service delivery: learnings from a transitional care program for individuals with complex needs in singapore. bmc health services research, 19(1), 1–15. https://doi.org/10.1186/s12913-019-3980-x. petitgout, j. m. 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(2016). developing an instrument to self-evaluate the discharge planning of ward nurses. nursing open, 3(1), 30–40. https://doi.org/10.1002/nop2.31. serfontein, l., visser, m., van schalkwyk, m., van rooyen, c., camicia, m., lutz, b. j., harvath, t. a., joseph, j. g., hughes, a. k., woodward, a. t., fritz, m. c., reeves, m. j., gledhill, k., hanna, l., nicks, r., lannin, n. a., suksatan, w., posai, v., kurniati, n., … fritz, m. c. (2020). effects of a structured discharge planning program on perceived functional status, cardiac self-efficacy, patient satisfaction, and unexpected hospital revisits among filipino cardiac patients: a randomized controlled study. rehabilitation nursing, 57(1), 65–75. https://doi.org/10.1097/rnj.0000000000000267. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.195-206 195 implementation early of initiation breastfeeding (eib) by health workers in the maternity room of 'aisyiyah ponorogo general hospital during covid-19 pandemic dian meilani saputra*, byba melda suhita, ratna wardani, nurdina institut ilmu kesehatan strada indonesia, kediri, indonesia *corresponding author: dianmeilani96@yahoo.com abstract background: early of initiation breastfeeding (eib) can reduce the infant mortality rate (imr) and maternal mortality rate (mmr). the covid-19 pandemic reduced early initiation of breastfeeding activities. as a result of the covid-19 pandemic, access to essential services such as breastfeeding counseling in hospitals has been disrupted. purpose: the purpose of this study is that researchers want to examine the implementation of the eib by health workers in the maternity room of "aisyiyah ponorogo" general hospital during the covid-19 pandemic. methods: the research used was qualitative with a case study design. the social situation in this study was delivery support health workers in the maternity room and perinatology room with informants consisting of five implementing midwives and six implementing nurses. the data collection process was carried out until the data collected experienced data saturation. data validity was tested using source triangulation, namely patients who gave birth at "aisyiyah ponorogo" general hospital. results: eib at 'aisyiyah ponorogo general hospital has always been applied to newborns since 2010 and underwent adjustments during covid-19 pandemic. the eib was not implemented due to several conditions which made it impossible. supporting factors for the implementation of early initiation of breastfeeding are the number and ability of health workers and the facilities available from both the hospital and the patient's family. the obstacle in this study is the perinatology room which is located far away so that the nurses in the perinatology department have difficulty carrying out several tasks at once which will cause a discrepancy in the duration of eib implementation. conclusion: collaboration between the hospital, health workers, and the community is needed in an effort to increase the implementation of eib. starting from the existence of policies from the hospital, the ability of health workers and the willingness of the community to improve the implementation of eib. keywords: covid-19, eib, implementation received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.366 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:dianmeilani96@yahoo.com https://doi.org/10.30994/jnp.v6i2.300 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.195-206 196 background early of breastfeeding initiation (eib) can reduce the infant mortality rate (imr) and maternal mortality rate (mmr). one of the causes of mmr in indonesia is the occurrence of postpartum hemorrhage. one program that can prevent postpartum hemorrhage is breastfeeding for 6 months because when the baby sucks the smooth muscles of the nipple, the pituitary gland will release the hormone oxytocin. the hormone oxytocin can stimulate the uterine muscles to contract better, thereby reducing the occurrence of bleeding. (susilawati, 2020). according to the 2013 basic health research (riskesdas), the highest percentage of breastfeeding in children aged 0-23 months is 1-6 hours (35.2%). the process of starting to breastfeed in the first hour after birth / eib is only 34.5%. eib has increased in 2018. based on the results of the 2018 riskesdas, the proportion of eib in children aged 0-23 months is 58.2%. of this proportion, only 15.9% did eib ≥ 1 hour. the 2019 strategic plan target regarding the coverage of newborns getting eib is 50%. whereas in east java it is known that the coverage of newborns receiving eib in 2019 is 69.81%. ponorogo regency, in 2019, 37.2% did eib in newborns less than one hour old. so that in 2019 ponorogo regency has not met the target set regarding eib coverage in newborns (kemenkes, 2019). the covid-19 pandemic reduced eib. this condition occurs because the visits of pregnant women are limited, so that pre-natal lactation counseling services are hampered. lactation counseling is one of the keys to the success of the exclusive breastfeeding program. not to mention the mothers giving birth who are positive for covid-19. this makes eib not run because it avoids close contact with the mother so that breastfeeding as often as possible according to the baby's needs is also not carried out (harsono, 2020). as a result of the covid-19 pandemic, access to essential services such as breastfeeding counseling in hospitals, health clinics, and through home and hospital visits has been disrupted. inaccurate information circulating about the safety of breastfeeding has reduced breastfeeding rates because mothers are afraid of passing diseases to their babies (who, 2020). methods the research used was qualitative with a case study design. the social situation in this study was delivery support health workers in the perinatology room and room with informants consisting of 5 implementing midwives and 6 implementing nurses. the data collection process was carried out until the data collected experienced data saturation. test the validity of the data using source triangulation, namely patients who gave birth at "aisyiyah ponorogo general hospital. results characteristics of informants the main informants in this study were 6 informants from the mashitoh room and 5 people from the perinatology room who had the following characteristics: table 1. characteristics of informants no resp name age (th) gender education length of work (th) job/position 01 nh 55 female diploma iii study program in midwifery. 30 head of mashitoh room https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.195-206 197 02 hz 40 female diploma iv study program in midwifery. 15 midwife in mashitoh room 03 nt 41 female diploma iii study program in nursing 18 nurse in the perinatology room 04 tjd 39 female bachelor of nursing 15 kepala ruangan perinatologi 05 ipl 31 female bachelor of nursing 6 nurse in the perinatology room 06 rps 36 female diploma iv study program in midwifery. 11 midwife in mashitoh room 07 hth 31 female bachelor of nursing 2 nurse in the perinatology room 08 sn 36 female bachelor of nursing 12 nurse in the perinatology room 09 wr 30 female diploma iii study program in midwifery. 6 bidan pelaksana di r. mashitoh 10 hc 37 female diploma iii study program in midwifery. 12 midwife in mashitoh room 11 s 46 female bachelor of nursing 24 nurse in the perinatology room the informants in this study were between the ages of 31 until 55 and all were female. the education possessed by the informants was from bachelor of nursing, diploma iv study program in midwifery, and diploma iii study program in midwifery where they were placed in a work space that was in accordance with their area of expertise, namely in the mashitoh room which was a delivery room at the 'aisyiyah general hospital ponorogo with midwives personnel while the perinatology room with nurse personnel. the two rooms worked together when carrying out delivery assistance in the mashitoh room. discussion eib implementation policy at 'aisyiyah ponorogo general hospital during the covid19 pandemic. some informants gave an explanation with some hesitation that the policy regarding eib had existed since the perinatology room was formed, which started in 2010. at that time the implementation related to eib was still going through the process of structuring and completing a simple guideline or standard operating procedure (sop). the implementation of eib is one of the neonatal services, namely ponek. but so far the implementation of eib is not necessarily the same in practice, it all depends on the condition of the mother after giving birth and the physical condition of her baby. the implementation of eib began with emas https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.195-206 198 (expanding maternal & neonatal survival) by making adjustments and improvements to the sop for implementing eib from the team at 'aisyiyah general hospital. the indonesian government supports the who and unicef policies regarding the eib program as a life-saving measure. the eib activities have been introduced by the government of indonesia since 2007. breastfeeding in the first hour of life which begins with skin-to-skin contact between mother and baby is declared a global indicator. this is a new thing for indonesia, and is a government program, so it is hoped that all health workers at all levels of health services, both private and community, can socialize and implement it to support the success of the program, so that it is hoped that quality indonesian human resources will be achieved. (depkes ri, 2008). activities in implementation of eib and exclusive breastfeeding are also supported by the government regulation of the republic of indonesia number 33 of 2012 concerning exclusive breastfeeding. the contents contained therein include that exclusive breastfeeding is the responsibility of the government, both the central, provincial and regional governments. the regulation also stipulates an article in the implementation of eib in which health workers and providers of health service facilities are required to carry out early initiation of breastfeeding for newborns (presiden ri, 2012). in accordance with the statement from the informant supported by evidence regarding the indonesian government's program related to the implementation of imd that the implementation of eib at 'aisyiah public hospital began in 2010. this activity proves that 'aisyiyah general hospital also supports a program from who and a program from the government that was formed since 2007 related to eib implementation policies. the indonesian government has supported the who and unicef programs and requires all health workers at all levels of health services, both private and public, to carry out eib in newborns for 1 hour. during the covid-19 pandemic, the government of indonesia issued a practical guidance protocol for health services for mothers and newborns during the covid-19 pandemic number: b-4 on april 5 2020. the protocol was prepared with reference to the references issued by the ministry of health and professional organizations, such as: guidelines for pregnant women, postpartum mothers and newborns during the covid-19 pandemic (kemenkes, 2020). the policy files related to eib implementation have been stored in the rs sim which is programmed on the computer at 'aisyiyah general hospital. the form of this policy is in the form of guidelines for implementing services for newborns in the perinatology room. however, this policy underwent changes and adjustments during the covid-19 pandemic. starting from steps in assisting the birth process, then policies in making decisions regarding the implementation of eib and exclusive breastfeeding to the process of caring for mothers and their babies. this policy changed over time during the pandemic according to the instructions of the leadership and following the regulations from the health protocol issued by the indonesian ministry of health, but the formulation team from the 'aisyiyah general hospital is still in the process of revising and compiling eib implementation guidelines. the changes in the implementation of eib at 'aisyiyah general hospital during the pandemic included that if the mother who gave birth tested positive for covid-19 then after the baby was born she was immediately separated from her mother and placed in an incubator, eib was not carried out and then the mother was treated in an isolation room. if the baby is in normal condition, the baby can be brought by a family that does not live in the same house as the mother and the baby is brought home with the permission of the mother via video call. whereas mothers who give birth are not confirmed positive for covid-19, the eib https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.195-206 199 implementation process is still implemented in accordance with the existing procedures at the 'aisyiah general hospital. implementation of the eib program in the delivery room of 'aisyiyah general hospital ponorogo during the covid-19 pandemic implementation time of imd implementation of imd depends on existing conditions. both sectio caesarea (sc) and normal are actually in a guideline still carried out by eib. however, in the implementation at 'aisyiyah general hospital in sc births, imd was rarely done because the temperature in the operating room was cold and there was fear that it would cause the baby to experience hypothermia. whereas in normal births it is still recommended to carry out eib because the process of normal births is in the delivery room. the process of implementing eib is not immediately implemented after the baby is born, this does not match the criteria specified in the eib implementation procedure, but the process is after 5 to 10 minutes of being born. after the baby is born, the baby will be cleaned beforehand to check the baby's health status starting from fitness, no cyanosis, has good reflexes, cleaned the mucus for about 5 minutes and then just do eib, but some take 15 minutes to cleaning and checking the baby's condition before placing the baby on the mother's chest. if there is an emergency from the mother or baby, for example bleeding, the mother is in severe pain or there are health problems in the baby, the eib will be postponed or even not implemented. in the eib process which is carried out at the 'aisyiyah general hospital, the baby is not placed directly on the mother's chest after the baby is born because the health worker will make sure in advance that the baby does not experience any problems or has any physical abnormalities. this is done to avoid an incident if the baby has a physical disorder, then the one who knows first is the health worker, so that the health worker will provide information and education related to the disorder experienced by the baby to the family and mother. in 2004 there was a decree of the indonesian minister of health no. 450/menkes/sk/iv/2004 concerning exclusive breastfeeding (asi) for infants in indonesia. mothers who have just given birth can only breastfeed their babies 30 minutes after giving birth, which is done in the delivery room. health workers help mothers to breastfeed all babies and all mothers without restrictions on the duration and frequency of breastfeeding (sujudi, 2004). in that year there was still no program regarding the implementation of eib, but it was still only an appeal to provide exclusive breastfeeding for newborns. in 2008 an activity module on eib was prepared which contained the stages in imd where health workers who help mothers go through the birthing process will carry out birth management activities as usual. like wise if the mother had to undergo a caesarean section. after birth, the baby is quickly dried as needed without removing the vernix (white skin). vernix (white) soothes baby's skin. the baby is then placed on the mother's chest or stomach, with the baby's skin against the mother's skin. to prevent the baby from getting cold, the baby's head can be put on a hat. then, if necessary, blanket the baby and mother. babies who are laid on their stomach on the mother's chest or stomach, are left to find their own mother's nipple (the baby is not forced into the nipple). basically, babies have a strong instinct to find their mother's nipples. the baby is left in a skin-to-skin position with the mother's skin until the first feeding is complete. after finishing breastfeeding, the new baby begins to be separated to be weighed, measured, stamped, given vitamin k and eye drops. mother and baby stay together and are cared for. room-in-room allows you to breastfeed your baby whenever he needs it, because breastfeeding has not yet been scheduled. care-in will also increase the bond between the mother and the baby, he will rarely cry because he always feels close to the mother and this can also make it easier for the mother to rest and breastfeed (depkes ri, 2008). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.195-206 200 the process of implementing eib in the general hospital 'aisyiyah ponorogo is not in accordance with what is arranged in the government's eib activity module because placing the baby on the mother's chest still has an interval of between 5 and 10 minutes after birth to do a physical health check on the baby. this action is not in accordance with government recommendations which suggest that after birth, the baby should be dried as soon as necessary without removing the vernix (white skin). in this case, only order as soon as possible to dry the baby as necessary. the baby is then placed on the mother's chest or stomach, with the baby's skin against the mother's skin. whereas in the physical examination of the baby it is recommended to do it after the eib process is complete. in addition to the discrepancy in the time required for placing the baby after being born to the mother's chest, the discrepancy is related to the length of time in the eib process. most of the babies were removed by health workers at the 'aisyiyah general hospital in less than an hour. the eib process will be stopped after the midwife or nurse who assisted the delivery in the sr general hospital 'aisyiyah delivery room has finished working on the patient's status within 15 to 30 minutes. the time for carrying out eib is not in accordance with the guidelines for carrying out eib which has been regulated in government regulation of the republic of indonesia number 33 of 2012 concerning exclusive breastfeeding in article 9, namely health workers and health service facility organizers are required to carry out early breastfeeding initiation for newborns to his mother for at least 1 (one) hour (presiden ri, 2012). socialization of eib implementation actions related to the implementation of eib at the 'aisyiyah ponorogo general hospital are always socialized situationally. the time for submitting information related to eib and exclusive breastfeeding is usually conveyed by looking at the mother's condition. the location when informing about this is directly in the delivery room or in the patient's room. after the baby is born, the health worker will socialize at that time and directly in the delivery room related to eib. health workers will offer mothers or families related to availability in implementing eib. however, the mother's choice to carry out or refuse eib for various reasons, both technical and non-technical, was stated. in fact, if the mother and baby are in a stable condition, eib should be implemented. fundamentally, a mother's right to request or refuse eib is protected by a regulation on consumer protection. in accordance with the science of communication which states that the recipient of the message is an important element in the communication process, because he is the target of communication. if a message is not received by the recipient, it will cause various kinds of problems that often require changes, whether at the source, message or channel. in order for communication to be effective, the method of conveying messages or information needs to be carefully designed according to the characteristics of the communicant and the circumstances in the social environment concerned (mulyana, 2014). wilbur schramm in his work entitled how communication works, once revealed what is called the condition of success in communication, which conveys various messages, one of which is that messages must be designed and delivered in such a way as to attract the intended target's attention. effective communication occurs when the message conveyed by the communicator is well received or the same by the communicant, so there is no misperception. in order for communication to be successful, messages or information need to be conveyed continuously or continuously. all appeals must always be conveyed through various media continuously so that the message can be embedded in the minds and influence people's behavior (effendy, 2017). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.195-206 201 related to the implementation of eib situationally and directly located in the delivery room or in the patient's room, it is actually not a hassle for the patient, but the time in providing information at the aisyiyah ponorogo general hospital is less than perfect, which is when the mother after giving birth definitely needs energy in her physical recovery . so if at that time it was socialized related to the implementation of eib and exclusive breastfeeding, there would be information that was not conveyed perfectly. in addition, information must be conveyed repeatedly so that it can be conveyed optimally. however, in the 'aisyiyah ponorogo general hospital, this is not implemented because the provision of information is only given once to the mother or after the baby is born. submission of information is also given directly to mothers and their families without using any media. supporting factors in the implementation of imd at 'aisyiyah ponorogo general hospital man the number of health workers in delivery assistance at 'aisyiyah general hospital is sufficient. health workers who are in charge of each delivery assistance consist of midwives from the delivery room or health workers, both midwives and nurses from the perinatology room. midwives in the delivery room focus on maternal care, while health workers, both midwives and nurses on duty in the perinatology room, will focus on baby care and the implementation of eib. the implementation of eib also works with the patient's family in waiting for the eib process to be completed. in addition, the 'aisyiyah general hospital also implements a shift system in each part of the room to reduce the workload on health workers in each room. in addition to a sufficient number of health workers, the implementation of eib at the 'aisyiyah general hospital is supported by the understanding and ability of the health workers who are in charge of the eib process. each health worker will take turns departing for training on the implementation of eib and exclusive breastfeeding. several types of training are apn training which is mandatory for all midwives to attend the training with the organizers, namely from the ibi professional organization. in addition, the training attended by health workers in the delivery room and perinatology room is lbw management training. materials related to eib are usually explained in this type of training. another type of training that was attended by several health workers was neonatal resuscitation training for emergencies in delivery assistance. as for some health workers who have not departed because their status is new to work in that place, even though they have never participated in several trainings, while on duty they will always be accompanied by their seniors and given an explanation related to the implementation of eib. in addition to carrying out assistance, the management of the 'aisyiyah general hospital also appealed to all health workers who had completed the training to inform other health workers about the results of their training through staff meetings so that new information obtained from the training results could be conveyed to all health workers. health workers on duty in the delivery room and perinatology room of 'aisyiyah general hospital have received training in turns and understand the steps in implementing eib, but many of the eib implementations applied to each patient are still not in accordance with eib guidelines. especially in terms of the implementation time, most of which are less than an hour, some babies are still assisted in finding the mother's nipple because the health workers can't wait to finish their task. whereas in placing the baby's position it is correct even though there are several sequences that are not appropriate, including the process of physical examination of the baby and giving intervention to the baby should be done after the eib is finished. however, this implementation was carried out at the beginning before eib was carried https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.195-206 202 out on the grounds that if the baby had several abnormalities, the health workers would immediately find out in advance. money eib is part of the delivery service process stage so that in the process of implementing eib there are no special fees billed to patients. patients also feel that there are no special bills related to the implementation of the eib. eib is a community right that has been regulated in government regulations and this is also confirmed in the tariff list information in early breastfeeding initiation services for newborns (eib) where there is no charge for eib services (panrb, 2012). this proves that the government fully supports the eib program so that the 'aisyiyah ponorogo general hospital also supports the implementation of the eib program by not charging fees to patients. the implementation of the eib is applied to all mothers who give birth at 'aisyiyah ponorogo general hospital except for some patients whose conditions do not allow or refuse eib. methode the stages in each eib process have been implemented, although there are several actions that do not need to be carried out and the duration or sequence is not in accordance with the eib guidelines. the placement of the baby's position is correct, that is, the baby is placed on the stomach or in the middle between the mother's two breasts without wearing clothes, the baby is only given a blanket or headgear (baby hat). after that the baby is left alone to find the mother's nipple. sometimes, some health workers help the baby to find the mother's nipple, which is actually not necessary. the actions that are out of order, namely the process of physical examination of the baby and giving intervention to the baby should be carried out after the eib process is complete, but at the 'aisyiyah general hospital the process was carried out even before the eib was implemented. this process is not in accordance with the activity module regarding eib which contains the stages in eib where health workers who help mothers go through the birth process, will carry out birth management activities as usual. likewise if the mother had to undergo a caesarean section. after birth, the baby is quickly dried as needed without removing the vernix (white skin). vernix (white) soothes baby's skin. the baby is then placed on the mother's chest or stomach, with the baby's skin against the mother's skin. to prevent the baby from getting cold, the baby's head can be put on a hat. then, if necessary, blanket the baby and mother. babies who are laid on their stomach on the mother's chest or stomach, are left to find their own mother's nipple (the baby is not forced into the nipple). basically, babies have a strong instinct to find their mother's nipples. the baby is left in a skin-to-skin position with the mother's skin until the first feeding is complete. after finishing breastfeeding, the new baby begins to be separated to be weighed, measured, stamped, given vitamin k and eye drops. mother and baby stay together and are cared for. room-in-room allows you to breastfeed your baby whenever he needs it, because breastfeeding has not yet been scheduled. hospitalization will also increase the emotional bond between the mother and the baby, he will rarely cry because he always feels close to the mother and this can also make it easier for the mother to rest and breastfeed (depkes ri, 2008). material in implementing the eib, the aisyiyah general hospital does not require special tools to support the implementation of the process. what is needed is only a blanket or headgear that covers the baby during the eib process. blankets or headgear are usually brought by the mother from home along with other baby equipment. if there are several mothers who do not bring https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.195-206 203 these equipment, the hospital has the supplies needed by the baby, for example clothes, blankets, diapers or other equipment to lend. aisyiyah general hospital does not have a special consultation room to inform or consult about eib and exclusive breastfeeding. socialization is delivered to patients while in the delivery room or in the patient care room. by implementing the provision of information in the patient care room, it will not be a hassle for the patient. when the patient lies in bed, the patient and family can still receive information related to eib and other information, but this information may not be conveyed perfectly due to interference from noises around the patient's treatment room. in the technical guidelines for class c hospital facilities and infrastructure, there are several requirements that must be met, one of which is that there must be facilities for serving the needs of the patient's family, namely (praying, waiting for patients, bathing, chapters, small kitchen/pantry, medical consultation). must be provided by the hospital is a room for conducting consultations by health professionals to patients and their families. the area of the room that must be provided is 9-16 m2 with several facilities in the form of tables, chairs, filing cabinets, telephones/intercoms, other office equipment (turgijono, 2007). according to the regulation of the minister of health of the republic of indonesia number 24 of 2016 concerning technical requirements for hospital buildings and infrastructure, it is stated that general consultation rooms in class c and d hospitals can be combined with nurse post rooms (kemenkes ri, 2016). aisyiyah general hospital is a type c hospital in ponorogo. so that the hospital can provide the facilities and infrastructure suggested in the technical guideline. however, the consultation room can also join the nurse's post in the delivery room. the advantage is if the hospital has its own consultation room, namely the information that will be conveyed to patients will be conveyed effectively because in conveying information the health workers who provide information and the patient or patient's family as recipients of information are not disturbed by the conditions around the treatment room. however, the delivery of information must have a procedure that must be established, namely the process of conveying information must be given before the action is carried out and the patient is still in a stable condition when receiving the information where the patient can still mobilize to the consultation room. obstacles for health workers in implementing eib in the delivery room of 'aisyiyah general hospital ponorogo during the covid-19 pandemic the 'aisyiyah general hospital has enough health workers in the delivery room and perinatology department. however, some of the obstacles faced by the 'aisyiyah general hospital are when the birth process services are almost simultaneously for several patients in the delivery room and there are several babies being treated in the perinatology room which must be monitored continuously by the nurse in the perinatology department, there will be imperfections in the implementation of the eib. because the midwife on duty in the delivery room only focuses on maternal care, while the perinatology nurse assists the midwife in the birth process and carries out examinations on the baby and must monitor the eib process which also has the same task, namely special monitoring of babies treated in the perinatology room. the perinatology room is far away and has a different floor from the delivery room and operating room, namely the delivery room on the 2nd floor, the operating room on the 3rd floor and the perinatology room on the 2nd floor. meanwhile, the perinatology nurse has to do two tasks at once. under these conditions, it can cause the eib implementation time to not run according to the guidelines. the perinatology room is a unit that provides health services for newborns who need special treatment, services are provided at the age of 0-28 days, especially for babies with high https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.195-206 204 risk. health workers on duty in the perinatology room consist of nurses and midwives where in every birth process in the delivery room, those who play a role in assisting the delivery process are midwives from the delivery room and health workers from the perinatology room. in this case, an appropriate spatial arrangement is needed so that the path between the delivery room and the perinatology room at the 'aisyiyah ponorogo general hospital can be reached. at the beginning of the pandemic, all informants were afraid of providing services to patients. however, as time went on, they felt used to helping deliveries during a pandemic. as long as you wear complete ppe, the fear of contracting covid-19 will disappear by itself. conclusion the implementation of the eib at 'aisyiyah ponorogo general hospital began in 2010. this activity proved that 'aisyiyah ponorogo general hospital also supports a program from who and the government of indonesia by making an eib guideline starting from the time when the preparation of these guidelines was adjusted to the understanding of health workers in the hospital is up to the adjustment of its implementation with the covid-19 pandemic. the eib implementation process at 'aisyiyah ponorogo general hospital is not in accordance with what is arranged in the eib activity module, starting from the sequence when the baby is placed on the chest to the eib implementation time which is less than 1 hour. however, socialization related to eib is always implemented even though the time for delivering the information is not right where the information is conveyed to patients after the baby is born and the mother's position is still in the treatment room. the supporting factors for the implementation of eib at 'aisyiyah ponorogo general hospital include the number of health workers providing eib services in the delivery room who are adequate and already have the ability to carry out eib. eib implementation does not require special costs or equipment so that eib can easily be implemented. the perinatology room is far away and is on a different floor from the delivery room and operating room. meanwhile, perinatology nurses have to carry out two tasks at once, namely helping patient care and monitoring specifically if there are babies being cared for in the perinatology room. under these conditions, it can cause the eib implementation time to not run according to the guidelines. references achmad yurianto, b. w. 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(2019). application of international best practice guideline in diabetic ulcer patients. journal of nursing practice, 3(1), 50-62. https://doi.org/10.30994/jnp.v3i1.65 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. https://doi.org/10.30994/jnp.v3i1.65 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.50-62 51 background diabetes mellitus is still a health problem in the world today, this disease is one of the health problems that are often experienced by people, and become a deadly disease in addition to cancer and heart attacks. diabetes mellitus itself is defined as a group of metabolic diseases that have the characteristics of excess blood sugar levels or hyperglycemia that occurs due to abnormalities in insulin secretion or insulin action or both (perkeni, 2015). the prevalence of people with diabetes mellitus in indonesia in 2007 is (1,5%), 2013 (2,1%) and 2018 (2,0%). while the prevalence of diabetes mellitus in east kalimantan in 2007 is (1,3%), 2013 (2,7%) dan 2018 (3,0%) (balitbang kemenkes ri, 2018). the results of a preliminary study conducted by researchers on march 5, 2019 at abdul wahab sjahranie hospital in samarinda, in 2018 there were as many as 1163 visits for diabetes mellitus cases. the highest number of visits was in the inpatient room of flamboyan room as much as 247 or 21.24% of the total visits. the majority of visits of patients suffering from diabetes mellitus based on these data were 646 or 55.55% women with age> 55 years of 567 or 48.75%. the majority of days of stay in the range of 0-10 days were 878 (75.49%) and the mortality rate due to diabetes mellitus was 147 or 12.64%. in addition, there were 357 data on the incidence of diabetic ulcers. the majority of sufferers were 181 women (50.7%) with age> 55 years 143 (40.06%). the highest incidence was in the inpatient installation of flamboyan room as many as 103 visits or 28.85% with a span of 0-10 days treatment time of 218 (61.06%). while the death rate that occurs due to diabetic ulcers is 36 or 10.08%. diabetic ulcers are chronic injuries that commonly occur in the area below the ankle caused by peripheral neuropathy, peripheral arterial disease or both which increase morbidity, mortality and reduce the quality of life of patients (perkeni, 2015). characteristics of diabetic ulcers are neuropathy, ischemia and infection. according to the international diabetes federation divides the risk factors for diabetic ulcers into three namely; peripheral neuropathy, deformity and trauma or history of diabetic ulcer (boulton et al., 2018) (ibrahim ammar, jude edwar, langton katia, jesus m fermin, gawis hanan, 2017). long suffer from diabetes mellitus also affects the risk of injury. people with diabetes mellitus who are> 5 years are 2 times more at risk of having an ulcer compared to patients who are <5 years old (fitria et al., 2017). diabetic ulcers have a variety of forms so their characteristics need to be known. assessment of wound characteristics using wound assessment tools, one of which is the international best practice guideline, which divides diabetic ulcers into neuropathic, ischemic and neuroiskemic wounds. (jain and joshi, 2013). diabetic ulcer assessment is very important to predict the duration of healing, provide information about the condition of the wound so that it becomes the basis for determining the appropriate intervention (yusuf, s., & tahir, 2018). assessment of wounds is carried out to determine management such as the selection of the principle of wound dressing, based on the results of research conducted by wahyuni (2016) at prof. dr. soekandar mojosari who applied the principle of moist wound healing or the principle of moist on the wound showed that all respondents (100%) experienced wound regeneration after being treated for 7 days (wahyuni, 2016). another benefit that can be obtained from applying proper wound assessment is determining the cost of treatment. the cost of treating diabetic ulcers that have experienced gangrene is higher when compared to diabetic ulcers that are non-gangrene, which is rp.386,790 for nongangrenous wounds and rp.950,211 for gangrenous wounds (sukmawati et al., 2016). journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.50-62 52 management of diabetic ulcers requires a multidisciplinary treatment team, therefore a proper assessment of the wound is very important as a team information in finding the cause of the wound. assessing the size, depth, presentation and location of the wound will help underlie selection and develop therapies and monitor various patient responses for intervention (chadwick p, edmonds m, mccardle j, 2013). objective this study aimed to find out how the characteristics of diabetic ulcers according to ibpg whose benefits can help the selection of appropriate and efficient wound care. appropriate treatment will provide many benefits, a short treatment period, improved wound healing, to reduce treatment costs. conversely, if not applying appropriate assessment and treatment allows for the emergence of various problems and even worsen the condition of the wound, so it needs to be appointed descriptive research on "application of ibpg in patients with diabetic ulcers". in other words, the main focus of this study is to determine the characteristics of diabetic ulcers based on the wound assessment tools of the international best practice guideline. methods the design used is descriptive with a case study approach through direct observation which results in general respondent characteristics and diabetic ulcer characteristics. the study was conducted in may 2019 at the flamboyant inpatient installation of abdul wahab sjahranie hospital samarinda, east kalimantan. the samples examined with the inclusion criteria in this study were as follows patients with diabetic wounds (diabetic ulcer) who were treated at abdul wahab sjahranie hospital samarinda, aged over 18 years. the exclusion criteria was a decrease in consciousness. the sampling technique uses purposive sampling. the instrument used was the international best practice guideline wound assessment tool which contained: sensation, callus, wound base, temperature and location (tabel 1, 2, 3). the participants were assured that their engagement was voluntary, and that anonymity, privacy, and confidentiality of the data were guaranteed. furthermore, they were informed about the purpose and the method of the study before signing a written informed consent. the questionnaires were distributed to eligible participants at the abdul wahab sjahranie hospital, and respondents were asked to complete and return them in the same time result the study was conducted by direct observation using wound observation sheets containing wound characteristics according to the international best practice guideline. characteristics of respondents respondent 1 (r1), 50-year-old woman, islam, banjar tribe, elementary school (sd) education, employment as a farmer. the length of treatment that has been undertaken for 2 days, a history of suffering from diabetes mellitus for 5 years. family history of diabetes mellitus and hypertension. history of wounds 1 week, the first time suffered injuries around may 5, 2019. injuries occur due to the use of shoes when working in the garden using shoes do not use socks so that the toes blister and are left to develop into ulcers. 60 kg body weight and 155 cm height. the ankle brakhial pressure index (abpi) value is 1.16, the blood glucose value is 70 mg / dl. diabetic ulcer on metatarsal digiti 5 with a size of about 2 cm, the wound smelled with moderate fluid. treatment was given journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.50-62 53 ceftriaxone 1gr / 12 hours iv, omeprazole 40mg / 12 hours iv, metoclorpramide 50mg / 8 hours iv and insulin apidra 4 units / 8 hours sc. high-calorie high-protein porridge diet is given three times per day. wound care is carried out by the method of moist (moist) with 0.9% nacl dressing and wrapped with gauze and hypapix plaster. respondent 2 (r2), 36-year-old woman, muslim, madurese, primary education, private occupation. the duration of treatment is 1 month. suffering from diabetes mellitus 1 year, first known in 2018. family history of diabetes mellitus. long suffered a wound of approximately 1 month, the wound initially occurred when the respondent walked barefoot and scratched nails on the sole of the foot and eventually developed into a diabetic ulcer. weight 55 kg and height 162 cm. abpi value of 1.0 and blood glucose value at 143 mg / dl. the wound is 10 cm long and 3 cm wide with minimal wound odor and minimal yellowish wound fluid. treatment is given ceftriaxone injection 1gr / 12 hours iv, metoclorpramide 50mg / 8 hours iv, lanzoprazole 500mg / 24 hours iv and novorapid insulin 12 units / 8 hours. high calorie diets high in protein three times per day. wound care uses 0.9% nacl dressing with gauze and hypapix tape. respondent 3 (r3), 53-year-old male, muslim, kutai ethnic with elementary school education, work as a farmer. duration of treatment for 3 weeks. history of the disease first diabetes mellitus 9 years ago. the family has no family history of diabetes mellitus. the history of the wound was experienced since april 2019, the wound was caused by not using footwear while on the move and tripping over a stone on the heel of the foot. weight 45 kg and height 160 cm. abpi value of 1.09, blood glucose at 104 mg / dl. wounds measuring 4 cm long and 6 cm wide, minimal wound odor with minimal hemoserous fluid. the treatment is given an injection of meropenem 1gr / 8 hours iv, omeprazole 1gr / 24 hours iv and novorapid insulin 8 units / 8 hours. high calorie diets high in protein three times a day. wound care with 0.9% nacl dressing and gauze with elastic bandages. characteristics of diabetic ulcers according to ibpg r1 is a neuroiskemic wound, which is characterized by some of the characteristics listed in table 1. the assessment of the wound is as follows: there is a decrease in sensational ability characterized by loss of sensitivity at 9 of the 10 points tested with 10 g monofilament, there is necrosis of metatarsal digiti 5, the basis black sores or having poor granulation tissue, cold foot temperature and weak palpable pulses, the location of injuries to the toes (figure 1). journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.50-62 54 table 1. characteristics of diabetic ulcer according to ibpg respondent 1 at a. wahab sjahranie hospital samarinda in may 2019 characteristics neuropathy ischemic neuroiskemic feeling / sensation loss of taste ability feeling pain (not losing feelings) decreased taste ability callus and necrosis callus, and usually thick generally necrosis there is minimal callus and necrosis wound base the granulated pink is surrounded by callus pale, yellow with its granulation tissue bad poor granulation tissue foot temperature and pulse warm with palpable pulses cold and no pulse / weakening cold, no pulse / weakened location in general in areas that hold heavy loads such as the metatarsal head, heels and dorsum of the toes fingertips, the edge of the nail and between the fingers and the lateral edge of the foot edges of toes and fingers r2 is a neuropathic wound, which is characterized by some of the characteristics listed in table.2 the assessment of the wound is loss of sensation ability, thick callus, pink wound base surrounded by callus and there is slough, palpable feet and weak pulse and the location of the wound in the area soles of the feet (figure 2). table 2. characteristics of diabetic ulcers according to ibpg respondent 2 at a. wahab sjahranie hospital samarinda in may 2019 characteristics neuropathy ischemic neuroiskemic feeling / sensation loss of taste ability feeling pain (not losing feelings) decreased taste ability callus and necrosis callus, and usually thick there is minimal callus and necrosis wound base the granulated pink is surrounded by callus poor granulation tissue foot temperature and pulse warm with palpable pulses cold and no pulse / weakening usually necrosis location in general pada area yang menahan beban berat seperti kepala metatarsal, tumit dan bagian dorsum dari jari kaki fingertips, the edge of the nail and between the fingers and the lateral edge of the foot pale, yellow with poor granulation tissue journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.50-62 55 r3 is an ischemic wound, which is characterized by several characteristics listed in table.3 the assessment of the wound has decreased / lost the ability to sensation, can still feel pain when the wound is touched and when treated, there is necrosis and slough tissue, the wound base shows red but surrounded by slough tissue, the foot is generally cold and the pulses are weak, the location of the wound is lateral to the foot to the bottom. (figure 3). table 3. characteristics of diabetic ulcers according to ibpg respondents 3 at a. wahab sjahranie hospital samarinda in may 2019 characteristics neuropathy ischemic neuroiskemic feeling / sensation loss of taste ability feeling pain (not losing feelings) decreased taste ability callus and necrosis callus, and usually thick usually necrosis there is minimal callus and necrosis wound base the granulated pink is surrounded by callus pale, yellow with poor granulation tissue poor granulation tissue foot temperature and pulse warm with palpable pulses cold and no pulse / weakening cold, no pulse / weakened location in general in areas that hold heavy loads such as the metatarsal head, heels and dorsum of the toes fingertips, the edge of the nail and between the fingers and the lateral edge of the foot edges of toes and fingers figure 1. r1 diabetic ulcer figure 2. diabetic ulcer r2 figure 3. diabetic ulcer r3 discussion characteristics of respondents respondents numbered three people with the sex of the respondents two women and one man. diabetes mellitus is more common in women than in men (perkeni, 2015). women tend to have high levels of fat that affect the work of insulin (perkeni, 2015). these results are in line with observational studies conducted by fitria in dr. zainal abidin hospital and meuraxa hospital in banda aceh in 2017, stating that 31 out of 57 respondents (54.4%) were women (fitria et al., 2017) therefore complications diabetes journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.50-62 56 mellitus such as diabetic ulcer is also more common in women than in men. respondents' ages are 50, 36 and 53 years, meaning that 2 out of 3 respondents have ≥ 50 years of age. age is a risk factor for diabetes mellitus and diabetic ulcers. organs in the elderly experience decreased function, such as insulin resistance which causes instability and even an increase in uncontrolled blood sugar levels that can cause various complications of diabetes mellitus such as reduced vision, decreased sensation due to diabetes neuropathy increases the incidence of unconscious ulcers which in the end developed into diabetic ulcers (perkeni, 2015). research conducted by jelantik in 2013 showed that 45 people out of 50 respondents (90%) with diabetes mellitus were aged berada40 years (jelantik and haryati, 2014). the results of research by fitria in 2017 the incidence of diabetic ulcers was more found in patients with an age range of 56-65 years (fitria et al., 2017). the average education of respondents is primary school, the level of education affects the level of understanding of a person in receiving information. people with a high level of education usually know more about disease or health information so that they have a high awareness about health. conversely people with low levels of education have low knowledge about health so that it affects awareness in maintaining health. research conducted by hardianti in 2018 states that low education affects the level of knowledge of respondents about the prevention of diabetic ulcers and their care (hardianti, 2018). education also affects the type of respondent's work, the research results found that 2 respondents worked as farmers and 1 respondent as a private worker. work activities such as farming are very risky for ulcers. the results of the interview respondents said that they sustained injuries while doing their work, namely when farming, r1 suffered injuries due to the use of narrow footwear, namely boots which cause blisters on the toes that develop into diabetic ulcers. r2 suffered injuries due to nails scratched on the sole of the foot when walking barefoot, r3 who also worked as a farmer suffered injuries due to being stepped on a stone on the heel of the wound initially left alone eventually became diabetic ulcers. the type of work is a risk factor that can result in trauma to the foot that can become diabetic ulcers. the length of suffering from diabetes mellitus is a risk factor for injury, in this case study it was found that the long history of suffering from diabetes mellitus at r1 was 5 years, r2 for 1 year and r3 9 years. these results indicate that 2 out of 3 respondents have diabetes mellitus ≥ 5 years, this is in accordance with research conducted by roza et al., 2015 which states that as many as 20 out of 39 respondents (63.7%) of diabetic ulcer sufferers have a history of suffering from diabetes mellitus during ≥ 5 years (loviana, rudy and zulkarnain, 2015). people with diabetes mellitus who are ≥5 years of age are twice as likely to have diabetic ulcers compared to patients who are ≤5 years old (fitria et al., 2017). the length of suffering from diabetes mellitus is likely to experience chronic hyperglycemia the greater the eventual cause complications such as retinopathy, neuropathy and diabetic ulcers (loviana, rudy and zulkarnain, 2015). family history is a factor that influences the occurrence of diabetes mellitus and its complications, of the three respondents who have a family history of diabetes mellitus are r2, r1 has a history of high fat / cholesterol and hypertension while r3 has no family history of the disease. family history of diabetes mellitus is a genetic or hereditary risk factor that causes a person to have diabetes mellitus (perkeni, 2015). research conducted (jelantik and haryati, 2014) found that 44 out of 50 respondents (88%) with diabetes mellitus had a history of hypertension and found a significant relationship between hypertension and journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.50-62 57 diabetes mellitus. hypertension causes damage to blood vessel endothelium causing platelet aggregation which can result in vascular deficiency resulting in ischemia in tissues that can cause diabetic ulcers (hardianti, 2018). increased peripheral resistance due to the attachment of cholesterol to the walls of blood vessels will increase the work of the heart, hypertension will occur and disrupt peripheral vascularization which leads to reduced oxygen circulation in the legs and ulcers occur. (setiati, 2014). the abpi values obtained at the time of the assessment were r1 1.16, r2 1.0 and r3 1.09. abpi is measured by using vascular dopler to assess arterial insufficiency. abpi is the ratio between systolic blood pressure of the foot (ankle) and systolic blood pressure in the arm (brachiallis). under normal circumstances systolic pressure on the legs and arms is the same or a little higher (sari y, 2015). in the results of the study, the abpi value of the respondents was within the normal range which meant there were no vascular disorders. abpi values <0.9 indicate peripheral arterial disease or pad which can increase the incidence and severity of diabetic ulcers (christian, sumumpang and limpeleh, 2015). the results of blood sugar when respondents obtained at the time of assessment are as follows r1 70 mg / dl, r2 144 mg / dl and r3 104 mg / dl, these results indicate that the average respondent has low blood sugar levels. this might occur due to lack of intake after being given insulin therapy so that blood sugar levels become low (ernawati, 2013). the results of the study of wounds generally found that r1 had a wound size of about 2 cm with smelling wounds due to localized gangrene of the metatarsal digiti 5 with a medium yellowish wound fluid and edema of the feet. r2 with a wound size of 10x3 cm with a minimum odor and a minimal yellowish wound fluid, while r3 has a wound size of 4x6 cm with a minimum odor and hemoserous wound fluid or mixed with blood. the size of the wound in the respondent is affected by the formation of an abscess or edema that causes surgery or incision in the wound to be done so that the fluid in the wound can be released and to improve the condition and healing of the wound. wound odor is found in wounds with a black base or that has become gangrene that starts from necrotic tissue. this occurs due to reduced or inadequate blood supply to the tissues either due to injury, radiation or chemicals that are compounded by bacterial infections. wound odor is influenced by the process of infection and the result of protein products so that wound management is needed that can minimize wound odor for patient comfort and the surrounding environment. yellow wound fluid indicates an infection of this fluid commonly referred to as a type of purulent exudate that can be yellow, gray or green, while the fluid mixed with blood is called hemoserous indicating damage to the capillaries or infection that has already affected the capillaries, causing blood leakage (mary greece, 2015). the duration of treatment carried out by respondents which was calculated at the time of the assessment on may 12, 2019 was at r1 for 2 days of treatment, r2 for 1 month of treatment and r3 for 3 weeks of treatment. the data is withdrawn for a long interval of treatment, which is 2 days 30 days. this result is in line with research conducted by sukmawati et al in 2016 stating that the average length of treatment for nongangrene ulcers is 27.3 days while for gangrene ulcers 91.8 days. the length of treatment for diabetic ulcers depends on the type of ulcer, the etiology of the ulcer and the type of treatment given (sukmawati et al., 2016). type of treatment while in hospital r1 and r2 get ceftriaxone antibiotic injection journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.50-62 58 therapy. cetriaxone is an antibiotic that works to inhibit bacterial cell wall synthesis and is more effective in gram-negative bacteria (yelly oktavia sari, dedy almasdy, 2018). the administration of ceftriaxone antibiotics is a type of empirical therapy that is the use of antibiotics in cases of infection that have no known type of bacteria, the purpose of giving empirical therapy is an effort to prevent the development of bacteria suspected of causing infection (ri ministry of health, 2011). in r3, meropenem antibiotic injection therapy is used. meropenem is an antibiotic that works widely against various types of bacteria, both gram negative, gram positive and anaerobic which are the most causes of infection (ministry of health republic of indonesia, 2011). research by agistia in 2017 states that meropenem has a high sensitivity to bacteria (agistia, mukhtar and nasif, 2017). the selection of meropenem antibiotics is the definitive therapy or therapy given after the bacteria is known (ministry of health republic of indonesia, 2011). the results of this case study differ from the research conducted by sari in 2018 which stated that the pattern of antibiotic administration in diabetic ulcers was at most a combination of ceftriaxone and metronidazole as much as 26.1% (yelly oktavia sari, dedy almasdy, 2018). determination of diet must be done in accordance with the calorie requirements in this case study, the body mass index of each respondent was r1, 155 cm, height 60 kg, bmi 24.9 included in the risk category, r2, 162 cm, weight 55 kg, bmi 20.9 normal and r3 160 cm height, body weight 45 kg, bmi 17.5 which is included in the category of underweight. the diet conducted by all respondents during treatment was a high-calorie, high-protein porridge. the main purpose of implementing diet for diabetics is to reduce hyperglycemia, prevent hypoglycemia in patients receiving insulin treatment and reduce the risk of cardiovascular complications (ernawati, 2013). the type of wound care received by all respondents was sterile gauze dressing moistened with 0.9% nacl. wound care with the concept of moist or moist wound healing is to maintain the condition of the wound remains in a moist state that facilitates the movement of cells at the base of the wound and allows neutrophils and macrophages to migrate better (wahyuni, 2016). the moist wound healing treatment conducted by wahyuni (2016) in his research on the effect of the moist wound healing technique showed that 20 respondents (100%) had regenerated wounds after being treated for 7 days. before dressing the wound with a nacl 0.9% moist gauze dressing wound was first washed with 0.9% nacl wound washing fluid. nacl 0.9% wound washing solution is one of the recommended washing fluid solutions because it is non-damaging to tissue and isotonic to the body so it is safe for granulation tissue (maryunani, 2015). characteristics of diabetic ulcers r1 based on characteristics of the international best practice guideline is including neuroisemic wounds with ulcer assessment results according to the following characteristics: feelings / sensations, r1 has decreased sensation ability in the legs, this is evidenced by the results of the assessment using a 10 g monofilament which shows no sensation of 9 out of 10 points tested. r1 only feels one point, which is the lateral part of the foot. there is tissue necrosis which is characterized by the presence of gangrene ulcers with poor granulation tissue. the palpable pulses are weak when touched and the feet tend to be cold while the location of ulcers on the toes is a characteristic of neuroiskemic injuries. neuroiskemic ulcers are a combination of the etiology of neuropathy and ischemic ulcers. neuropathy is a microvascular complication of diabetes mellitus that occurs due to journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.50-62 59 uncontrolled blood sugar or hyperglycemia (ernawati, 2013). the state of hyperglycemia triggers an increase in the metabolism of the polyol pathway resulting in the deposition of sorbitol and fructose in the peripheral nerves which causes disruption of nerve implants. besides neuropathy is also caused by vascular disorders resulting from vascular autonomic nerve disorders that affect sensory neuropathy in the form of loss of sensation in the legs, whereas in motor neuropathy causes atrophy of the intrinsic muscles of the foot, causing contractures and deformities in the legs that increase the incidence of ulcers diabetikum (suriadi, 2015). according to research conducted by armstrong et al. in 2011 stated that the prevalence of neuroisemic wounds was 50% of the incidence of diabetic ulcers (chadwick p, edmonds m, mccardle j, 2013). while the results of research conducted by christia et al. in 2015, 31 out of 100 respondents (31%) experienced neuroiskemic ulcers (christia, yuwono and fakhrurrazy, 2015). r1 ulcers experienced by the presence of necrotic tissue in the metatarsal digiti 5 with the basic color of a black wound / gangrene that indicates poor tissue injury. gangrene is caused by vascular disruption in blood vessels which causes blood supply to decrease or stop. in r1, abpi 1.1 results are obtained, which means there are no vascular or atherosclerotic disorders, so gangrene that occurs is likely a result of metabolic disorders due to uncontrolled blood glucose levels. this is supported by a history of r1 who has diabetes mellitus for 5 years and has a family history of diabetes mellitus, coupled with the presence of bacterial infections that aggravate diabetic ulcers (maryunani, 2015). r1 has decreased sensation and numbness so that the foot temperature is generally felt cold with the location of the ulcer located on the finger which is characteristic of neuroiskemic ulcers. r2 had a neuropathic ulcer characterized by loss of taste ability at 10 points tested with 10 g monofilament. neuropathy is caused by a state of hyperglycemia that triggers metabolic abnormalities and also by vascular abnormalities that are caused which will ultimately reduce the sensation in people with diabetes mellitus, foot deformities that increase the incidence of diabetic ulcers (maryunani, 2015)(suriadi, 2015). formation of thick callus on ulcer r2 caused by excessive pressure on the plantar legs, callus or also known as hyperkeratinocytes can be formed due to hardened wound edges, this callus formation will inhibit the contraction of wound edges (suriadi, 2015). according to research conducted by edmonds and foster in 2006, callus in neuropathic ulcers should be eliminated because it can suppress the wound underneath as a result of the formation of new wounds, inflammation and bleeding under the callus that can cause tissue death or necrotic (edmonds, me, & foster , 2006). the base of the r2 wound is pink which indicates granulation, but is surrounded by a callus that can inhibit the growth of new tissue (edmonds, m. e., & foster, 2006). although including neuropathic ulcers, in r2, cold feet temperature with weak pulse such as ischemic or neuroischemic wounds is obtained. neuropathic complications have two categories, sensory neuropathy which decreases pain sensation, leg temperature and taste ability, while motor neuropathy results in deformity in the legs which increases the risk of trauma. another factor that causes the respondent's feet to cool down is the length of time suffering from diabetic ulcers which can increase the risk of peripheral arterial disease so that neuropathy wounds can become ischemic injuries (boulton et al., 2018). the injury occurred in the plantar part of the foot which holds the load, caused by trauma affected by nails that scratch the soles of the feet unnoticed by respondents who developed into diabetic ulcers, this occurs because in patients with neuropathy there has been loss of taste ability. neuropathic injuries have a high incidence of diabetes mellitus journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.50-62 60 in 35% (armstrong, d. g., boulton, a. j. m., & bus, 2017). in r3, the results of ischemic ulcers without loss of taste and still feeling pain, the results of sensation testing with 10 g monofilament respondents were able to feel sensations. the cause of ischemic ulcer is an indication of peripheral arterial disease that is started by increasing blood glucose levels which causes hardening and even damage to arteries and capillaries (maryunani, 2015). poor blood sugar control is a cause of peripheral arterial disease (pad) (lepantalo, m., apelqvist, j., setaccie, c., riccof and donato, g. de, becker, f., ... davies, 2011). in addition, poor peripheral vascularization also causes inhibition of wound healing due to oxygen and nutrients needed so that tissue necrosis or death is marked by the presence of sloughs or black sores (chadwick p, edmonds m, mccardle j, 2013). weakened pulses and cold tendencies are the result of inadequate peripheral vascularization with a characteristic wound position that occurs on the lateral edge of the foot, the incidence of ischemic injury itself is 15% of the incidence of diabetic ulcers (amstrong, d. g., boulton, a. j. m., & bus, 2017). conclusion characteristics of respondents in this study were 2 women and 1 man, with the age of each respondent 50, 36 and 53 years, the last education was elementary school, 2 respondents worked as farmers, and 1 as a private worker. a history of diabetes mellitus of an average of ≥5 years and a history of diabetic ulcers in the treatment range of 2-30 days. characteristics of diabetic ulcers based on the international best practice guidline (2013), r1 is neuroiscemic ulcers, r2 with neuropathic ulcers and r3 with ischemic ulcers. the characteristics of diabetic ulcers international best practice guidline (2013) can be taught in more depth as an additional reference for wound assessment. health agencies should prepare a variety of wound assessment instruments that are complete so that it can be applied by existing health workers in dealing with diabetic ulcers. reference agistia, n., mukhtar, h. and nasif, h. 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(2014) ‘hubungan faktor risiko umur, jenis kelamin, kegemukan dan hipertensi dengan kejadian diabetes melitus tipe ii di wilayah kerja puskesmas mataram’, media bina ilmiah39, 8(1), pp. 39–44. available at: http://www.lpsdimataram.com/phocadownload/februari-2014/7hubungan faktor risiko umur jenis kelamin kegemukan-jelantik haryati.pdf. kemenkes ri (2011) ‘pedoman umum penggunaan antibiotik.’ jakarta: kementrian kesehatan republik indonesia. kristiani, a. l., sumangkut, r. m. and limpeleh, h. p. (2015) ‘hubungan ankle brachial index dengan keparahan ulkus pada penderita kaki diabetik’, jurnal biomedik (jbm), 7(3), pp. 171–177. lepantalo, m., apelqvist, j., setaccie, c., riccof, j.-b. and donato, g. de, becker, f.,… davies, a. h. (2011) ‘diabetic foot’, in 42(s2), pp. 60–74. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.1. october 2019. page.50-62 62 loviana, r. r., rudy, a. and zulkarnain, e. 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(2016) ‘effect moist wound healing technique toward diabetes mellitus patients with ulkus diabetikum in dhoho room rsud prof dr . soekandar mojosari’, stikes bina sehat ppni mojokerto, pp. 1–7. yelly oktavia sari, dedy almasdy, & a. f. (2018) ‘evaluasi penggunaan antibiotik pada pasien ulkus diabetikum di instalasi rawat inap ( irna )’, jurnal sains farmasi & klinis, 5(2), pp. 31–40. yusuf, s., & tahir, t. (2018) ‘study literatur : pengkajian luka kaki diabetes’, jurnal luka indonesia, 4(2), pp. 123–137. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.165-171 165 factors correlated with quality of patient’s handover in inpatient room of the hospital wiwin sulistyawati, arif nurma etika, restu novitasari universitas kadiri kediri, indonesia corresponding author : wiwin.sulistyawati86@gmail.com abstract background: communication failure during handover is the main cause of the patient's injury and is the root cause of 65% of the sentinel incident. bad handover is assumed to have correlation with clinical diagnosis inaccuracies, delay in diagnosis, delay in laboratory tests, treatment errors, inconsistent or misinterpretation of results, duplication of tests, increase in complications of the hospital. purpose: this study aimed to determine the factors related to the quality of the patient's handover in inpatient room of the hospital. methods: this research used a correlational analysis study with a cross sectional approach. data retrieval use questionnaires and observation sheets. the number of samples on this study is 79 nurses taken in random sampling techniques. statistical analysis used is a test of spearman rank. results: the result of this research revealed that most of the respondents (69.6%) are diploma graduates, and 72.2% of respondents have a working time of < 5 years. almost all respondents (93.7%) have good motivation, and 94.9% of respondents have good handover quality. the last educational variable (p = 0.388) and the nurse’s working time (p = 0.209) are not related to the quality of the handover, while the motivation (p = 0.000) and the implementation of the chief nurse’s supervision (p = 0.000) relate to the quality of the handover between the shifts in the inpatient room of the hospital. conclusion of this study is the motivation and the implementation of the chief nurse’s supervision relate to the quality of the handover between the shifts in the inpatient room of the hospital. hospital’s management is expected to raise the motivation of nurses in conducting handover and enhancing the supervision of the chief nurse to improve the quality of the patient's handover and minimize the errors in information exchange conducted by nurses. keywords: handover, education level, motivation, nurse, supervision of the chief nurse received august, 29, 2019; revised november 25, 2019; accepted january 15, 2020 doi: https://doi.org/10.30994/jnp.v3i2.84 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-noncommercial-sharealike 4.0 international license. mailto:wiwin.sulistyawati86@gmail.com https://doi.org/10.30994/jnp.v3i2.84 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.165-171 166 background nursing handover becomes a priority research for the safety of patients and all parties strive to improve handover communication (smeulers, m., lucas, c., vermeulen, 2014). handover is one of the techniques for providing information to the nursing team at the time of the change of service, and it is a guide to practice in providing information on the latest patient conditions, treatment goals, patient care plans and determining service priorities (rushton, 2010). communication failure during handover is the main cause of the patient's injury and is the root cause of 65% of the sentinel incident (joint commission international, 2011). bad handover is assumed to have correlation with clinical diagnosis inaccuracies, delay in diagnosis, delay in laboratory tests, treatment errors, inconsistent or misinterpretation of results, duplication of tests, increase in complications of the hospital, increase in treatment period and lower patient and employee satisfaction (smeulers, m., lucas, c., vermeulen, 2014). based on the results of preliminary data by conducting interviews with nursing department in inpatient room hospital x kediri in november 2018, it was concluded that the implementation of handover was not optimal. perceptions of nurses were varied in term of handover and not yet available sop (standard operational procedures) concerning with the implementation of handover in every room. hughes, r (2008) mentioned that individual factors, groups, and organizations affect the process of handover of the patient. factors of knowledge, attitude, availability of sop, leadership and associates significantly affect the handover. the knowledge factor is the most influential factor towards handover. (kullberg, 2018). based on the background above, the researchers want to conduct research on the analysis of factors that affect the quality of handover in the inpatient room of hospital x in kediri. objective this study aimed to determine the factors related to the quality of the patient's handover in inpatient room of the hospital methods the design of this research is correlational analytic with a cross-sectional approach. the population of this study is 99 executive nurses in inpatient room. this research sample is 79 nurses taken using simple random sampling. independent variables in this study are variable level of education, working period, supervision of the chief nurse, and motivation. dependent variable is handover. research instrument for variable level, education, working period, supervision of the chief nurse, and motivation is questionnaires. meanwhile, handover uses the observation sheet. statistical analysis uses spearman test. result tabel 1. characteristics of total respondents based on gender, age, and education of nurses at hospital x in 2019. variable frequenc y percentag e gender male 23 29,1 female age 56 70,9 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.165-171 167 20 – 30 years old 31 – 40 years old >40 years old last education diploma ners working period <5 years 5-10 years >10 years 67 12 0 55 24 57 20 2 84,8 15,2 0 69,6 30,4 72,2 25,2 2,5 tabel 2. characteristics of respondents based on motivation, supervision, and handover quality of nurses at hospital x in 2019. variable total percentage motivation poor 0 0,0 fair 5 6,3 good supervision poor good handover quality poor fair good 74 6 73 0 4 75 93,7 7,6 92,4 0,0 5,1 94,9 based on table 2, almost all (93.7%) respondents have good motivation in doing handover, 92.4% of the nurses are well-supervised by the head of the room, and 94.9% of respondents carried out handover properly. tabel 3. cross tabulation of the relationship of last education with handover quality at hospital x year 2019. last education handover quality among shifts good fair total diploma 53 (67,1%) 2 (2,5% ) 55 (69,6%) ners 22 (27,8%) 2 (2,5% ) 24 (30,4%) total 75 (94,9%) 4 (5,1% ) 79 (100%) p value = 0,388* r = -0,099* α = 0,05 based on table 3, ρ value = 0.388 > α = 0.05, then ho is accepted and h1 is rejected. it means there is no relationship between the last education and the quality of handover among shifts at the hospital hospital x in 2019. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.165-171 168 tabel 4. cross tabulation of relationship of working period with handover quality among shifts at inpatient room of hospital in 2019. working period handover quality among shifts good fair total < 5 years 55 (69,6 % ) 2 (2,5% ) 57 (72,2%) 5-10 years 19 (24,1% ) 1 (1,3% ) 20 (25,3%) >10 years 1 (1,3 %) 1 (1,3% ) 2 (2,5%) total 75 (94,9% ) 4 (5,1% ) 79 (100%) p value = 0,209* r = -0,143* α = 0,05 based on table 4, the result of spearman test is ρ value = 0.209 > α = 0.05, then ho is accepted and h1 is rejected. it means there is no relationship between working period and the quality of the handover among shifts at inpatient room in the hospital in 2019. tabel 5. cross tabulation of relationship of motivation with handover quality among shifts at inpatient room of the hospital in 2019. motivation handover quality among shifts good fair total good 74 (93,7%) 0 (0,0% ) 74 (93,7%) fair 1 (1,3%) 4 (5,1% ) 5 (6,3%) total 75 (94,9%) 4 (5,1% ) 79 (100%) p value = 0,000* r = 0,888* α = 0,05 based on table 5 ρ value = 0.000 < α = 0.05, then ho is rejected and h1 is accepted. it means there is a relationship between the motivation and the quality of the handover among shifts at inpatient room in the hospital x in 2019. with a coefficient value of correlation r = 0.888, the strength of the relationship can be concluded very strong. direction of linear relationship (+) which means better nurse motivation, better handover quality among shifts will be tabel 6. cross tabulation of relationship of supervision of chief nurse with handover quality at hospital x in 2019. supervision of chief nurse handover quality among shifts good fair total good 73 0 73 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.165-171 169 (92,4% ) (0,0% ) (92,4%) poor 2 (2,5%) 4 (5,1% ) 6 (7,6%) total 75 (94,9% ) 4 (5,1% ) 79 (100%) p value = 0,000* r = 0,806* α = 0,05 table 6 shows that ρ value = 0.000 < α = 0.05, then ho is rejected and h1 accepted. there is a significant relationship between the supervision of the chief nurse and the quality of the handover among shifts in hospital x in 2019. with a coefficient value of correlation r = 0.806, it can be inferred that the relationship is very strong. direction of linear relations (+) which means better supervision of the chief nurse, better handover quality among shifts will be. discussion relationship between last education and handover quality table 3 shows 67.1% of diploma-nurses have a good quality of handover among shifts, rather than the ners-nurses (27.8%). the result shows that there is no relationship between the last education and the quality of handover among shifts in hospital x kediri. the result of this research is in accordance with previous research that there is no relationship between education level (vocational and professional) and the performance of nurses to the obedience of conducting sop (nazvia, 2014). at the first time of the nurse workday, they will be directed to perform of how to have an information exchange properly. considering that handover is the nurses routine in every shift-exchange, it must be handled precisely in order to avoid any errors in conducting handover itself. this direction brief can enhance nurse performance in conducting information exchange. moreover, information exchange conducted repeatedly will enhance nurse skill in doing handover. thus, in this research, there is no relationship between education level and handover quality. relationship between working period and handover quality the result shows that there is no meaningful relationship between the working period and the quality of the handover shifts in the inpatient room. the result is similar to (zahara, sitorus, and sabri, 2011) stating that there is no meaningful relationship between working period and performance. handover is the activity of delivering information about the patients in every shift exchange. something that is done repeatedly will make nurses become proficient in doing handover. in conducting a good handover, nurse does need much time or even years. relationship between motivation and handover quality the result of the study is gained a significant relationship between motivation and quality of handover among shifts in the inpatient room. table 5 shows that 93.7% of good motivation also has a good quality of handover among shifts. the research is in line with (sulistyawati, 2018) stating that there is a relationship between nurse motivation and handover quality with strong relationship. motivation is the accumulation of various processes that affect and direct the individual’s behavior to achieve certain objectives (negussie, 2012). work motivation is a very relevant factor that affects the quality of performance, especially in the health sector (toode, routasalo, and suominen, 2011). journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.165-171 170 in this research, generally, nurses are motivated and their working performance in conducting their information exchange is good. the nurses simply agree that conducting handover is their responsibility in which they are granted an authority so that they will pay much attention on their outcome. good communication is a sort of communication that is able to empower as well as involve the family. it becomes a very crucial thing in giving family centered care. enhancing quality and quantity are proved in giving advantage to patient treatment, patient satisfactory, and patient’s family (zhu, 2014). relationship between chief nurse supervision and handover quality the result of the spearman test shows that there is a relationship between the supervision of the chief nurse and the handover quality among shifts in hospital x. the result of this study is in line with stating that the most dominant factor affecting working performance is supervision. nurse who has good supervision will have better working performance 72.952 times more than the nurse who has lack of supervision. (zahara, sitorus, and sabri, 2011). it is also in accordance with (sulistyawati, 2016) stating that the function of direction and controlling brief from chief nurse has a significant relationship on the implementation of discharge planning. the quality of nursing care in patients will be assured when supervision is conducted in accordance with established guidelines. good supervision will increase the motivation of nurses who have an impact on improving the performance of nurses (zahara, sitorus, and sabri, 2011). the supervision of sbar communication affects the quality of handover in melati and bougenvil room of hospital x in blitar. sbar supervision is one of the ways to improve patient safety and reduce the occurrence of errors caused by communication failures (sulistyawati & haryuni, 2019). conclusion and suggestion conclusion from the results of the study, it can be concluded that nurses are mostly graduated from diplomas and have working period for < 5 years. almost all respondents have good motivation, good perception on the implementation of the supervision of the chief nurse and good quality handover. result of bivariate analysis shows that; last education and working period are not related to the quality of handover. however, there is a meaningful relationship between the motivation of nurses with the quality of the handover among shifts within a strong relationship and the direction of the relationship (+), and there is a relationship between implementation of the supervision of the chief nurse with a quality handover within a strong relationship and direction of the relationship (+). suggestion it is hoped that the field of nursing could give supervision and motivation periodically to improve the quality of handover. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.165-171 171 references hughes, r. (ed.). (2008). patient safety and quality: an evidence-based handbook for nurses (vol. 3). rockville, md: agency for healthcare research and quality. joint commission. (2011). sentinel event data event type by year 1995-2015. kullberg, a., sharp, l., dahl, o., brandberg, y., & bergenmar, m. (2018). nurse perceptions of person-centered handovers in the oncological inpatient setting: a qualitative study. international journal of nursing studies, 86, 44-51. https://doi.org/10.1016/j.ijnurstu.2018.06.001 nazvia, n., loekqijana, a., & kurniawati, j. (2014). faktor yang mempengaruhi kepatuhan pelaksanaan sop asuhan keperawatan di icu-iccu rsud gambiran kota kediri. jurnal kedokteran brawijaya, 28(1), 21-25. http://dx.doi.org/10.21776/ub.jkb.2014.028.01.17 negussie, n. (2012). relationship between rewards and nurses’ work motivation in addis ababa hospitals. ethiopian journal of health sciences, 22(2). rushton, c. h. (2010). ethics of nursing shift report. aacn advanced critical care, 21(4), 380-384. https://doi.org/10.4037/nci.0b013e3181ef8648 smeulers, m., lucas, c., & vermeulen, h. (2014). effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients. cochrane database of systematic reviews, (6). https://doi.org/10.1002/14651858.cd009979.pub2 sulistyawati, w., & haryuni, s. (2018). hubungan motivasi perawat dengan kualitas handover pasien di ruang rawat inap rumah sakit. jurnal ilmiah keperawatan, 13(2). https://doi.org/10.30643/jiksht.v13i2.9 sulistyawati, w. (2016). implementasi fungsi manajemen dalam pelaksanaan discharge planning. jurnal ilmiah keperawatan, 889. sulistyawati, w., & haryuni, s. 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2614-3496 (online) vol.3 no.2. april 2020. page.226-232 226 effectiveness of giving compress against reduction of body temperature in children: systematic review nurul zakiah burhan, arbianingsih, syamsiah rauf, huriati uin alauddin makassar, indonesia corresponding author : nrzakiah09@gmail.com abstract background: fever is a clinical manifestation that is often experienced by sick children. fever can be dangerous if there is a high fever. seizures can occur as a result of high fever which is not treated early, causing hypoxia of brain tissue and ultimately damage. according to who estimates that around 17 million cases of fever worldwide, there are 600,000 deaths each year. purpose: this study aimed to find out effective interventions to reduce body temperature in children. methods: this research used quantitative descriptive design with systematic review approach. the research instrument uses duffy’s research appraisal checklist approach. results: after searching the article, there were 9 articles related to giving warm compresses, 6 articles with the location of administration in the axilla and tepid songe areas (wiping the whole body), 7 articles by giving compresses for 30 minutes and 10 articles with compressed water temperature 37oc. conclusions: of the 15 articles that have been traced successfully, the most interventions given were warm compresses in the axilla and tepid sponge areas by giving compresses for 30 minutes and compressed water temperature of 37oc. keywords: children, compress, temperature received january, 29, 2019; revised february 19, 2019; accepted march 28, 2020 doi: https://doi.org/10.30994/jnp.v3i2.91 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:nrzakiah09@gmail.com https://doi.org/10.30994/jnp.v3i2.91 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.226-232 227 background fever is a clinical manifestation that is often experienced by sick children. the high incidence of fever, according to who estimates that around 17 million cases of fever cases worldwide with an incidence of 600,000 deaths each year. pneumonia is the main cause of infant mortality in the world. this disease accounts for 16% of all deaths of children under 5 years, which cause death in 920,136 toddlers, or more than 2,500 per day, or it is estimated that 2 children under five die every minute in 2015 (lunze, 2017). fever can be dangerous if there is a high fever. seizures can occur as a result of high fever that is not treated early, causing hypoxia of brain tissue and ultimately brain damage. high body temperature causes the brain to be sensitive and prone to cell death. high body temperature is dangerous because it results in local bleeding and parenchymatic degeneration throughout the body, this disorder will cause disruption of cell function. fever occurs as the body's response to an increase in set points, but there is an increase in temperature due to excessive heat formation but not accompanied by an increase in set points (hall, 2016). compress is a method of maintaining body temperature by using fluids or tools that can cause warm or cold to the parts of the body that need it. there are two types of compresses, warm compresses and cold compresses. the purpose of a warm compress is to facilitate blood circulation, reduce pain, provide warmth, comfort, and calm to the client, expedite exudate expenditure, stimulate intestinal peristalsis. areas of hot and cold compresses can cause systemic responses and local responses. this stimulation sends peripheral implants to the hypothalamus which then becomes a normal body temperature sensation (murakami, 2015). optimum body temperature is essential for cell life to function effectively. extreme changes in body temperature can be harmful to the body. therefore, nurses must try to be able to maintain the client's body temperature to remain normal (yunianti, 2019). there have been many studies on compresses, but to find out the type of compresses and the location of the most effective compresses is not widely known, so the authors intend to conduct a systematic study review study related to giving compresses to decrease body temperature in children. objective this study aimed to find out effective interventions to reduce body temperature in children. methods this research uses a quantitative descriptive design with a systematic review approach. this study uses a systematic review approach to find out effective intervention strategies to prevent children from stunting / reduce the incidence of stunting in children. literature search through database: pubmed, science direct, google scholar, portal garuda, journal of islamic nursing (join), rumah jurnal uin alauddin, emerald, international journal of science and research, oxford serta springer. the inclusion and exclusion criteria in this study are the inclusion criteria: articles published in 2015-2019; full text articles that fit the purpose of the research namely effective intervention strategies to prevent stunting / reduce the number of stunting in children; there is issn or doi or volume; research using human subjects; limits of experimental research. exclusion criteria include: articles that are double publications and articles that have a low quality rating of articles based on duffy's score. after collecting data and information, all of the data and information is selected by using duffy's research appraisal checklist approach with the problem being examined. to present the problem to be discussed, the data collected is analyzed descriptively. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.226-232 228 google scholar science direct ijsr ijar emerald (n=345) (n=570) (n=5) (n=135) (n=4) figure 1. flow chart for study selection and inclusion results 1. type of intervention given based on the results of an analysis of 15 articles, 9 articles (60%) were obtained using a warm compress intervention to reduce body temperature in children, then an onion and pelster compress intervention was obtained with the same value of 2 articles (13.3%) and obtained vinegar compress intervention and aloe vera with the same value of 1 article (6.7%). article identified (n = 1059) identification exclusion : double publication (n= 12) screening screening results (n =1047 ) eligiblity assessment with duffy’s research appraisal checklist approach exclusion : no full text (n= 0) not according to research questions (n=1023) inclusion article (n=15 ) according to research questions (n= 15) inclusion group below average paper (score 0-102) (n=0 ) group average paper (score 103-204) (n=0 ) group superior paper (score 205-306) (n=15 ) journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.226-232 229 tabel 1.1 frequency distribution of effective interventions against decrease in body temperature intervention journal article percentage (%) aloe vera 1 6.7% vinegar compress 1 6.7% plaster compresses 2 13.3% shallot 2 13.3% warm compresses 9 60% total 15 100% 2. the location of the intervention based on the analysis of 15 articles, it was found that 6 articles were mostly given to the axilla area (40%) and the tepid sponge technique (40%) foot to ankle area (6.67%). table 1.2 frequency distribution of location for intervention intervention location number of locations percentage (%) forehead 1 6.66% axilla 6 40% thigh 1 6.67% leg area to ankle 1 6.67% tepid sponge 6 40% total 15 100% 3. duration of giving compress based on the analysis of 15 articles, there were 7 articles with a duration of compressing for 30 minutes (46.7%), there were 5 articles with a duration of compressing for 15 minutes (33.3%), there were 2 articles with a duration of compressing for 20 minutes (13.3%) and found an article with a duration of compressing for 10 minutes (6.7%). tabel 1.3 distribution frequency of duration of compress duration of giving number of articles percentage (%) 10 minute 1 6.7% 15 minute 5 33.3% 20 minute 2 13.3% 30 minute 7 46.7% total 15 100% 4. temperature of applying compresses based on the analysis of 15 articles, there were 10 articles with 370c (66.7%) compressing temperature, 2 articles with 200c and 400c (13.3%) compressing temperatures and 1 article with 430c compressing temperature (6.7%). journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.226-232 230 tabel 1.4 distribution frequency of compress water temperature giving temperature number of articles percentage (%) 20 oc 2 13.3% 37 oc 10 66.7% 40 oc 2 13.3% 43 oc 1 6.7% total 15 100% discussion based on the 15 articles identified. there are interventions, locations, duration of compressing and temperature given to a decrease in body temperature in children, namely: 1. type of intervention given based on the results of the most frequent interventions given are warm compresses. warm water compresses can reduce body temperature through the evaporation process. compress with warm water causes the body temperature outside to be warm so the body will interpret that the temperature outside is hot enough, eventually the body will lower the temperature control in the brain so as not to increase the temperature of the body regulator, with the temperature outside warm will make the blood vessels in the skin edge widening and experiencing vasodilation so that the skin pores will open and facilitate heat dissipation so that there will be a decrease in body temperature (dewi, 2016). in line with the results of aminatul fatayati's study which stated there was an effect of warm compresses on decreasing body temperature in febrile children (fatayati, 2010). 2. the location of the intervention based on the results of the frequency of the location of the most intervention given at the axilla location and tepid sponge technique (by wiping the entire body). in the axilla area, from several locations giving warm compresses it was found that the axilla area was more effective than the location of the groin and forehead folds. this shows, giving warm compresses to the axilla as an area with the location of large blood vessels is an attempt to provide stimulation in the hypothalamic preoptic area in order to reduce body temperature. the occurrence of spending more body heat through two mechanisms, namely peripheral blood vessel dilation and sweating (potter & perry, 2016). 3. the duration of the compress based on the duration of the compress from the 15 most articles in 30 minutes. based on sunarti's research (2018), by giving warm compresses and measuring body temperature 3 times, before the action, 15 minutes after the action and 30 minutes after the action. obtained a decrease in body temperature every minute. in line with research conducted by putra (2018), the administration of a warm compress is given for 30 minutes. there was a decrease, before the intervention was given, the average body temperature of the respondent was 38.10c and after the intervention was given the average body temperature of the respondent was 37.20c with a decrease in temperature of 0.90c. 4. temperature of applying compresses based on the analysis of 15 articles, there were 10 articles with a temperature of 370c compress. in line with research conducted by antono (2015) with the provision journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.226-232 231 of a counter carried out at 370c. in line with research conducted by putra (2018) giving compresses at 370c to children who have a fever. the provision of compress shallots according to cahyaningrum (2017), which suggests that the greater the mass of onion given, the less amount of time needed to reduce the temperature of the mixture, so that the more effective in lowering body temperature. conclusion based on the results of the analysis of 15 articles found, namely: intervention of giving compost to a decrease in body temperature in children. compress is an intervention that is commonly known to be associated with handling fever in children. however, based on the analysis of 15 articles that were received, the most intervention given was warm compresses. warm water compresses can reduce body temperature through the evaporation process. compress with warm water causes the temperature of the body outside to be warm so the body will interpret that the temperature outside is hot enough, eventually the body will lower the temperature control in the brain so as not to increase the temperature of the body regulator, with the temperature outside warm will make the peripheral blood vessels in the skin widening and experiencing vasodilation so that the skin pores will open and facilitate the removal of heat so that there will be a decrease in body temperature. the location where most interventions were given was the axilla location and tepid sponge technique (by wiping the whole body). based on the duration of the compress from the 15 most articles in 30 minutes. from 15 articles, there were 10 articles with temperatures of 370c compresses. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.226-232 232 references antono, s. d. (2015). the effectiveness of warm vinegar compress in lowering children body temperature with acute febrile illness. journal international of science and research (ijsr), 1-8. 1820-1827. cahyaningrum, e. d., & putri, d. (2017). perbedaan suhu tubuh anak demam sebelum dan setelah kompres bawang merah. medisains, 15(2), 66-74. dewi, a. k. (2016). perbedaan penurunan suhu tubuh antara pemberian kompres air hangat dengan tepid sponge bath pada anak demam. jurnal keperawatan muhammadiyah, 1(1). 63-71. fatayati, a., nawangsih, u. h. e., & kes, m. (2010). pengaruh pemberian kompres hangat terhadap penurunan suhu badan pada balita dengan demam di rs pku muhammadiyah yogyakarta tahun 2010. thesis. universitas' aisyiyah yogyakarta. hall, j. e. (2016). guyton and hall textbook of medical physiology, jordanian edition ebook. elsevier. lunze, k., biemba, g., lawrence, j. j., macleod, w. b., yeboah-antwi, k., musokotwane, k., ... & steketee, r. (2017). clinical management of children with fever: a cross-sectional study of quality of care in rural zambia. bulletin of the world health organization, 95(5), 333-342. http://dx.doi.org/10.2471/blt.16.170092 murakami, d. k., blackie, c. a., & korb, d. r. (2015). all warm compresses are not equally efficacious. optometry and vision science, 92(9), e327-e333. http://dx.doi.org/ 10.1097/opx.0000000000000675 potter, p. a., perry, a. g., stockert, p., & hall, a. (2016). fundamentals of nursing-ebook. elsevier health sciences. putra, a. a. (2018). perbedaan efektivitas antara pemberian tepid sponge bath dan kompres plester terhadap perubahan suhu tubuh anak batita yang mengalami demam di ruang anak rsud dr. r. soedjono selong lombok timur. prima: jurnal ilmiah ilmu kesehatan, 4(2). 89-96. sunarti, s. (2018). pengaruh kompres hangat jahe merah (zingiber officinale roscoe) terhadap penurunan skala nyeri artritis reumatoid pada lansia di upt. pelayanan sosial lanjut usia dan anak balita wilayah binjai dan medan. jurnal keperawatan priority, 1(1). yunianti, s. c., astini, p. s. n., & sugiani, n. m. d. (2019). pengaturan suhu tubuh dengan metode tepid water sponge dan kompres hangat pada balita demam. jurnal kesehatan, 10(1), 10-16. https://pdfs.semanticscholar.org/fee0/744cd825a274ae47a46e89dce865bf4d6ab4.pdf https://pdfs.semanticscholar.org/fee0/744cd825a274ae47a46e89dce865bf4d6ab4.pdf http://www.jurnalnasional.ump.ac.id/index.php/medisains/article/view/1642 http://journal.um-surabaya.ac.id/index.php/jkm/article/view/dw/272 http://journal.um-surabaya.ac.id/index.php/jkm/article/view/dw/272 http://digilib.unisayogya.ac.id/3445/ http://digilib.unisayogya.ac.id/3445/ https://books.google.com/books?hl=id&lr=&id=qyfrdwaaqbaj&oi=fnd&pg=pp1&dq=guyton+fever+2011&ots=r16i8fabfo&sig=q4tiut1el9uzwv6hdu_t3yzoejy http://dx.doi.org/10.2471/blt.16.170092 http://dx.doi.org/%2010.1097/opx.0000000000000675 https://books.google.com/books?hl=id&lr=&id=eckkcwaaqbaj&oi=fnd&pg=pp1&dq=potter+fundamentals+of+nursing&ots=osuhcf6xlb&sig=hlhtlpn1ew2i80vtfdmeu-mrlqc http://128.199.127.86/e-journal/index.php/jpri/article/view/115/85 http://128.199.127.86/e-journal/index.php/jpri/article/view/115/85 http://jurnal.unprimdn.ac.id/index.php/jukep/article/view/48 http://jurnal.unprimdn.ac.id/index.php/jukep/article/view/48 http://www.ejurnal.poltekkes-tjk.ac.id/index.php/jk/article/view/897 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.172-180 172 nutritional pattern and healing of perineum wound on postpartum period heni frilasari 1 , noer saudah 2 , veryudha eka prameswari 3 , yeni nur azizah 4 , byba melda suhita 5 1,2,3,4 sekolah tinggi ilmu kesehatan bina sehat ppni indonesia 5 institut ilmu kesehatan strada indonesia coresponding author: noersaudah15@gmail.com abstract background: postpartum period was the return of uterine implants such as before pregnancy which takes 6 weeks after born. good nutrition patterns would speed healing wound perineum. the high nutritional content of calories, protein, fluids, and vitamins needed for speed up perineal wound closure. purpose: this study aimed to determine the relationship of postnatal maternal nutritional patterns with the healing of perineal wounds in puri community health center mojokerto. methods: analytical research design with cross-sectional. the population used postpartum mothers with perineal injuries. the sampling technique was through consecutive. the sample size was 90 respondents. the independent variable was nutrition pattern and the dependent variable was perineal wound healing. the instrument used was a questionnaire sheet postpartum maternal nutrition pattern and observation sheets for perineal wound healing. results: the results showed 56 respondents (63.3%) had good nutrition patterns and good perineal wound healing, 27 respondents (30%) had poor nutrition patterns and moderate perineal wound healing, as many as 7 respondents (6.7%) had nutritional patterns less and bad perineal wound healing. chi-square statistical test results showed ρ (0,000) <α 0.05. conclusion: it could concluded that there was a relationship between the nutritional pattern of the puerperal mother with the healing of perineal wounds. high caloric, protein, fluid and mineral intake and vitamins in the puerperium mother will accelerate the process of new cell regeneration so that the puerperal perineal wound heals faster. postpartum mothers are expected to maintain a nutritional pattern for healing the perineal wound and not do certain food restrictions during the puerperium. keywords: nutritional pattern, perineal wound, postpartum, puerperal received august, 29, 2019; revised november 27, 2019; accepted january 25, 2020 doi: https://doi.org/10.30994/jnp.v3i2.85 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. noersaudah15@gmail.com noersaudah15@gmail.com https://doi.org/10.30994/jnp.v3i2.85 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.172-180 173 background the postpartum period begins after the placenta is born and ends when uterine utensils return to their pre-pregnancy state. the postpartum period lasts for approximately 6-8 weeks (wahyuningsih, 2019). during the puerperium, wounds on the birth canal are usually called the perineal wounds. the perineal wound is a wound in the area between the two thighs, between the vulva and the anus caused by rupture or episiotomy wound at the time of delivery (syaiful, 2019). perineal wound healing if no infection occurs will heal within 6-7 days (syaiful, 2019). the speed of healing of perineal wounds is influenced by the basic needs of postpartum mothers about nutrition. during the puerperium, high nutrition is needed with enough calories, protein, fluids, and vitamins. nutritional factors will affect the healing of birth canal wounds. sari (2014) explained the nutritional status will affect wound healing. in some patients, a decrease in protein content will affect wound healing. the phenomenon at the puri community health centers in mojokerto regency shows that postpartum mothers experience delays in healing perineal wounds due to the habit of abstaining from food and avoiding fishy-smelling foods such as eggs and fish. also obtained is the healing of the perineal wounds for more than 7 days. perineal wounds in indonesia are experienced by 75% of vaginal delivery mothers (boyle, 2009). in 2015 it was found that out of 1,951 spontaneous vaginal births, 59% of mothers received perineal sutures (29% due to episiotomy and 30% due to spontaneous tears) (kemenkes, 2015). based on pws-kia mojokerto in 2017 reports were reported on postpartum mothers totaling 16,413 people and in 2018 there were 13,673 people (dinkes mojokerto, 2015). documentation of perineal wounds in mojokerto district has not been officially documented. based on a preliminary study conducted on december 12, 2018, at puri health center mojokerto through interviews and observations on 5 postpartum mothers who control 7 days with perineal wounds, 2 people said they did not consume meat, eggs, chicken and the amount of drinking 1 large bottle per day. the results of the observation of perineal wounds appear to be still reddish in color. 3 people said they ate meat, eggs, chicken, salted fish but did not limit the amount of drinking. observation results of perineal wounds appear dry. the results of this study are in line with research from (suryati, 2013) showing that with good nutritional status, 74,2% of respondents experienced normal wound healing. this can be seen from the observation that the perineal wound appears dry and tight, there are also no signs of infection such as pain, heat, swelling, redness, and dysfunction. while patients with malnourished status experienced an abnormal wound healing process of 77,8%. the impact of abstinence behavior during puerperium is a lack of nutrients so that healing of wounds will heal for a longer period of time even infection can arise. especially in postpartum women certainly, need nutritious food to restore the condition to accelerate the healing of perineal wounds and the lactation process. if the nutrition of postpartum mothers can be fulfilled properly then the perineal suture can heal quickly and the mother can carry out daily activities (saidah, 2011). based on the description above, the researcher was interested in further investigating the relationship of the nutrient patterns of postpartum mothers with the healing of perineal wounds at puri health center mojokerto. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.172-180 174 objective the purpose of this study was to analyze the relationship between the nutritional pattern of postpartum mothers and the healing of perineal wounds at puri health center mojokerto. methods this study used a type of analytic correlation study with a cross-sectional approach. the population in this study was postpartum mothers with perineal wounds at puri health center mojokerto. the sampling technique used the consecutive sampling technique the sample size was 90 respondents. independent variables of postpartum maternal nutrition pattern and the dependent variable of perineal wound healing. retrieval of postpartum mother nutrition pattern data used a questionnaire sheet and perineal wound healing using an observation sheet. the time of the study was conducted on february 20 april 21, 2019. analyze data used the chi squares statistical test. respondents were certain to receive an explanation of this research and asked to fill out and sign an agreement with the guarantee of confidentiality of information to unauthorized parties. the participants were assured that their engagement was voluntary, and that anonymity, privacy, and confidentiality of the data were guaranteed. furthermore, they were informed about the purpose and the method of the study before signing a written informed consent. results a. general data table 1. frequency distribution of respondents of postpartum mothers at puri health center mojokerto source: primary data, 2019 based on table 1 shows the characteristics of respondents based on age most respondents aged 26-30 years as many as 33 respondents (36.7%). shows that the majority of respondents have jobs as housewives as many as 57 respondents (63.3%). shows that the majority of respondents have the last education is high school as many as 69 respondents (76.7%). characteristics of respondents f (%) age < 20 years 9 10 20-25 years 30 33.3 26-30 years 33 36.7 31-40 years 18 20 work entrepreneur 3 3.3 private 27 30 civil servants 3 3.3 housewife 57 63.3 education elementary school 18 20 high school 69 76.7 college 3 3.3 total 90 100 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.172-180 175 b. special data this data illustrates specific data about the relationship of nutritional patterns of postpartum mothers with the healing of perineal wounds at puri health center mojokerto table 2. frequency of respondents distribution based on nutrition patterns of post partum mothers at puri health center mojokerto no. criteria of nutrition pattern f (%) 1. good 57 63.3 2. less 23 36.7 total 90 100 source: primary data, 2019 based on table 2 shows that the majority of respondents had good nutrition pattern criteria, namely as many as 57 respondents (63,3%). table 3. frequency distribution of respondents based on healing perineal wounds at puri health center mojokerto no criteria healing wound f (%) 1. good 57 63.3 2. medium 27 30 3. bad 6 6.7 total 90 100 source: primary data, 2019 based on table 3 shows that the majority of respondents had good healing perineal wounds criteria, namely as many as 57 respondents (63.3%). table 4. relationship between postpartum maternal nutrition patterns with healing perineal wounds at puri health center mojokerto source: primary data, 2019 the nutrition patterns healing of perineal wounds total good medium bad f % f % f % f % good 57 100 0 0 0 0 57 100 less 0 0 9 82 6 6.7 11 100 total 57 63 27 30 6 6.7 90 100 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.172-180 176 based on table 4 the results of cross-tabulation showed that of the 90 respondents that the respondents with good nutritional patterns were found to have perineal wound healing as many as 57 respondents (63.3%). while the respondents with less nutritional patterns were found to have moderate perineal wound healing as many as 9 respondents (30%) and poor perineal wound healing as many as 6 respondents (6.7%). based on statistical tests that have been determined in data analysis using the chisquare test technique obtained a significant level of 0,000 with α <0,05 so that there is a relationship between nutritional patterns of postpartum mothers with the healing of perineal wounds at puri health center mojokerto. discussion the nutrition pattern of postpartum mother based on table 2 shows that the majority of respondents have good nutritional pattern criteria as many as 57 respondents (63.3%). the pattern of nutrition that is formed is very closely related to one's eating habits. in general, the factors that influence the formation of nutritional patterns are factors of knowledge, prejudice, habits, preferences, and economics (damayanti, 2015). based on table 1 shows that most of the last education of respondents is high school, which is as many as 69 respondents (76.7%). education in this case usually associated with knowledge will affect the selection of food ingredients and fulfillment of nutritional needs. the higher the education of a person, the easier it is to receive information so that the more knowledge he has, the less education will inhibit one's attitude towards the values introduced (notoatmodjo, 2010). one example of the principle possessed by someone with low education is usually the important thing to consider so that the portion of food sources of carbohydrates is more than other foodstuffs. conversely, higher education people have a tendency to choose food sources of protein and will try to balance with other nutritional needs. almost all respondents have good nutritional pattern criteria due to the high level of education that the respondents have. the level of education affects the level of knowledge of a person, the higher the level of education, the higher the level of knowledge about health, one of which is the pattern of nutrition. if a good pattern of nutrition will affect the level of health, one of them is the healing of the perineal wound in the postpartum mother. healing of perineal wounds based on table 3 shows that most respondents have good wound healing criteria as many as 57 respondents (63.3%). perineal wound healing is beginning to improve perineal wounds with the formation of new tissue that covers the perineal wound within a period of 6-7 postpartum days. the act of cleaning the vulva can provide an opportunity to carry out a careful inspection of the perineum area. infection can occur is very unlikely if the perineal wound is treated properly (bahiyatun, 2009). based on table 3, it shows that the respondents have poor wound healing criteria, which are as many as 9 respondents (6.7%). as a result of improper perineal treatment can result in the condition of the perineum that is affected by the lock a become moist so it is very supportive of the development of bacteria that can cause infection in the perineum (puspitasari, 2011). inadequate treatment of perineal wounds will result in journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.172-180 177 inflammation or infection (saidah, 2015). personal hygiene factors that are not able to slow healing, this can cause the presence of foreign objects such as dust and germs. the infection causes an increase in inflammation and necrosis which inhibits wound healing. relationship between nutrition patterns of postpartum mothers and the healing of perineal wounds at puri health center mojokerto based on table 4 the results of cross-tabulation showed that of the 30 respondents that the respondents with good nutritional patterns were found to have perineal wound healing as many as 57 respondents (63.3%). while the respondents with less nutritional patterns were found to have moderate perineal wound healing as many as 9 respondents (30%) and poor perineal wound healing as many as 2 respondents (6,7%). based on the results of statistical tests using chi-square, there was a significant level of 0,000 with α <0,05 so that there was a relationship between the nutritional pattern of postpartum mothers and the healing of perineal wounds at puri health center mojokerto. the pattern of nutrition is a variety of information that provides an overview of the type and amount of food consumed every day by one person and is a characteristic for a particular group of people (sulistyoningsih, 2011). nutrition patterns affect the healing of perineal wounds in postpartum mothers. during the puerperium, quality nutrition is needed with enough calories, protein, fluids, and vitamins. nutrition is needed by the body for metabolic purposes. nutritional needs during the puerperium, especially if breastfeeding will increase by 25% because it is useful for the healing process because after childbirth. all that will increase three times the usual needs. foods consumed are useful for activities, metabolism, reserves in the body, the process of producing breast milk (wahyuningsih, 2019). based on table 3, it shows that the respondents have poor wound healing criteria, which are as many as 9 respondents (6.7%). as a result of improper perineal treatment can result in the condition of the perineum that is affected by the lack a become moist so it is very supportive of the development of bacteria that can cause infection in the perineum (puspitasari, 2011). inadequate treatment of perineal wounds will result in inflammation or infection (onyango aw. et.all, 2011). during the puerperium microorganisms such as bacteria, viruses and fungi are very easy to find. therefore, the maintenance of perineal wounds during the puerperium period must be properly guarded (sofian, 2011). personal hygiene factors that are not able to slow healing, this can cause the presence of foreign objects such as dust and germs. identification of the type of bacteria as a cause of genital infection in women, especially intimate organs, must be washed properly and dried, no ointment is needed. most perineal wounds occur because postpartum mothers are afraid to clean them so that the wound area is buried with dirt and postpartum blood which is a medium for germ growth. moreover, ointments that contain oil, dirt will be buried and the base of the wound covered with fat so it cannot dry. if perineal wound care is done correctly, the wound will heal quickly, and vice versa. during the period of puerperal infection is very wide, it must be maintained the cleanliness of the wound because the germs like the moist area and will also disrupt the wasting of the uterus (involution) so that the uterus will remain enlarged. perineal wound healing is due to the mother's knowledge of nutritional needs during the puerperium period is not following the rules of the fulfillment of good and balanced nutrition so that the wound is not dry. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.172-180 178 conclusion based on the results of the study, it was shown that there was a relationship between the nutritional pattern of postpartum mothers and the healing of perineal wounds at puri health center mojokerto. the perineal wound healing process requires adequate nutrition, nutritional requirements for the puerperium are determined by a pattern of good nutrition by postpartum mothers. good protein intake in postpartum mothers will improve the new cell regeneration process so that the perineal wound of the postpartum mother tends to heal faster. mothers with good nutritional patterns will accelerate the formation of scar tissue and accelerate the formation of fibrin threads so that the wounds heal soon. acknowledgments researchers would like to thank the chairman of institute health science bina sehat ppni for providing research funding facilities. thank you also goes to the researchers would like to thank the chairman of the ppni health development institute for health sciences for providing research funding facilities. thank you also to respondents who participated in the research conflicts of interest there is no conflict of interest in this study. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 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(2011). sinopsis obstetri: obstetri fisiologi, obstetri patologi. jakarta: egc. sulistyoningsih, h. (2011). gizi untuk kesehatan ibu dan anak. yogyakarta: graha ilmu. https://www.google.com/books?hl=id&lr=&id=zkpup-5ozy8c&oi=fnd&pg=pa1&dq=buku+ajar+asuhan+kebidanan+post+partum+normal&ots=4xul95pamu&sig=-catgobvh9vdgw5ya3ewzfpzkt4 https://books.google.co.id/books?id=rsxsgmbut5yc&dq=pemulihan+luka:+seri+praktik+kebidanan&hl=id&sa=x&ved=0ahukewiptmwqtmpoahvtccskhxxzb7yq6aeiktaa https://www.google.com/books?hl=id&lr=&id=e_pecqaaqbaj&oi=fnd&pg=pr6&dq=buku+ajar+keterampilan+dasar+kebidanan&ots=75pggotz8a&sig=mvzidwwz8yo8_sr9inzckrrp5uw https://www.kemkes.go.id/resources/download/pusdatin/profil-kesehatan-indonesia/profil-kesehatan-indonesia-2015.pdf https://docplayer.info/47847280-profil-kesehatan-kabupaten-mojokerto.html https://docplayer.info/47847280-profil-kesehatan-kabupaten-mojokerto.html https://eric.ed.gov/?id=ej1091724 https://eric.ed.gov/?id=ej1091724 http://r2kn.litbang.kemkes.go.id:8080/handle/123456789/77547 https://doi.org/10.1111/j.1740-8709.2010.00295.x http://www.ejournal.stikesmuhgombong.ac.id/index.php/jikk/article/view/25 http://www.ejournal.stikesmuhgombong.ac.id/index.php/jikk/article/view/25 http://ejournal.stikesmajapahit.ac.id/index.php/hm/article/view/41/46 http://ejournal.stikesmajapahit.ac.id/index.php/hm/article/view/41/46 http://ejournal.stikesmajapahit.ac.id/index.php/hm/article/view/41/46 http://103.38.103.27/repository/index.php/pub-keb/article/view/190 https://www.google.com/books?hl=id&lr=&id=d9_ydwaaqbaj&oi=fnd&pg=pa3&dq=asuhan+keperawatan+kehamilan+yuanita&ots=rivrskgzhm&sig=0yuamp7djf-prbzk5vckwh0oohc https://www.google.com/books?hl=id&lr=&id=d9_ydwaaqbaj&oi=fnd&pg=pa3&dq=asuhan+keperawatan+kehamilan+yuanita&ots=rivrskgzhm&sig=0yuamp7djf-prbzk5vckwh0oohc https://www.google.com/books?hl=id&lr=&id=d9_ydwaaqbaj&oi=fnd&pg=pa3&dq=asuhan+keperawatan+kehamilan+yuanita&ots=rivrskgzhm&sig=0yuamp7djf-prbzk5vckwh0oohc http://r2kn.litbang.kemkes.go.id:8080/handle/123456789/77016 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.172-180 180 suryati, y., kusyati, e., & hastuti, w. (2013). hubungan tingkat pengetahuan ibu nifas tentang perawatan luka perineum dan status gizi dengan proses penyembuhan luka. jurnal manajemen keperawatan, 1(1). wahyuningsih, s. (2019). buku ajar asuhan keperawatan post partum dilengkapi dengan panduan persiapan praktikum mahasiswa keperawatan. deepublish. https://jurnal.unimus.ac.id/index.php/jmk/article/view/946 https://books.google.co.id/books?hl=id&lr=&id=cbkfdwaaqbaj&oi=fnd&pg=pr5&dq=buku+ajar+asuhan+keperawatan+post+partum+dilengkapi+dengan&ots=vkhkjrcqwz&sig=ybin8dinrepv4pz1m56jleultc4&redir_esc=y#v=onepage&q=buku%20ajar%20asuhan%20keperawatan%20post%20partum%20dilengkapi%20dengan&f=false journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.163-167 163 knowledge about labor influence on primigravide readiness for labor erma nur fauziandari department of midwifery, karya husada health polytechnic yogyakarta, indonesia *corresponding author: erma.nf@gmail.com abstract background: the high maternal mortality rate in indonesia is caused by the unpreparedness of mothers in facing childbirth. many things affect the readiness of mothers in facing childbirth. the factors that affect the readiness of the mother are knowledge, education, socio-culture and economy. purpose: knowledge influences primigravida readiness to face childbirth. methods: this type of research is analytical research with an observational approach. sampling was taken by purposive sampling with the criteria primigravida with a minimum gestational age of 28 weeks. data analysis used chi square statistical analysis. results: the sample in this study was 53 primigravidas with the third trimester of gestation. the results of statistical tests show that the p value is 0.00 <0.05. these results suggest that the hypothesis is accepted, namely that knowledge affects primigravida readiness for labor. conclusion: the better the primigravida knowledge, the better prepared it will be to face childbirth. keywords: knowledge, primigravida, readiness for childbirth received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.254 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:%20erma.nf@gmail.com https://doi.org/10.30994/jnp.v6i2.300 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.163-167 164 background primigravida is a woman who is experiencing pregnancy for the first time. primigravida who do not yet understand about childbirth and pregnancy will often have difficulties in preparing for labor. midwives have a fairly important role in pregnancy, especially for primigravida in providing knowledge about childbirth. in accordance with the opinion of geniofam (2010) that the lack of readiness for childbirth is influenced by low knowledge and education, socioeconomic and socio-cultural. according to ristica (2017) that the high maternal mortality rate (mmr) in indonesia is caused by the unpreparedness of mothers in facing childbirth. indonesian population demographic survey (sdki) in 2017 that the maternal mortality rate in indonesia was 309/100,0000 live births. 90% of maternal mortality occurs at the time of delivery and 95% of the causes of maternal death are obstetric complications that are often not foreseen in advance, so the health department's policy to accelerate the reduction of mmr is to strive for every delivery to be helped or at least accompanied by a midwife and obstetric services as close as possible to all pregnant women (saefuddin in ristica 2017). the mother's unpreparedness in dealing with childbirthit causes a delay in the discovery of obstetric complications and the mother does not understand the preparation needed before delivery, so the mother does not get appropriate and timely services. this has caused three delays in referrals, namely firstly delays in making decisions to refer, second is delays in reaching health facilities, third is delays in obtaining assistance at health facilities. three lates are late in making referral decisions due to ignorance of where to seek help, cultural factors, decisions depending on the husband, fear of the costs that need to be paid for transportation and hospitalization, as well as distrust of the quality of health services, the second is the delay in reaching health facilities, influenced by distance, availability and efficiency of means of transportation, as well as costs, the third is the delay in obtaining assistance in health facilities, influenced by the number and skills of health workers, the availability of tools, drugs, blood transfusions and consumables, management and condition of health facilities. the optimal role of midwives can support efforts to accelerate mmr with the implementation of a comprehensive ante natal care (anc). anc services are the second pillar of the safe motherhood effort which is a way of preparing mothers for childbirth. based on data from the health profile of the special region of yogyakarta, it was found that the mmr in 2017 was 34 deaths with the most cases being primigravida, which was 41. 18 %. the most common causes of death in yogyakarta are bleeding, heart disease and eclampsia. the cause of death according to the delay was found to be 29. 41% of deaths are caused by late referrals caused by the inability of the mother or family members to recognize red flags, cultural factors and ignorance of where to seek help. based on these data, researchers are interested in conducting a study "knowledge of childbirth and its effect on primigravida readiness in the face of childbirth". methods the research was conducted in the prambanan health center area, yogyakarta. this type of research is analytical research with an observational approach. the inner population is all third trimester pregnant women in the prambanan health center area with a total of 125 people. there were 53 respondents with the purposive sampling method, namely primigravida pregnant women with a minimum gestational age of 28 weeks. the method of collecting data by means of respondents filling out a questionnaire of knowledge and https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.163-167 165 readiness for childbirth. after the data is collected, data analysis is carried out using chi square. results characteristics of respondents table 1. characteristics of respondents characteristic category sum % education tall 13 24.5 intermediate 38 71.7 basis 2 3.8 readiness ready 44 83.0 1 not ready 9 16.9 9 knowledge good 48 90.6 enough 5 9.4 less 0 0 table 1 shows that a total of 38 respondents (71.7%) were middle-educated. judging from the knowledge, 48 respondents (90.6%) had good knowledge about childbirth. for childbirth readiness a total of 44 respondents (83.01%) were ready to face childbirth and a number. the data obtained were then analyzed using chi square and the results of the analysis were obtained in table 2. table 2. cross-table of knowledge of readiness for childbirth knowledge readiness for childbirth p value ready % not ready % good 43 81.1 5 9.43 0.000 enough 1 1.88 4 7.54 less 0 0 0 0 the results of the chi square analysis obtained a sig value of 0.00<0.05 so that the hypothesis was accepted, namely that knowledge has an influence on primigravida's readiness to face childbirth. the results of the study are in accordance with the opinion of muthoharah (2018) who stated that knowledge affects the readiness of primgravida in the face of childbirth. discussion knowledge judging from table 1 that most respondents have good knowledge about childbirth. this good knowledge is influenced by many factors, namely education. it is known that 51 respondents (96.2%) had a secondary education and above. according to nursalam's opinion in muthoharoh (2018) that the higher a person's level of education, the easier it will be to receive new information. new information received can increase the mother's knowledge of childbirth. primigravida is the first woman to become pregnant. with less experience, primigravida needs help from various elements to have a good knowledge of childbirth. the ministry of health of the republic of indonesia (2012) states that a person's parity is a https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.163-167 166 predisposing factor for antenatal services. the higher the parietas, the higher the experience and reduced anxiety of the mother in the face of childbirth. the results in this study are different from the statement of the ministry of health of the republic of indonesia (2012) caused by other factors that affect knowledge. among these factors is the role of midwives in providing midwifery care during the implementation of the anc. midwives as leading health workers in improving the health of mothers and children play an important role in providing information about pregnancy and childbirth to all pregnant women, especially primigravida. other sources of information about childbirth can be accessed directly by pregnant women through information media such as newspapers, magazines, blogs or online information media. readiness to face childbirth the tabulation results from table 1 found that as many as 44 respondents (83.01%) were ready to face childbirth. according to prawirohardjo in muthoharoh (2018) that childbirth readiness plays an important role in reducing mmr caused by three lates. the three delays are late decisions in providing assistance to mothers, late in bringing to health care and late medical personnel providing assistance. materson in agustina (2017) that the preparation for childbirth aims to prepare all the necessary needs during childbirth. such readiness includes physical readiness, psychological readiness, social readiness and cultural readiness. childbirth readiness helps mothers to be able to achieve standardized delivery services and reduce delays when mothers have to receive emergency services. the readiness of respondents in facing childbirth is inseparable from the role of midwives as leading health workers. midwives as female partners are in charge of providing support, iec and care during pregnancy, childbirth and puerperium. this care includes prevention efforts, promotion of normal childbirth, detection of complications in mother and child, and access to medical assistance or other appropriate assistance, as well as carrying out emergency measures. of all respondents, there were also 9 respondents who were not ready to face childbirth. this makes input and evaluation for midwives in providing services and care to primigravida so that they can prepare for childbirth and avoid the occurrence of three lates so as to help reduce maternal mortality. the effect of knowledge on childbirth readiness the sign value in table 2 is 0.00<0.05 which means that the hypothesis is accepted that knowledge has an influence in childbirth readiness. the results of this study are in accordance with research conducted by oktalia (2016) that maternal knowledge has an influence on childbirth readiness. mothers who have good knowledge of childbirth will make good preparations for childbirth compared to mothers who lack knowledge of childbirth. this research is also in line with the results of research from muthoharoh (2018) which states that primigravida knowledge affects readiness to face childbirth. the subjects in this study were primigravida with gestational age starting in the iii trimester. primigravida is a woman who is pregnant for the first time where the woman has no experience of pregnancy or childbirth. to gain knowledge about pregnancy and childbirth, primigravida must get information from health workers, especially midwives, experienced people and also information from social media. information from social media today varies, especially pregnant women can access it online via the internet, so that pregnant women can more easily get information other than the information provided by the midwife. childbirth readiness is a way to assess the success of the labor process. a mother who does not yet have the readiness to face childbirth is feared to have various difficulties in https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.163-167 167 childbirth. good childbirth readiness will reduce various risks both physical and psychological. this lack of influential knowledge in childbirth will lead to 3 late i.e.; late decision-making, late in bringing health duties and being slow to get help. the incident of 3 late is currently still the cause of the high maternal mortality rate in indonesia. therefore, the role of midwives is very necessary to increase maternal knowledge, especially primigravida in childbirth so as to increase maternal readiness in facing childbirth. the knowledge of pregnant women in the iii trimester primigravida about their delivery is also influenced by other factors. according to mubarak in muthoharoh (2018)⁵ the factors that can influence a person's knowledge are education, occupation, age, interests, experience, environmental factors, information on economic status and social relations. conclusion there is an influence of knowledge on childbirth readiness indicated by a sig value of 0.00 < which means that the better the primigravida knowledge in childbirth, the more prepared it is to face childbirth. references agustina, rika. (2017). factors related to the readiness of childbirth at the pity i health center, bantul regency. digilab unisa jogja. center for statistics. (2017). demographic survey of indonesian population. diy health. (2018). evaluation of maternal and infant mortality in diy provinces in 2017. diy health. geniofam. (2010). 99 tips to prepare and maintain pregnancy. leutika: jakarta. ministry of health ri. (2012). guidelines for the implementation of classes for pregnant women. jakarta. ministry of health ri. muthoharoh. husnul. (2018). the relationship between primigravida's mother's knowledge and mother's readiness to face childbirth in the work area of the lamongan regency health center. strada journal of health sciences. pages 40-46. oktalia, july. (2016). mother's readiness to face pregnancy and the factors that influence it. journal of health sciences and technology. pp 147-159. ristica, od. (2017). the relationship between attitude knowledge and family support of primigravida's mother with normal childbirth preparation at bpm khairani asnita, lppm umsb science tower. november. pages 79-86. https://thejnp.org/ journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 8 15 the influence of therapy do'a in islam to the cooperative clients skizofrenia cooperative water pathway in public health center karanganyar, gandusari trenggalek, east java sunaryo puskesmas karanganyar trenggalek corresponding author : sunaryopuskesmaskaranganyar@gmail.com abstract background: coping mechanism is a process whereby individuals try to handle and master stressful situations that suppress the consequences of the problems it faces, it is very necessary in patients with psychiatric. purpose : the purpose of this study was to analyze the effect of preand post-intervention therapy on cooperative mechanisms of cooperative schizophrenia methods : the research design used in this research is experimental pre with one group pretest and posttest approach where the mechanism of client cloning before and after schizophrenia is given intervention in the form of prayer therapy. the analysis used is descriptive where the data is taken directly on each respondent, the score obtained from each respondent will be adjusted with the standard assessment, while testing the hypothesis using t test dependent analysis. result : based on the result of statistical test, the mechanism of cooperative schizophrenia client cooperate in outpatient care in health center of puskesmas karanganyar gandusari district trenggalek mean difference of therapy of prayer in islam before therapy and after therapy is 0,400 with standard deviation 0,503. beside that got value p value = 0,002. conclusion :the results of this study indicate there is a significant difference between before prayer therapy and after therapy do'a to coping mechanism of client of schizophrenia. keywords : prayer therapy, coping, skizofrenia received february 03, 2018; revised february 24, 2018; accepted march 10, 2018 how to cite: sunaryo. (2018). the influence of therapy do'a in islam to the cooperative clients skizofrenia cooperative water pathway in public health center karanganyar, gandusari trenggalek, east java. journal of nursing practice. 1(2). 8-15. the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-noncommercialsharealike 4.0 international license. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 8 15 background schizophrenia is a disorder generally characterized by fundamental and distinctive distortions in the process of thinking and perception, unfit and dull affects. this disorder involves the most basic functions that make a normal individual feel the feelings of individuality, such as the most intimate thoughts, feelings, and behaviors often seem to be known to others and delusions may be explained, as the effects of natural forces and supra natural that affect the way of thinking and behaving that is often strange. the magnitude of mental health problems from household health surveys conducted by the indonesian ministry of health research and development (mohri) with susenas-bps (badan pusat statistik) sample of 65,664 households found the prevalence of mental disorders 140/1000 household members and the prevalence of schizophrenia reached 3/1000 population. trenggalek regency in 2011, there were 1599 cases of mental disorders. visits to the karanganyar community health center in 2011 there were 127 new cases and 379 old cases, most (70%) were serious mental disorders. preliminary studies of dipoli mental health of the 11 patients observed had never been given prayer therapy. coping mechanism is a process whereby individuals try to handle and master stressful situations that suppress the effects of problems faced by how to make changes in cognitive and behavior in order to obtain a sense of security in itself. the two coping strategies employed by individuals are solfing focused coping problems that actively seek solutions to problems or situations that cause stress and emotion focused coping where the individual involves attempts to regulate his emotions in order to adapt to the impact that a conditions or stressful situations. spiritual spiritual therapy is also called holistic therapy meaning physical, psychological, psychosocial and spiritual therapy. through the workshop of religion and psychiatric model of partnership (1993), advocated adding religious therapy in addition to psychic and medical therapy (setiyo, 2007). confidence (self confidence) and hope of healing (optimism) are two things that are essential for the cure of disease in addition to medication and medical treatment. one of the religious actions is to pray. that is to say a plea to god to obtain a desired desire so as to affect the psychological changes and somatic changes. the purpose of this study is to analyze the influence of prayer therapy before and after intervention to cooperative mechanism of cooperative schizophrenia journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 8 15 objective the purpose of this study was to analyze the effect of preand post-intervention therapy on cooperative mechanisms of cooperative schizophrenia methods the research design used in this research is experimental pre with one group pretest and posttest approach where the mechanism of client cloning before and after schizophrenia is given intervention in the form of prayer therapy. the population of this study are all schizophrenia clients registered in poly soul puskesmas karanganyar gandusari trenggalek as many as 186 people, with a large sample of 20 respondents. sampling using consecutive sampling is selecting samples that meet the study criteria until a certain time so that the number of samples are met. the research was conducted in health polyclinic puskesmas karanganyar gandusari trenggalek for 1 month since 17th of march until 17th april 2012. the analysis used is descriptive where the data is taken directly on each respondent, the score obtained from each respondent will be adjusted with the standard of assessment. while testing the hypothesis using t test dependent analysis. results the working area of puskesmas karanganyar is 17.83 km², divided into 5 villages namely sukorame, krandegan, melis, karanganyar, and widoro. population density is 1.009 inhabitants / km². puskesmas karanganyar is located at rt 06 rw 02 karanganyar village, gandusari district. the human resources of the health personnel at the community health center consist of two doctors, 1 dentist, 2 nurses, 13 nurses, midwives 7 people, 1 dental nurse, 1 pharmacist assistant, 1 sanitarian, 1 person nutritionist, administrative personnel 9 people. descriptive analysis results on variables prior to prayer therapy it was found that most (65%) or 13 of 20 respondents stated their coping mechanism was effective. table 1. characteristics before prayer therapy in schizophrenic patients before therapy f % efective coping 7 35 inefective coping 13 65 jumlah 20 100 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 8 15 whereas after prayer therapy based on the distribution of characteristics after prayer therapy in schizophrenic patients showed most (75%). table 2. characteristics after therapy of prayer in schizophrenic patients after therapy f % efective coping 15 75 inefective coping 5 25 jumlah 20 100 the dependent t test is often used in experimental data analysis. besides, the dependent t test is often called t pair / related test or pair. this is in accordance with the variables in this study, ie the two dependent variables in which the sample groups are compared have the same subject. table 3. the average therapy of prayer in the patients with schizophrenia no variabel mean sd se 1. before therapy 1,650 0,489 0,109 2. after therapy 1,250 0.444 0,099 the average of prayer therapy in islam in prayer therapy in islam toward coping mechanisms of cooperative schizophrenic clients in outpatient care in puskesmas karanganyar gandusari trenggalek community health center at the time before therapy was 1.65 with a standard deviation of 0.489. whereas in the second measurement obtained on average after receiving prayer therapy in islam mechanism of cooperative schizophrenia client cooperate in outpatient care in health clinic puskesmas karanganyar gandusari trenggalek 1,250 with standard deviation 0,444. to test the proposed hypothesis accepted or rejected, then in this study used in t test dependent because both samples are dependent. in addition, because the variables are compared have the same object that is compared cooperative mechanism cooperative schizophrenia between before and after follow prayer therapy. t test result dependent with provisions if p value <0,05 then h0 is rejected and h1 accepted. conversely, if p value> 0,05 then h0 is accepted and h1 is rejected. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 8 15 table 4. test statistics of prayer therapy in schizophrenic patients no variabel mean sd se p value 1. before therapy 0,400 0,503 0,112 0,002 2. after therapy based on the result of statistical test, the mechanism of cooperative schizophrenia client cooperate in outpatient care in health center of puskesmas karanganyar gandusari district trenggalek mean difference of therapy of prayer in islam before therapy and after therapy is 0,400 with standard deviation 0,503. beside that got value p value = 0,002, hence can be concluded that there is significant difference between before therapy of prayer and after therapy do'a to mechanism of cooperative client cooperative schizophrenic cloning in health polis health puskesmas karanganyar gandusari trenggalek. discussion seeing the results of descriptive analysis before the do'a therapy describes most schizophrenic clients in the mental health pole karanganyar puskesmas gandusari trenggalek less have the ability to handle and master stressful situations that suppress the consequences of the problems it faces. naturally conscious or unconscious individuals have actually used coping strategies in the face of stress. coping strategies are the way in which to change the environment or situation to solve a problem that is being felt or faced. effective coping produces persistent adaptations that are new habits and improvements from the old situation, whereas ineffective coping ends with maladeprojects that are deviating from normative desires and can harm themselves or others or the environment. based on the description it can be assumed that a schizophrenic client whose coping mechanism is ineffective has an inability: to pour out the heart of the problem, to seek information about the problem at hand, to connect problems faced with a spiritual approach, to relax, to discuss with others about alternative problem solving. while descriptive analysis after prayer therapy on client skizofreniamenggambarkan most clients skizofreniadi poli mental health puskesmas karanganyar gandusari trenggalek after doing prayer therapy in islam has the ability to handle and master stressful situations that suppress the consequences of the problems it faces. coping mechanism is a process whereby individuals try to handle and master stressful situations that suppress the consequences of journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 8 15 problems faced by how to make changes in cognitive and behavior in order to obtain a sense of security in itself. in addition, experts classify two coping strategies that can be used by individuals solfing focused coping problem where individuals are actively seeking solutions from problems to eliminate stressful and emotion focused coping situations or situations where the individual involves attempts to regulate his emotions in order to adapt yourself with the impact that will be caused by a stressful condition or situation. from the analysis the researcher assumed that the patient of cooperative schizophrenia outpatient in the health policewomen of puskesmas karanganyar gandusari district of trenggalek regency after receiving the therapy do'a have the ability to handle and master stressful situation that suppress the result of the problem that is facing. it is possible that prayer provides an opportunity for individuals to renew confidence and trust in almighty god in a more formal way. based on the result of t test of dependent (paired sample test) it can be concluded there is a significant difference between before the therapy of prayer and after prayer therapy in islam against coping mechanism of client cooperative schizophrenia outpatient in health polis health puskesmas karanganyar gandusari trenggalek (p value = 0.002). praying that is done solemnly, solemnly, accurately, sincerely and continuously, is thought to foster positive perception and motivation in activating coping, as rehatta said, that positive emotional response (positive thinking) can avoid stress reactions (rehatta, 2004 in sholeh, 2005 ). prayer is also a positive reinforcement and motivator, so prayer can make the spirit and soul able to defeat everything that has a negative impact on them. based on the description, the authors assume that the therapy of prayers performed on the patient's cooperative schizophrenia outpatient in the mental health pole karanganyar puskesmas gandusari trenggalek district has a very big role in determining and encouraging the ability to handle and master stressful situations that suppress the effects of problems that are faced him. conclusion from the results of research ynag researchers have done in the health of mental health center karanganyar gandusari trenggalek regency starting from 17 march to 17 april 2012 can be concluded that: journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 8 15 1. the coping mechanism of an outpatient schizophrenic client prior to prayer therapy showed that most (65%) or 13 of the 20 respondents stated the coping mechanism was ineffective. 2. the coping mechanism of an outpatient schizophrenic client following a prayer therapy showed that most (75%) or 15 of 20 respondents stated their coping mechanism was effective. 3. there is a significant difference between before and after prayer therapy on the mechanism of cooperative cooperative schizophrenic coping of outpatients in the mental health pole of karanganyar puskesmas gandusari trenggalek, as indicated by the dependent t test, that is, the average value of the difference of 0.400 with a standard deviation of 0.503 and a significance value of 0.002 (p <alpha). references agusno,mahar, (2009) perjalanan panjang skizofrenia,indoesian psychiatric quarterly jakarta : yayasan kesehatan jiwa dharmawangsa. arikunto,suharseni (2006 ) prosedur penelitian suatu pendekatan praktik, jakarta : rineka cipta burdah, ibnu (2005) do’a dan penyembuhan cara nabi, yogyakarta : mitra pustaka darwis,yulisar,dkk (2004) pedoman pelayanan kesehatan jiwa dasar di puskesmas, jakarta : depkes ri hidayat, a. aziz alimul (2007) riset keperawatan dan teknik penulisan ilmiah, surabaya salemba medika issaes, ann (2005) keperawatan jiwa dan psikiatrik, edisi 3, jakarta, egc keliat, budiana dkk (2006) proses keperawatan jiwa ,edisi 2, jakarta : egc maramis, wf (2005) catatan ilmu kedokteran jiwa, surabaya : airlangga university press rasmun, (2005) stress, koping dan adaptasi, jakarta : sagung seto ridwanullah, qosdi, dzikir pagi dan sore beserta fadhilahnya, 2008, boyolali, zaka. sangkan, abu (2006) pelatihan sholat khusyu’,sholat sebagai meditasi tertinggi dalam islam, jakarta : sholat centre dan baitul ihsan sholeh, muhammmad ( 2007) terapi sholat tahajud menyembuhkan beberapa penyakit, jakarta : hikmah populer stuart w gail, (2007) buku saku keperawatan jiwa, edisi 5, jakarta, egc journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 8 15 thalib, muhammmad (2005) dzikir dan do’a sholih, jakarta : media hidayah tun k bustaman, at all, (2003) leksikon istilah kesehatan jiwa dan psikiatrik, jakarta : egc widyastuti, palupi (2004) manajemen stress, jakarta : egc yosep, iyus (2009) keperawatan jiwa, bandung : refika aditama journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 7 11 7 the precision of the giving of the drug based on service identifikation of patien compliance at “darmayu” general hospital ponorogo agusta dian ellina¹, suwarno², alfian fawzi 3 1,3 stikes surya mitra husada kediri ² rsu darmayu ponorogo corresponding author: agustadian85@gmail.com abstract background: the research was distributed by drug services granting conditions up to this moment there are still many problems. as for the problem of the research is "whether the compliance of nurses in identifying influence on accuracy in the service of dispensing". purpose: aim of this research is to know the level of compliance officers perform identification before providing the service of medicine, knowing compliance do identification relationship and analyze correctness of granting of service remedy with precision identification in "darmayu" general hospital ponorogo. methods: in this study data collected through questionnaire method against 40 people the respondents admitted in "darmayu" general hospital using the aksidental method, ponorogo for knowing the responses of respondents to each variable. then conducted an analysis of the data obtained in the form of quantitative analysis. quantitative analysis includes the test validity and reliability, as well as test the correlation of phi. result: of research results, data the respondents obtained shows that the level of accuracy of the perwat in the service of the drug still has not been fullest is demonstrated from 40 respondents, there were 22 stating the precision. likewise, the level of compliance of nurses in conducting identification is still lacking, from 40 respondents, 14 respondents declared not obedient in doing identification. the results of the analysis of the compliance officers do get that the identification of the effect on the precision in the service of medicine. hypothesis testing using the test correlation of phi showed that independent variables examined is proven to significantly affect the dependent variable. conclusion: patient safety incidents can be prevented by the presence of the nurse in conducting compliance identification as well as precision in running the sop. sosiaisasi and high awareness of nurses on the importance of obedience and compliance in carrying out procedures will greatly affect the success of a service to patients at home sick. keyword: patient safety, nurse compliance, patient, identification received: february 03, 2018; revised february 24, 2018; accepted march 10, 2018 how to cite: ellina, a.d., suwarno., & fawzi, a. (2018). the precision of the giving of the drug based on service identifikation of patien compliance at “darmayu” general hospital ponorogo. journal of nursing practice. 1(2). 7-11 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 7 11 8 background patient safety is part of a priority in nursing services. nurses as the front guard in health services are required to always provide quality services and ensure patient safety. many cases in health services occur from nursing actions performed by nurses not in accordance with the standard operating procedures (spo) that has been set. the institute of medicine in the united states reported that in utah and colorado there was an adverse event of 2.9%, of which 6.6% of them died. while in new york unwanted event (ktd) was 3.7% with mortality rate 13.6%. the number of deaths due to ktd in hospitalized patients across america amounting to 33.6 million per year ranged from 44,000 to 98,000 per year. who publication in 2004, collecting hospital research figures in various countries: america, england, denmark, and australia, found ktd with a range of 3.2 to 16.6%. with these data, various countries immediately conduct research and develop the patient safety system (moh ri, 2011). the impact caused by frequent ktd, knc, kpc and senetinel event is very complex, for patients the impact is going to be the length of hospitalization (alos), with the increasing number of days of care will also increase the cost (cost) . the most dangerous impact of death is very detrimental to the patient due to not doing the procedure as specified. in indonesia, according to mohri (2011), data on ktd and knc are still scarce, but on the other hand there is an increase in mal-practice allegations that are not necessarily in accordance with the final verification. incidence of patient safety breach 28,3% done by nurse. therefore, the nurse as one of the implementers has great potential in making a mistake if it does not have the knowledge and awareness is high that the actions performed will have an effect on the patient. the results of preliminary survey of researchers obtained from the patient safety committee at the research site on november 2, 2016, has been socialized program 6 target patient safety but still not well understood and implemented about the patient's safety, this can be seen from the front office or information who has not performed a record of identity well where in the medical record document the patient has not listed the birth date of the patient, in the er, the patient's identity bracelet is still listed patient's age not the date of birth, also the patient has not been given education / explanation about the benefits of the installation of the bracelet, identifier not installed or removed or covered. in the treatment room is also still common where the officer before the action did not do a good identification. from the incident report data on the error in the provision of drug services due to the lack of proper identification of patient identification procedures, indicating that in the last 3 months (july, august, september) there were 4 cases of ktd (unexpected events) identification. this occurs because the patient's name is the same (2 occasions), patient moved bed / bed (1 event), one patient / patient sealed closed bracelet (1 event) (pmkp rsu data "darmayu"). objective aim of this research is to know the level of compliance officers perform identification before providing the service of medicine, knowing compliance do identification relationship and analyze correctness of granting of service remedy with precision identification in "darmayu" general hospital ponorogo methods this type of research uses descriptive quantitative research design based on a philosophy of positivism that emphasizes objective phenomena and is studied quantitatively. the journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 7 11 9 design objectivity maximization of this research is done by using numbers, statistical processing, structure and controlled experiments. there are several research methods that can be incorporated into non-experimental quantitative research. the research design used in this research is by cros sectional approach which is a research where the cause or risk variable and the effect or case happened on the research object is measured and collected by stimulant, moment or one time at one time / setiadi, 2009). this study taking sampling is aksidental based on the characteristics of individual traits that will be studied in accordance with the consideration of the researcher so that it can represent the population are: patients with age ≥ 18 th or already married, patients can read and write patients who are willing to become respondents. for scoring independent and dependent variables using nominal scale. score 1: if the answer is never 2: if answer sometimes 3: if answer always to get the value or the number of compliance and non-compliance, the researcher uses technical data analysis with the calculation of mean. mean is an average value that can represent a set of representative data. the mean of compliance and accuracy in this study is 14. if the total score is ≤ 14 then the code is 1 (not petak / not exact), utuk total score ≥ 14 then the code 2 (obedient / precise) in this study validation test using 10 respondents who were hospitalized in muslimat general hospital ahmad yani ponorogo. by using computer program reliability test is the level of stability of a measuring device in measuring a symptom / occurrence. the higher the reliability of a measuring device, the more stable the measuring device is. according to nunnaly (1967) in ghozali (2001), a construct is said to be reliable if it gives a cronbach alpha value> 0.6. results table 1. result of respondent's answer to variable compliance identification obedient not obey responden 22 18 table 2. results of respondents' answers to the variables of the accuracy of drug services obedient not obey responden 26 14 table 3. phi corelation test tabel uji korelasi phi value df asymp. sig. (2sided) exact sig. (2sided) exact sig. (1sided) pearson chi-square 9.808a 1 0.002 continuity correctionb 7.832 1 0.005 likelihood ratio 10.213 1 0.001 fisher's exact test 0.003 0.002 linear-by-linear association 9.563 1 0.002 n of valid casesb 40 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 7 11 10 discussion compliance level of patient identification at rsu "darmayu" from the result of the questionnaire about the identification compliance given to the respondent on the identification of the patient conducted by the nurse, the result of 22 respondents (55%) said that the officer did the identification before the drug administration and 18 respondents (45%) said that the nurse did not identify before drug. according to kaur et al (2008) compliance from health workers relate to the knowledge they have. this knowledge will then be derived in the form of attitudes or behavior of health workers in the face of patients. compliance in the standard precautions here is closely related to the behavior of health workers in preventing the occurrence of infection when dealing with patients. looking at the facts and theories from previous research indicates that many factors that influence nurse compliance in identifying them, less knowledge of nurses about what and how to identify before taking action. in addition, the nurse's awareness in understanding the importance of identifying prior to the action is still lacking, it is based on the hospital periodically who has conducted socialization about patient safety which includes identifying before taking action. another factor that may affect the level of nurse compliance is the lack of supervision by the boss or supervisor of the services performed by the ataf so that the assurance that the policies, procedures and spo are well run is lacking. level of accuracy of drug delivery service in rsu "darmayu" ponorogo from respondent data showed that the accuracy in drug service resulted 26 respondents (65%) of respondents stated that the nurse was right in giving medicine service and 14 respondents (35%) stated that the nurse was not appropriate in providing drug service. based on the researcher's observation when giving questionnaires to be filled, seen some respondents are still confused because the respondents did not pay much attention to what the nurse did when giving medicine. by looking at the results of research conducted as well as from the facts and theories above it is found that the accuracy in the provision of drug services based on compliance in applying the principle 6 can be influenced by the level of knowledge, education and full awareness by the nurses about the impact of behavior caused by inaccuracy in providing drug services becomes very important. this is based on respondents' answers where the majority answered sometimes, meaning that the nurse has been socialized but not orderly in running it. compliance relation analysis identification with the accuracy of drug delivery services at rsu "darmayu" ponorogo from the data of respondents from 40 respondents 75% showed a relationship where 30 respondents said that the nurses are obedient in identifying also meyatakan appropriate in providing drug services as well as vice versa. while the respondents who say nurses obedient in identifying but not appropriate in providing drug services or vice versa a number of 10 respondents. by looking at the results of data analysis shows that there is a significant relationship between compliance in identifying with accuracy in the provision of drug services. the more obedient the officer in identifying the accuracy in the drug service will be better too. conversely the accuracy of drug services will decrease if the level of compliance officers in the identification also decreased. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 7 11 11 conclusion the level of nurse compliance in the identification is still lacking, this is due to lack of understanding of the importance of identifying and still weak supervisory supervisor on the implementation of the established procedures. in the application of the principle of 6 right by the nurse is still not optimal, this is caused by a lack of understanding of the way the implementation of these 6 principles and periodic socialization has not done and regular evaluation. based on statistical test by using phi correlation test by using spss program got α = 0,05 ≥ p value value that is: 0,003 or ha accepted, ho rejected in other words there is a very significant relationship between compliance to identify with the accuracy of drug service delivery in rsu "darmayu" ponorogo. references bernadeta dece harus ; ani sutriningsih 2015, pengetahuan perawat tentang keselamatan pasien dengan pelaksanaan prosedur keselamatan pasien di rumah sakit, jurnal care vol. 3 no 1, http://ejournal.unsrat.ac.id/index.php/ebiomedik/issue/view/838 2015. cahyono, j.b 2010. membangun budaya keselamatan pasien dalam praktek kedokteran. yogyakarta : kanisius. kars, 2011. standar akreditasi rumah sakit , jakarta : departemen kesehatan ri. kemenkes ri. 2008. panduan nasional keselamatan pasien rumah sakit (patient safety): utamakan keselamatan pasien. jakarta: depkes ri. kkp-rs. 2008. panduan nasional keselamatan pasien rumah sakit. jakarta: depkes ri. kozier.erb.berman.snyder, 2010, fundamental keperawatan, jakarta : egc persi. 2011. join commution international standar akreditasi rs.edisi 4. jakarta gramedia pmk ri nomor 1691/menkes/per/viii/2011 tentang keselamatan pasien rumah sakit. rekam medis rsu “darmayu” ponorogo 2016, laporan insiden keselamatan pasien. undang undang nomor 44 tahun 2009 tentang rumah sakit dona dwi ekawati, 2013 evaluasi penerapan identifikasi pasien dibangsal rawat inap rsi siti aisyah madiun http://ejournal.unsrat.ac.id/index.php/ebiomedik/issue/view/838%202015 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.123-131 123 effects of sunlight exposure for treatment of tuberculosis : literature review liza novitasari wijaya, sri nabawiyati nurul makiyah universitas muhammadiyah yogyakarta, indonesia corresponding author: lizawijaya94@gmail.com abstract background: tuberculosis is a contagious infectious disease caused by mycobacterium. tuberculosis which can attack various organs, especially the lungs. it is necessary to study the effectiveness of sunlight therapy and the vitamin d diet as supporting tuberculosis treatment. purpose: this study aimed at investigating the literature for of provision of sunlight in tuberculosis patients. methods: this library review uses a database with the electronic search on ebsco, clinicalkey, google scholar, and sciencedirect published in 2016 2019. results: six articles were used to review. the article discusses vitamin d deficiency as a causative factor for tuberculosis, the effectiveness of clinical treatment in a sanatorium using vitamin d and the use of sunlight as a treatment for tuberculosis in the days before the discovery of antibiotics. conclusion: sun exposure has been shown to provide a clinical improvement in patients by providing comfort and improving moods that are unable to increase the elimination of bacteria in the lungs. keywords: tuberculosis, tb, vitamin d, sunlight. received august, 29, 2019; revised november 24, 2019; accepted january 13, 2020 doi: https://doi.org/10.30994/jnp.v3i2.78 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:lizawijaya94@gmail.com https://doi.org/10.30994/jnp.v3i2.78 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.123-131 124 background tuberculosis is an infectious disease caused by mycobacterium. tuberculosis which can attack various organs, especially the lungs (kemenkes ri, 2016). the record of global tuberculosis report data in 2015 around 10.4 million new cases of tuberculosis occurred worldwide. six countries with the highest new cases of tuberculosis were india, indonesia, china, nigeria, pakistan, and south africa. indonesia is the 2nd ranks in the most tb sufferers after india and accounts for 45% of tuberculosis cases globally (who, 2016). the indonesian tuberculosis eradication association (ppti) describes tb regulation, the government includes tb services in hospitals as one of the conditions for accreditation. therefore, there should a need for the latest breakthroughs in therapy to improve repair and healing (buku saku ppti, 2010). sugiarti at al explained, before oat therapy was found, nutrition was considered to be the main therapy against tb, for example, vitamin a and vitamin d. since the discovery of oat in the 1940s, the provision of nutrition was no longer plays an important role. it was also stated that vitamin d supplementation on oat therapy has been shown to prove a significant clinical improvement (sugiarti, 2018). research in jakarta stated that the group with vitamin d supplementation had higher sputum conversion time and improved radiological picture (100%) compared to the placebo group (76.7%). the study concludes that vitamin d therapy is effective in addition to oat therapy so vitamin d is suggested to be prophylactic for the environment that is in direct contact with patients because it is easy and the costs needed are quite affordable. one practical and efficient method is sun therapy or known as heliotherapy (sugiarti, 2018). heliotherapy is a treatment with sunbathing under heat or sunlight that is believed to cure several infectious diseases. hippocrates, over 2400 years ago, has said that the sun is very useful for dealing with various diseases. he has mentioned heliotherapy which means treatment with sunlight (emokpae et al, 2016). the sunlight that reaches the earth in eight minutes after traveling 15,000 million miles, is the most amazing germicide. although today antibiotics are more used to deal with infections, healing with sunlight has been done, especially by people who are less able to buy modern medicine. theoretically, bacteria exposed to ultraviolet light and direct sunlight will die within two hours. infectious diseases that can be used in heliotherapy include sore throat, pneumonia, and leprosy (emokpae et al, 2016). the purpose of this article is to conduct a literature review of articles that research or discuss the effects of giving sunlight to tuberculosis patients. objective this study aimed at investigating the literature for of provision of sunlight in tuberculosis patients. methods search strategy this compilation literature review uses various databases by using searches in several electronic media such as ebsco, clinicalkey, google scholar, and sciencedirect that have been conducted on december 2018 to january 2019. searches are limited with articles published from 2016 to 2019 which are available in indonesian and english. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.123-131 125 some terms or keywords are combined in a search strategy to get the right articles such as using the terms "sunlight therapy", "heliotherapy", "sunlight therapy" + "tuberculosis" or "terapi sinar matahari", "sunlight therapy and tuberculosis" article selection criteria the process of selecting articles included in this literature review must meet several criteria. inclusion criteria are ; i) there's a paper, journal, or scientific article ; ii) discussion of the profits and benefits of sunlight ; iii) the discussion focuses on tuberculosis patients or respiratory infections ; iv) articles published from 2016 to 2019. exclusion criteria are; i) duplicate article; ii) articles that are not published in scientific journals. articles that have been obtained meet the inclusion and exclusion criteria then analyzed, compared to each other, discussed and concluded. from these articles, 1 article discusses the trigger factors for tuberculosis where one was the lack of vitamin d originated from uv-b exposure and food sources, 1 article discusses the use of vitamin d, cod liver oil, sunlight and phototherapy for the treatment of tuberculosis in the era before the discovery of antibiotics, 1 article on the effectiveness of exposure to tuberculosis and respiratory infections, and 3 articles discuss the history of clinical medicine in a sanatorium using sunlight. the six articles obtained, two articles were original research, two journal review articles and two other scientific articles (table 1). results the selection process from the literature review is shown in figure 1. the results of the search strategy in the database received 132 articles but as many as 126 articles were issued because they did not comply the criteria. six articles were obtained that matched the inclusion criteria and were approved. figure 1. the results of the search strategy no author article title writing purpose results 1. boere et al (2017) english solar ultraviolet b exposure and global variation analyze the incidence of tuberculosis and its causative factors in several countries 3.16% of 100,000 populations in 154 countries has occur the relevant articles searched articles are filtere d articles rejected articles which fit the criteria n = 6 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.123-131 126 ecology study in tuberculosis incidence : an ekological analysis new cases of tuberculosis per year. triggers for tb cases are urbanization, lack of uv-b exposure, and nutrition. 2 greenhalgh and butler (2017) english historical descriptive sanatoria revisited : sunlight and health explore the historic of treatment for tuberculosis patients in sanatorium in the 18th century proper exposure, sunlight can be useful for tb treatment 3. handono et al (2016) indonesia case study research the effect of sunlight to improve the effectiveness of airway cleansing in copd patients in selogiri health center knowing the influence of sunlight on copd patients. there is an effect of sunlight on the airway cleaning in copd patients 4. martin. k (2016) english a journal review modernism and the medicalization of sunlight: d. h. lawrence, katherine mansfield, and the sun cure explore the perceptions of patients having tuberculosis treatment in the 1920s healing by sunbathing can improve clinical conditions while forming good emotions. 5. mccullough dan lehrer (2018) english a comprehensive review vitamin d, cod liver oil, sunshine, and phototherapy: safe, effective and forgotten tools for treating and curing tuberculosis infections — a comprehensive review review reports before the antibiotic era documented clinical improvement in the treatment of tuberculosis using vitamin d, cod liver oil, sunlight and phototherapy vitamin d, cod liver oil, sunlight and phototherapy have a tremendous impact on improving clinical cure for tuberculosis at an affordable cost. 6. rushton. k (2016) english historical descriptive the records of stannington children’s sanatorium: charting half a century of tuberculosis care explore medical records of treatment for tuberculosis on stannington children's in sanatorium before the era of antibiotics for 46 years children who were cared for at stannington sanatorium by getting both artificial and natural sunlight were supported with adequate nutrition and rest to help fight disease journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.123-131 127 discussion tuberculosis is still a major health problem especially in developing countries like indonesia. patients who have been diagnosed with tuberculosis will undergo treatment for oat (anti-tuberculosis drugs) for six months. there needs to be a strong body system during treatment so prevention of complications and worsening conditions can be avoided (sugiarti, 2018). long before the discovery of antibiotics, tb treatment was something terrible. doctors in 18th century used the pneumothorax method, which surgically knocked down or deflated a portion of the lungs to heal and thoracoplasty or chest autopsy that cut two to three ribs so that the lungs would have more space and were believed to cure patients, but unfortunately this has a negative impact, many patients experience complications until they die. the treatment of tuberculosis is highlighted by heliotherapy (sunlight), which was popularized by dr. danish niels finsen in 1900s, many tb patients were accommodated in the sanatorium for healing. in the 1940s tb treatment began to shift with the discovery of vitamin d. independently vitamin d has been proven to cure infections without using penicillin simultaneously. until 1947 the first anti-tb drug was discovered by dr. selman waksman, this is changing all tb treatments that have been used and are now almost forgotten (mccullough, 2018). the main advantage of tb antibiotics is the ability to avoid prolonged hospitalization and does not require long maintenance costs (mccullough, 2015). but along with the rapid development of pharmacology, we are faced with a crisis of antibiotic resistance. the emergence of new problems with the increasing prevalence of mdr tb and the development of tb-hiv disease, this requires more complex tb control and the need for breakthroughs in tb treatment so that it can improve and accelerate healing. this article will review articles that discuss tb and vitamin d, sunlight therapy, sanatorium, and emotional. tuberculosis and vitamin d the famous standard tb therapy is oat therapy (anti-tuberculosis drugs). before the discovery of oat therapy, a therapy that had been used as the main therapy for tb was the provision of nutrients, namely vitamin a and vitamin d. the tuberculosis patients get treatment using oral vitamin d and injections that are injected intrapleural (sugiarti, 2018). in 1945, dr. j.e.m. wigley commented on the extraordinary thing about vitamin d's ability to cure tb: "i think we all agree on the results of this treatment, shown in these six cases, that many striking results that might be an update of time". this was also acknowledged by dr. in 1947 michelson stated "the most important part, the recommended safe dose of vitamin d. dowling and thomas noted signs of mild intolerance in 8 of 38 patients except 1, all of whom were able to tolerate smaller doses without discomfort. interestingly it is estimated that the need for vitamin d is needed high enough in the body. daily vitamin d intake in doses exceeding 10,000 iu per day per pound of body weight, or higher than 20,000 iu per day per kg of body weight is considered necessary to prevent toxicity" (mccullough, 2018). this is not much different from the research conducted by lubis et al. in 2015, it provided complementary treatment of 100,000 iu (2.5 mg) oral vitamin d in tuberculosis patients undergoing oat treatment. the results showed that vitamin d improved clinical journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.123-131 128 conditions as measured by sputum conversion times faster than patients who only received oat treatment. it is known that vitamin d deficiency occurs in patients affected by tuberculosis and is one of the risk factors for contracting this disease. the highest incidence of tuberculosis occurs in countries that experience socio-economic problems such as population density and malnutrition. besides uv-b exposure and vitamin d status are additional determinants of tuberculosis. so it's important to have enough vitamin d in the body to prevent tuberculosis. besides being obtained in the form of medicines, vitamin d can also be obtained from sun exposure or food (boere, 2017). but for those who do not suffer from tb and as a precaution, a vitamin d diet is lower than a deficient tb patient. recommendations from the us medical institute (600 iu per day for adults ≤ 70 years and 800 iu per day for those who are ≥ 71 years old) (desai et al, 2012). sanatorium since 18th-century tuberculosis has become the leading cause of death worldwide. this is a highly contagious infectious disease and finding effective treatments to fight tb requires a lot of time. one of the first treatments that worked was to live in a sanatorium. the sanatorium is a medical facility that is used to treat long-term illnesses, especially tuberculosis patients. this sanatorium was very popular in europe at the end of the 18th century, the sanatorium provides patients with fresh food and air especially because it was exposed to more sunlight (greenhalgh, 2017). the first sanatorium was opened in 1903 by dr. auguste rollier (1874–1954) in the city of leysin, in the swiss alps and a major supporter of sunlight therapy with dr. danish niels finsen (1860-1906). the first sanatorium was dedicated to caring for tb children and immediately began bringing tb patients from europe (greenhalgh, 2017). figure 1. children basked in sanatorium source: the newsletter of the university of virginia school of nursing eleanor crowder bjoring center for nursing historical inquiry. volume 23, issue 2 october 2015 dr. rollier revealed the main principle behind sun therapy is a combination of good food and rest to strengthen patients and enable them to fight and fight diseases better (11). from journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.123-131 129 this information, the medical staff develops individual therapy plans that include sunbathing, high-fat diets, cereals, vegetables, and milk, plus planned exercise. sunlight exposure to children and their reactions to cold air, temperature, and their physical activity are monitored carefully (keeling, 2015). in the early 1930s, the enthusiasm of doctors for heliotherapy and sanatorium began to decrease. their success has not been proven in most medical facilities. doctors agree that sunlight, fresh air, and nutritious food increase the general health of tb children, but do not cure them from tuberculosis. in 1953 sanatorium was converted into a children's hospital before finally being completely closed in 1984 (rushton, 2016). sunlight therapy the necessity of the sun to humans has been recognized for thousands of years. the ability to provide warm sunlight, a sense of well-being, and the ability to plant crops for food needs. in ancient egypt, greece, india, and rome recognized the extraordinary power of healing diseases using the sun, but in the early 18th century the medical profession began to develop and began to critically investigate whether the sun could heal. these pioneering medical doctors introduced it as sunlight therapy, which includes heliotherapy (sunlight) phototherapy (ultralight or artificial light). this therapy has proven effective in treating several forms of tuberculosis, a deadly disease that has infected humans for centuries (keeling, 2015). actual data is presented in a report stating that patients suffering from tb differ from one country to another. in an ecological study that explored the relationship between uv-b exposure and the incidence of tuberculosis, it was shown that countries with high uv-b sun exposure had a tb incidence rate of 78% lower than countries in low exposure areas (boere, 2017). the lowest mortality rate is because tb is located in countries in the rocky mountains, which have more sun exposure, less rainfall, and are at much higher altitudes than in countries with high mortality. the conclusions put forward by experts are "extraordinary things where the low mortality rate in the rocky mountain country seems to be due to the uniqueness and favorable climate conditions, from the conclusion that climate affects tb treatment" (mccullough, 2018). one example of improvement was a girl who was treated at the sanatorium with peritoneal tb on may 1, 1925, when she was 8 years 11 months old. dr. t.c. hunter who handled it gave a detailed report on his case and his treatment with heliotherapy. the entry time is 115 cm and weighs only about 1.5 kg. immediately he received treatment for artificial sunlight by using a mercury vapor lamp for two minutes every day and rising slowly to five minutes, but his condition in a few months became worse and it was decided to stop artificial sunlight treatment. during the spring of 1926, it was possible to start the treatment of natural sunlight because of the amount of sunlight that was falling and at the request of patients with artificial sunlight treatment. slowly his condition then began to improve (rushton, 2016). the picture below was taken within two years. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.123-131 130 figure 2. source: social history of medicine vol. 29, no. 4 pp. 829–839 besides, sunlight therapy can also reduce tightness in patients with impaired airway cleaning. research conducted by handono in copd patients decreased rr 24 times/minute from 26 times/minute. this sun therapy can be done each morning and evening or if the family feels short of breath because cold allergies appear. duration of administration of sunlight therapy is about 15 to 20 minutes in a sitting position (handono, 2016). emotional aspect sun exposure also influences emotional changes. the research conducted by handoko explained that copd patients who have been given sunlight therapy experience a decrease in congestion and provide comfort and tranquility (handono, 2016). katherine mansfield, a writer who got a treatment program for sunbathing against tuberculosis, also wrote in her writing during treatment that sunrise and sunset provide a touch that affects not only her physical but also mood and this is an extraordinary natural tonic for the body. as explained earlier that sunlight was very popular for the treatment of tb in the early 20th century. this perception of healing is not only intended for physical healing but also can provide feelings of pleasure in the feelings of patients when getting a treatment program (martin, 2016). this happens because when the skin is stimulated with uvb radiation, human skin produces beta-endorphin in response to exposure, this opioid peptide has the result of increasing feelings of well-being, improving the immune system, relieving pain, increasing relaxation, healing wounds, and being able to overcome the mild effects of depression to mood swings. skin also releases nitric oxide, a compound that can accelerate the amount of blood flow, stimulate vasodilation and reduce blood pressure. during active exposure to uva, diastolic blood pressure drops by about 5 mmhg and remains lower for 30 minutes after exposure. a decrease in diastolic blood pressure of 5 mmhg reduces the risk of stroke by 34% and coronary heart disease by 21% (baggerly, 2015). conclusion tuberculosis control is still a particular concern in indonesia and even the world so that breakthroughs in tb treatment are needed so that they can improve and accelerate healing. in the pre-antibiotic years, medical staff popularized the treatment using sunlight to treat tuberculosis patients. this therapy provides clinical improvement to the patient and provides a calm sensation and improves mood even though it has not been able to eliminate the bacteria in the lungs until anti-tb drugs are found and this sunlight therapy is forgotten. the emergence of an antibiotic resistance crisis, we may have to rethink to revive drugs in a sanitarium in the 19th century as a companion treatment to accelerate the healing process by utilizing sunlight therapy, a diet high in vitamin d and a healthy lifestyle. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.123-131 131 references baggerly, c. a., cuomo, r. e., french, c. b., garland, c. f., gorham, e. d., grant, w. b., ... & pittaway, m. (2015). sunlight and vitamin d: necessary for public health. journal of the american college of nutrition, 34(4), 359-365. https://doi.org/10.1080/07315724.2015.1039866 boere, t. m., visser, d. h., van furth, a. m., lips, p., & cobelens, f. g. (2017). solar ultraviolet b exposure and global variation in tuberculosis incidence: an ecological analysis. european respiratory journal, 49(6), 1601979. https://doi.org/10.1183/13993003.01979-2016 desai, n. s., tukvadze, n., frediani, j. k., kipiani, m., sanikidze, e., nichols, m. m., ... & seydafkan, s. (2012). effects of sunlight and diet on vitamin d status of pulmonary tuberculosis patients in tbilisi, georgia. nutrition, 28(4), 362-366. https://doi.org/10.1016/j.nut.2011.08.012 emokpae, a. a., mabogunje, c. a., imam, z. o., & olusanya, b. o. (2016). heliotherapy for neonatal hyperbilirubinemia in southwest, nigeria: a baseline pre-intervention study. plos one, 11(3). https://10.1371/journal.pone.0151375 greenhalgh, i., & butler, a. r. (2017). sanatoria revisited: sunlight and health. the journal of the royal college of physicians of edinburgh, 47(3), 276-280. https://doi.org/10.4997/jrcpe.2017.314 handono, n. p. (2018). pengaruh sinar matahari untuk meningkatkan efektifitas bersihan jalan nafas pada pasien ppok. jurnal keperawatan gsh, 5(2). keeling, a. w., & brodie, b. (2015). historical perspectives on fresh air, sunshine, and public health. windows in time, 23(2), 1-2. kemenkes, r. i. (2016). infodatin: tuberkulosis temukan obati sampai sembuh. jakarta: pusat data dan informasi. martin, k. (2016). modernism and the medicalization of sunlight: d. h. lawrence, katherine mansfield, and the sun cure. modernism/modernity 23(2), 423-441. https://doi.org/10.1353/mod.2016.0028. mccullough, p. j., & lehrer, d. s. (2018). vitamin d, cod liver oil, sunshine, and phototherapy: safe, effective and forgotten tools for treating and curing tuberculosis infections—a comprehensive review. the journal of steroid biochemistry and molecular biology, 177, 21-29. https://doi.org/10.1016/j.jsbmb.2017.07.027 perkumpulan pemberantasan tuberkulosis indonesia. (2010). buku saku ppti rushton, k. (2016). the records of stannington children’s sanatorium: charting half a century of tuberculosis care. social history of medicine, 29(4), 829-839. https://doi.org/10.1093/shm/hkw027 sugiarti, s., ramadhian, m. r., & carolia, n. (2018). vitamin d sebagai suplemen dalam terapi tuberkulosis paru. jurnal majority, 7(2), 198-202 who-world health organization, & who-world health organization. (2016). global tuberculosis report 2016. http://apps.who.int/iris/bitstream/10665/250441/1/9789241565394-eng.pdf https://doi.org/10.1080/07315724.2015.1039866 https://doi.org/10.1016/j.nut.2011.08.012 https://10.0.5.91/journal.pone.0151375 https://doi.org/10.4997/jrcpe.2017.314 http://journal.akpergshwng.ac.id/index.php/gsh/article/view/48 https://www.nursing.virginia.edu/media/windows_in_time_2015_october.pdf https://pusdatin.kemkes.go.id/download.php?file=download/pusdatin/infodatin/infodatin-tb-2016.pdf https://doi.org/10.1353/mod.2016.0028 https://doi.org/10.1016/j.jsbmb.2017.07.027 https://agus34drajat.files.wordpress.com/2010/10/buku_saku_penanggulangan-tuberkulosis-ppti-2010.pdf https://doi.org/10.1093/shm/hkw027 http://juke.kedokteran.unila.ac.id/index.php/majority/article/view/1876 http://apps.who.int/iris/bitstream/10665/250441/1/9789241565394-eng.pdf journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.181-187 181 effectiveness of virgin coconut oil in the provision of injury pressure sores stroke patients: systematic review nurul indah sya'bani, muh. anwar hafid, a. budiyanto adi putra uin alauddin makassar, indonesia coresponding author: nurulsyabani2027@gmail.com abstract background: vco is an oil made from fresh coconuts and processed naturally or do not require heating and do not add other chemicals. the fatty acids contained in the vco has the added benefit of making your skin soft. vco is effectively applied as a moisturizer to the skin so that it can improve skin hydration and promotes healing of the skin. decubitus is damage to the skin caused by friction or pressure on the skin located bony section. purpose: this literature review aimed to determine the effectiveness of the vco in reducing the risk of decubitus sores method: this research method quantitative descriptive approach systematic review through some journals that are relevant to this article. this research article search by using keywords 1 "prevention of decubitus sores" keyword 2 "vco" search database sources used in this study is portal garuda, isjd and google scholar were published from 2015 to 2019 year. results: the results of this study identified include the use of vco prevent decubitus sores, that vco is effective in prevention of decubitus sores in patients with stroke or bedrest.the use of vco as decubitus sores preventive therapy has many benefits. substances that are contained in the vco can provide benefits or nutrients to keep the skin moist. conclusion: nurses as nursing care providers are expected to use the vco to prevent decubitus sores in patients with stroke or bedrest as an intervention in a hospital or as therapy can do at home community. keywords: wound pressure sores, patient stroke, virgin coconut oil (vco) received august, 29, 2019; revised november 27, 2019; accepted january 25, 2020 doi: https://doi.org/10.30994/jnp.v3i2.86 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:nurulsyabani2027@gmail.com https://doi.org/10.30994/jnp.v3i2.86 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.181-187 182 background decubitus is damage to the skin caused by friction or pressure on the skin located bony section (npuap, 2014). the inability to move actively so that the pressure and friction on the skin surface that stands out, the pressure on the skin can cause ischemia and hypoxemia due to reduced blood flow (mccance, 2018). stroke is a disease of the brain nerve dysfunction locally or globally, the rise of a sudden, progressive, and fast (mendis, 2015). strokes can occur due to the blood and oxygen should be delivered to brain disorders such as obstruction or rupture of blood vessels, where deliver blood vessels these components resulting in less oxygen in the brain affects the body movement that controlled the brain is not functioning (mozaffarian, 2016). mendis (2015), states that stroke is the second sequence of the deadly disease after heart disease. a stroke more triggered by hypertension, diabetes mellitus, obesity and various disorders of blood flow to the brain. the incidence of stroke the world as much as 37% of the 58.5 million people 17.7 million people worldwide died. judging from the results riskesdas 2018, in indonesia the incidence of stroke increases with age. obtained the number of stroke patients in 2018 at the age of 55-64 years (32.4%), aged 65-74 years (45.3%) and the highest at the age of 75 years and older (50.2%). the prevalence of stroke cases in indonesia is based on a diagnosis of health personnel by 10.9 per mill. the prevalence of stroke cases is highest in east kalimantan province (14.7%) and the lowest in the province of papua (4.1%). the prevalence of stroke male (11.0%) and women (10.9%). while the prevalence in south sulawesi region amounted to (9.8%) (riskesdas, 2018). who survey conducted on 55 hospitals in 14 countries showed 8.7% of the hospital there are patients with decubitus sores. the incidence of decubitus sores in stroke patients based on research walker (2017) of 265 stroke patients, as many as 56 people (21%) had pressure sores. in indonesia alone, the number of incidence of pressure sores are quite high in asia, where the incidence of pressure sores ranging from 2.1 to 31.3%. based on the results of research conducted by said (2018), in hospitals labuang makassar baji states that 32.3% of patients experienced decubitus sores. virgin coconut oil (vco) is yielding coconut oil processed naturally or do not require heating and do not add other chemicals to produce oil with a clear color. fatty acids contained (especially soluble acid and oleic) in vco effectively applied as a moisturizer to the skin so that it can improve skin hydration and accelerate healing of the skin. (kappally, 2015). nursing theory is applied as an approach to the theory of dorothy orem, said that self-care is a conceptual model to improve the ability of the patient or the family in caring for themselves and care for his family independently and used as a basis independence nurses to patients or their families according to their ability or level of dependency. therefore, to be able to meet the objectives of the theory according to orem, namely, the ability of nurses to help clients meet the needs and provide partial self-care, such as nurses to help stroke patients in the mobilization and intervention prevention of decubitus sores. decubitus sores would interfere with the recovery process of patients, and also followed with pain and infectious complications that add to the long duration of treatment. many of intervention or therapy in the prevention of decubitus sores on pasie stroke or other bedrest. so it takes the value of the effectiveness of the treatment will be given. this journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.181-187 183 literature review aimed to determine the effectiveness of the vco in reducing the risk of decubitus sores. objective this literature review aimed to determine the effectiveness of the vco in reducing the risk of decubitus sores. methods the design of this research is descriptive quantitative systematic review approach. this study uses a systematic review approach to find an effective intervention strategies in the provision of virgin coconut oil to prevent decubitus sores in stroke patients.this research article search strategy using the keyword 1 "prevention of decubitus sores" keyword 2 '' virgin coconut oil''sumber search database used in this study is portal eagle, google schoolar and isjd. the inclusion and exclusion criteria in this study are the criteria for inclusion: articles that terpublish in 2015-2019; articles fullteks articles that match the topics and there issn; journal vco intervention as preventive therapy decubitus sores, exclusion criteria: interventions that require a lot of tools and materials. after collecting data and information, all of the data and the relevance of such information selected by using duffy's research appraisal checklist approachwith the considered problem. to present the issues to be discussed, the data collected was analyzed descriptively. portal eagle google scholar isjd 2 20 1 figure 1. a flow diagram for selection and inclusion studies identification screening exclusion: not full text (n = 3) not according to the research question (n = 5) according to the research questions (n = 7) eligiblity rate by duffy's research appraisal checklist approach inclusion category average paper (score 103-204) (n = 1) inclusion: articles in 2015-2019 the article identified (n = 23) category below average paper (score 0-102) (n = 0) category superior paper (score 205-306) (n = 6) screening results (n = 15) articles inclusion (n = 6) journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.181-187 184 results a total of 23 articles were identified from all three search literature data after the selection (years 2015 to 2019, the research only in humans and are associated with a research question). authors assess all articles identified independently for inclusion in the systematic review. of the 23 articles that have the potential, there are three exclusion because it is not a full text, 5 were excluded because it does not suit the purpose of research. studies diinklusi for this literature review should be (1) a focus on intervention vco preventive therapy of decubitus sores, (2) fullteks articles according to the topic and there issn and (3) published from 2015 to 2019. from 7 articles were taken, one article was excluded because it is an average of paper (a score of 103-204) based on an assessment by duffy's research appraisal checklist approach. thus, only 6 articles that met the inclusion criteria with articles intervention. figure 2 illustrates the process of inclusion of the study. the article was included and criticized using assessment tools to duffy's research appraisal checklist approach. discussion decubitus is damage to the skin caused by friction or pressure on the skin located bony section (npuap, 2014). the inability to move actively so that the pressure and friction on the skin surface that stands out, the pressure on the skin can cause ischemia and hypoxemia due to reduced blood flow (mccance, 2018). vco is yielding coconut oil processed naturally or do not require heating and do not add other chemicals to produce oil with a clear color. fatty acids contained (especially soluble acid and oleic) in vco effectively applied as a moisturizer to the skin so that it can improve skin hydration and support healing of the skin. (kappally, 2015). the first journal written by sihombing (2014) shows the results of the study found a back massage using vco can prevent decubitus sores by 80% in patients who have significant risk (p <0.05). white back massage using petroleum jelly can prevent decubitus sores by 68% in patients at risk were significantly (p <0.05). it can be seen that the administration of the vco has a higher effectiveness compared to white petroleum jelly. giving vco in patients with stroke or bed rest can be recommended as a treatment to prevent decubitus sores. in line with the research results dewandono (2014), states that a massage with vco can be done as a nursing intervention to prevent injury dekbutis in patients who have a risk of injury decubitus, according to the nursing models by orem, where the main focus of the conceptual model self-care is increasing a person or family's ability to care for themselves or their family members independently in order to reach the ability to sustain the health and well-being. the second journal written by wasliyah (2018), shows the results of research that administration of vco and olive oil are equally effective in the prevention of decubitus sores. based on the results handayani (2010) shows the results of research that between administration without giving vco and vco against decubitus sores have significant differences. the third journal written by fatonah (2016), with the title. vco awarding research shows more effective for lowering scale compared decubitus wound with ordinary coconut oil. nevin (2010), conducted research to identify the effect of topical skin and vco to component amtioksidan status during dermal wound and found that wounds treated with vco cured more quickly. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.181-187 185 according to dhikhil (2014), some of the health benefits contained in the vco is: reduce inflammation; support in the repair and healing of tissue, killing the bacteria that cause ulcers, throat infections, urinary tract infections, gum disease and oral cavity, pneumonia and help the immune system function. the fourth journal written by setyawati (2015), shows the results of research that does mobilization intervention every two smpai 3 hours by giving vco against decubitus sores equally has an efficiency the also no difference. results of previous studies regarding the risk of decubitus sores in patients bedrest stated that the vco can reduce the risk of decubitus wound on a patient bed rest (dhikhil, 2014). the fifth journal written by lertwattanaruk (2015), show study results showed that their efficiency the vco in the provision in the prevention of decubitus sores which do experiments in the intervention group was given the vco while the control group without the vco. according to the institute for clinical systems (icsi), reveals one decubitus sores prevention is to reduce or eliminate friction and pressure. periodically, use hypoallergenic lubricating oils, creams or lotions that can reduce pressure and friction. virgin coconut oil can be used as a topical prevention of decubitus sores because the content varied. journal of the sixth written by setiani (2017), shows the results of the study that administration of vco as a medium for massage on the prevention of injuries decubitus produce efficiency the good which is done on two groups, namely a group of interventions that massage with vco and a control group that is sop care in preventing injuries decubitus. the main cause of the stroke is happening motor deficits such as hemiplegia hemiparase and thus experience a state of mobility. this situation can cause a decline in general limb muscle strength, decreased flexibility and strength of joints that can lead to contractures and ultimately the patient will be experiencing limitations to perform activities. due to a decrease in muscle strength in patients with stroke will usually impaired mobility or the ability to move the body and normal free thus have an increased risk for pressure sores during treatment. patients must be hospitalized and impaired mobility will occur the onset of pressure sores, because of pressure on the body. so patients with prolonged immobilization great potential to experience pressure sores (widodo, 2017). thus the vco is pure coconut oil has many benefits is very easy to get out of a wide range of products that are in indonesia and this vco though we can also create your own or where the materials and tools make it easy to obtain vco. conclusion based on 23 articles were obtained from several databases that portals eagle, google scholar and isjd, then checked back in inclusion and exclusion criteria, there are 7 articles. after the assessmentby duffy's research appraisal checklist approach showed 6 articles. there are 6 article is about the effectiveness of virgin coconut oil (vco) in decubitus sores stroke patients, that intervention on patients with stroke vco administration effective for use in preventing the risk of decubitus sores. the results of the six articles indicate that some journals do research with quasi experiment research design to injured patients at risk of pressure sores and administration of the vco to prevent the decubitus sores. systematic review of the results, it can be concluded that some journals award vco) of patients with stroke above show significant effectiveness and therapy given to prevent the risk of decubitus sores. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.181-187 186 references dewandono, i. d. 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(2017). pengaruh tindakan keperawatan reduksi luka tekan terhadap penurunan risiko luka tekan. jurnal ilmiah kesehatan keperawatan, 13(2). https://doi.org/10.26753/jikk.v13i2.214 http://dx.doi.org/10.30659/nurscope.1.2.1-6 https://www.semanticscholar.org/paper/antibacterial-activity-of-aqueous-garlic-(allium-sihombing-silalahi/a4ec325ae9e32085db26645080dfc7e2aac673b2#citing-papers https://www.semanticscholar.org/paper/antibacterial-activity-of-aqueous-garlic-(allium-sihombing-silalahi/a4ec325ae9e32085db26645080dfc7e2aac673b2#citing-papers http://gneaupp.info/wp-content/uploads/2014/12/prevenciondeulcerasporpresionyprotocolodetratamiento.pdf https://doi.org/10.1177%2f1747493017711815 http://jurnal.poltekkesbanten.ac.id/medikes/article/view/60/43 http://jurnal.poltekkesbanten.ac.id/medikes/article/view/60/43 https://doi.org/10.26753/jikk.v13i2.214 this page is intentionally left blank journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.143-152 143 family preparedness in caring patients with cancer: a literature review akbar u saun, erna rochmawati universitas muhammadiyah yogyakarta, indonesia corespondending author: akbarusaun@yahoo.com abstract background: cancer patients choose to understand at home. families have an important role in the care of clients specifically at home. readiness is needed in order to provide optimal care and will be able to improve the quality of life of patients. this literature review aims to see how families are prepared to care for patients with cancer at home. purpose: the objective of this research was to analyze the journal literature about family readiness to treat patients at home needs to be considered and nurses play an important role in providing education to the family in providing patient care at home so that the patient's welfare is fulfilled. methods: writing this journal literature uses study literature originating from the database, namely ebsco, proquest, pubmed, and google scholar using the keywords family preparedness, family caregiver, symptom management, palliative care, family quality of life, care parenting. using inclusion criteria that contain literature sources taken from 2009 to 2019, inclusion criteria, using english, conformity of approval keywords, linkages between the results of literature research and the discussion raised. results: there are 4 themes found in this literature review, namely family care in patient care, instruments in measuring family readiness, self-affection for families who care for patients at home, and psycho-education in increasing family readiness to care for patients at home. conclusion: family readiness to treat patients at home needs to be considered. nurses play an important role in providing education to the family in providing patient care at home so that the patient's welfare is fulfilled. keywords: family preparedness, family caregiver, symptom management, palliative care, caregiving burden. received august, 29, 2019; revised november 25, 2019; accepted march 23, 2020 doi: https://doi.org/10.30994/jnp.v3i2.80 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:akbarusaun@yahoo.com https://doi.org/10.30994/jnp.v3i2.80 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.143-152 144 background cancer is one of the most deadly chronic diseases in the world. according to us statistics, the number of deaths from cancer is around 23% of the total number of deaths in the country and is the second most deadly disease after heart disease (anand et al., 2008). the world health organization (who) said cancer was the main cause of first or second death in humans before reaching the age of 70 years, in 91 of 172 countries (mcguire, s. 2016). the proportion of cancer patients who live depending on the help of their family caregivers increases significantly. by 2020, the number of people with cancer is estimated to swell by 31% from 13 to more than 18 million. family care for patients at home is very important to optimize the quality of life and well-being of patients, especially cancer patients (silveira et al., 2018). families as caregivers of patients at home often feel unprepared in handling patients. this level of readiness is an important factor to improve their welfare. this readiness refers to how ready families carry out their duties and demands in carrying out their roles as caregivers of patients at home (hendrix et al., 2016). care of patients at home will increase patients' sense of security and comfort in life-threatening problems by providing palliative care needs at home (sarmento et al., 2017). caregivers of patients, especially patients with cancer at home, often face huge demands during a disease recovery program, when giving services, and during mourning. caregiver burden, needs, satisfaction, quality of life, and how home care is often not monitored by the clinic so that the need to deal with problems in patients at home is not fulfilled and can cause undesirable problems (tanco et al., 2017). this literature review aims to discuss how family preparedness includes anything (instrument, burden?) in caring for patients with cancer and other life-threatening diseases at home. objective the objective of this research was to analyze the journal literature about family readiness to treat patients at home needs to be considered and nurses play an important role in providing education to the family in providing patient care at home so that the patient's welfare is fulfilled. methods writing this literature review comes from the theoretical concepts of the research under study. data collection was carried out by filtering 18606 literature sources into 8 related literature which were discussed in the writing of the literature review. there are inclusion criteria used in filtering literature that are suitable for topics taken such as families caring for patients with cancer, paliative care. the specified criteria are literature sources taken from 2009 to 2019, suitability of writing keywords, journals with english, the relevance of the results of literature writing with discussion. in journal collection, searches are conducted through several accredited journal search sites such as proquest, pubmed, and google scholar. the keywords used in the search for literature related to this topic are "family preparedness or caregiver and symptom management family and palliative care and caregiving burden". table 1. literature search strategy ebsco proquest pub med google cendikia first attempt “family preparedness or family caregiver and symptom management and palliative care and caregiving burden” all result journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.143-152 145 693 articles 415 articles 198 articles 17.300 articles second attempt filter by years (2009-2019) abstract and full text scholary journal academic journal filter by years (2009-2019) abstract and full text filter by years (2009-2019) abstract and full text filter by years (2009-2019) abstract and full text 110 articles 205 articles 109 articles 6.231 articles third attempt inclution abstract and full text 85 articles 107 articles 46 articles 1.806 articles fourth attempt include abstract and full text 0 articles 3 articles 3 articles 2 articles data analysis data analysis is done by looking at the literature writing year (2009-2019), reading abstracts from selected research journals, reading the research journal skimming if the abstract does not explain several points in the journal, then marking / recording important things and their relevance to the research problem appointed. recording sources of information is also done in analyzing this data to prevent elements of plagiarism. information obtained based on notes, quotes, or information is arranged systematically so that it can be easily searched if needed at any time. the use of characteristic studies is intended to make it easier to make conclusions from the journal obtained. the study of these characteristics contains the name of the author and the year of journal writing, the research design used, the intervention provided, the number of samples, instruments, and results. from the results obtained, the author will analyze each of these results in order to see how the family's readiness in treating patients at home, especially in cancer patients. the inclusion criteria used in this literature are articles that use english, a publication journal with a range from 2009 to 2019, and articles in full text. exclusion criteria used in executing journals that are not used include, among other things, incomplete articles, usually there are only abstracts and books. how is the readiness of the family in the caregivers of patients with cancer, the preparation of the family in treating patients at home is the main focus in writing this literature review. a total of 18,606 journals were searched in several journal search sites, then excluded studies were carried out by including the inclusion criteria, namely families caring for cancer patients and paliative care, so that the total journals that met the requirements and used in the literature review were 8 journals. table 2. study of characteristics of literature authors (year) conflict of theory study design sample instrument implication (grant et al., 2013) the diagnosis of cancer that is of concern is the patient and his family. the care provider at home, namely the family is a social unit that can make a negative impact on the cancer quantitative, descriptive 163 participa nts questionnair e caregivers experience a high level of caregiver burden and report a decrease in psychological well-being and overall quality of life. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.143-152 146 continuum, from the beginning of the diagnosis of the disease to the end of his life (ferrell & mazanec, 2009; given, given, & sherwood, 2012; lewis, 2004) (hendrix et al., 2016) having a life with a diagnosis of cancer creates difficulties for both the patient and the family caring for them at home. self-efficacy is an important concept in parenting because it is a prerequisite for delivering actions that are actually good and right for patients. enhanced-ct is known as a protocol that teaches the knowledge and skills of caregivers to manage symptoms and strategies for managing their own psychological stress as carers for cancer patients at home. quantitative, intervention, rct 138 participa nts questionnair e the enhanced-ct protocol is given to improve family self-efficacy in the management of symptoms and stress when giving care to patients at home. (chih et al., 2013) the pattern of parenting carried out by families with cancer patients is something that needs to be considered. follow-up care for cancer patients at home is the responsibility of the family caring at home so that it requires care management in terms of symptoms that occur in the patient appropriately. management of this symptom must be done well and on time, therefore the online symptom reporting system quantitative, intervention, rct 235 participa nts questionnair e by using a symptom reporting system online, it can reduce the level of emotional pressure because with this online system caregivers can report or communicate about the patient's condition and know the management of symptoms that must be done in a timely manner. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.143-152 147 may be a way that can be applied to reduce family burden in providing care at home. (anette henriksso n et al., 2015) the validity and reliability of an instrument is needed to find out how effective the instrument is used to measure the level of family readiness in handling patients at home. the preparedness caregiving scale has items that capture various levels of preparedness. quantitative 647 participa nts questionnair e the preparedness for care scale (pcs) is a measurement scale that is effective in measuring the level of family readiness in providing care for patients with palliative care at home. pcs can be used by all genders, ages and languages. (anette henriksso n & årestedt, 2013) families as caregivers of patients at home often feel unprepared in handling patients. this level of readiness is an important factor to improve their welfare. this readiness refers to how ready the family carries out tasks and demands in carrying out its role as caregivers of patients at home. quantitative, cross sectional 125 participa nts questionnair e the level of patient readiness is significantly related to life expectancy, higher appreciation, and reduced anxiety. readiness in treating patients at home is very important when caregivers experience a problematic situation in a patient or the patient shows life-threatening symptoms. the psycho-education support model is considered important to improve caregiver readiness in handling patients at home. (fujinami et al., 2015) caregivers of patients at home often have a psychological decline because of the stress they experience in handling patients at home. the need to know what kinds of problems are usually experienced by caregivers so that more attention is given to the appropriate interventions to handle them. quantitative 163 participa nts questionnair e there are several types of problems experienced by caregivers in providing care to cancer patients. among them are self-care problems and maintenance of quality of life, components of caregiver roles, and components of stress caregivers. this can be used as a reference for any components that need to be considered in terms of the challenges experienced by patient caregivers, namely families in providing patient care at home. (dionneodom et caregivers of patients at home quantitative 294 paticipan questionnair e most caregivers are not much involved in the journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.143-152 148 al., 2017) have a level of wellbeing in patient care and self-affirmation or how they make different decisions. the need to know what the impact is and is accepted by adult patients with cancer who have a poor prognosis in each family care with these different components. ts practice of self-care, depression and anxiety and mental health of cancer sufferers. the need for interventions to improve caregiver welfare, preparedness, and selfefficacy in order to increase health responsibility, stress management, interpersonal relationships, and self-care practices and grow the spiritual role of patients at home. (annette henriksso n, andershe d, benzein, & årestedt, 2012) families have a big responsibility in managing patients who need care at home. family readiness, competence, and rewards available to reduce negative risks related to care provided. there are several instruments to measure all three, namely the preparedness for care scale, the caregiver competence scale and rewards of care scale which need to be tested psychometrically so that they can be used in various countries and further research is available. quantitative, correlation 125 participa nts questionnair e the preparedness for care scale, the caregiver competence scale and rewards of caregiving scale is a basic instrument that can and is worthy of being used to see readiness, competence, and rewards for families who care for patients at home. results based on the results of a review of several existing literature and journals, several topics were found related to family readiness in caring for patients at home. some of the topics / themes include family care in caring for patients, instruments for measuring family preparedness, self-affection for families who care for patients at home, and psychoeducation in increasing family readiness to care for patients at home. no theme authors 1 foster family burden in caring for patients (grant et al., 2013); (fujinami et al., 2015); (dionne-odom et al., 2017) 2 instrument in measuring family preparedness (anette henriksson et al., 2015); (annette henriksson et al., 2012) 3 self-efficacy in families who care for patients at home (hendrix et al., 2016); (chih et al., 2013) journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.143-152 149 4 psychoeducation in increasing family readiness to care for patients at home (anette henriksson & årestedt, 2013) discussion foster family burden in caring for patients families in this case caregivers of patients who need care at home often have a high upbringing. they tend to experience a decrease in psychological well-being and have a low quality of life (grant et al., 2013). families as caregivers of patients at home, who provide advanced health services for sufferers have the types of problems that need to be considered. self-care, maintenance of quality of life, components of low caregiver roles, and components of stress experienced by caregivers are problems that need to be addressed and this can be used as a reference for how nurses can develop existing interventions in dealing with these problems (fujinami et al., 2015). the number of families who have a role as caregivers of patients at home and not cared for self-care, the level of depression and anxiety in cancer patients and other life-threatening diseases will pose a risk of new problems. it is necessary to provide appropriate interventions to improve her well-being, readiness, and affection (dionne-odom et al., 2017). instrument in measuring family readiness family readiness in handling patients at home is something we need to pay attention to. the nurse through her role needs to identify how prepared the family is to carry out the care of the patient independently at home. the preparation caregiving scale (pcs) is a standard instrument to measure the level of family readiness in caring for patients at home (henriksson et al., 2015). the preparedness for care scale, the caregiver competence scale and rewards of caregiving scale is a basic instrument that can and is worthy of being used to see readiness, competence, and rewards for families who care for patients at home. families have a big responsibility in managing patients who need care at home. family readiness, competence, and rewards available to reduce negative risks related to care provided (henriksson et al., 2012) self-affirmation to the family who care for patients at home having responsibility as a family with patients with palliative care creates difficulties both for patients and families who care for them at home. self-efficacy is an important concept in parenting because it is a prerequisite for delivering actions that are actually good and right for patients. enhanced-ct is known as a protocol that teaches the knowledge and skills of caregivers to manage symptoms and strategies to manage their own psychological stress as caregivers of cancer patients at home. enhanced-ct protocol can improve selfefficacy in stress management in palliative care at home (hendrix et al., 2016). there is an online patient symptom reporting system model that is also used as a research result that can be applied. this online symptom reporting system has a special procedure that allows families to communicate efficiently and on time the symptoms experienced by patients during treatment at home. this can reduce family stress levels in giving patient care independently (chih et al., 2013). psycho-education in increasing family readiness to care for patients at home the level of patient readiness is significantly related to life expectancy, higher appreciation, and reduced anxiety. readiness in treating patients at home is very important when caregivers experience a problematic situation in patients or the patient shows lifejournal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.143-152 150 threatening symptoms. the psychology of education for patients at home (henriksson and årestedt, 2013). family readiness in caring for patients at home including the burden of family care. families often have a high upbringing because of the demands of care, making them vulnerable to new problems. we need to examine how the family preparedness process has the demands of caring for what interventions can be given. the self-efficacy of families that is often difficult for families to understand. the provision of psycho-education also needs to be implemented and can be maximized and the family is fulfilled. conclusion family readiness in caring for patients at home is an important thing to note. family members who need care at home often have a high upbringing. they tend to experience decrease in the psychological well-being and have a low quality of life (grant et al., 2013). the prepared caregiving scale (pcs) we can measure the level of family readiness in caring for patients at home, the need to improve self-affection in families who have patient care at home, as well as health care for children at home. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 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(2017). a systematic review of instruments assessing dimensions of distress among caregivers of adult and pediatric cancer patients. palliative and supportive care, 15(01), 110–124. https://doi.org/10.1017/s1478951516000079 https://doi.org/10.1177/0269216311419987 https://doi.org/10.1371/journal.pone.0209436 https://doi.org/10.3945/an.116.012211 https://doi.org/10.1188/18.onf.197-205 https://doi.org/10.1136/bmjspcare-2016-001141 https://doi.org/10.1097/01.nnr.0000299852.75300.03 https://doi.org/10.1188/08.onf.49-56 https://doi.org/10.1016/j.procs.2018.10.042 https://doi.org/10.1017/s1478951516000079 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.143-152 153 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.132-142 132 the implementation of practice based simulation of new nurse toward self confidence: a literature review yusriani saleh baso, fitri arofiati universitas muhammadiyah yogyakarta, indonesia corresponding author: yusigd4@gmail.com abstract background: to enhance the quality of nursing service at hospital, it needs learning process (education and training) using clinical skills facility. it gives ideal place for the development of nurse‟s confident before entering the real world of work. problem based learning approach is able to use simulation learning method or practice based simulation model can enhance new nurse‟s confidence. purpose: the objective of this research was to literature review of the practice based simulation that may be expected to enhance new nurse‟s self confidence. methods: this research used literature review. source of the research was taken from some database. searching was conducted in december 2018 through database of pubmed of 3016 articles, google scholar of 13.5000 articles, science direct of 3466 articles, pro quest of 256 articles using combination of key words “self confidence” and practice based simulation+new graduates nursing. from all database, there were only 7 which fulfilled inclusion criteria. results: based on the result of literature review from 7 articles, it was found that applying simulation method to new nurse can enhance self confidence. new nurse would be more independent, able to make decision and conduct nursing care and be more calm while working. conclusion: the aim of this literature review obtains the result that application of practice based simulation can increase self confidence of nurse. key words: simulation, self confidence, new nurse, practice received august, 29, 2019; revised november 25, 2019; accepted january 15, 2020 doi: https://doi.org/10.30994/jnp.v3i2.79 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-noncommercial-sharealike 4.0 international license. mailto:yusigd4@gmail.com https://doi.org/10.30994/jnp.v3i2.79 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.132-142 133 background nurse is the most human resources in hospital service. nurse is an individual who has been graduated from nursing academy/education and able to conduct nursing care or nursing services. nursing service is a form of professional service which is an integral part of health services based on nursing knowledge and tips aimed at individuals, families, groups, or communities, both healthy and sick, which are supported by human resources who work in accordance with their competencies (law no. 38 2014 concerning nursing). therefore, a nurse must have professionalism and confidence in conducting their duties and responsibilities. professionalism and self confidence of a nurse can bee seen when they can adapt in working environment and they conduct nursing care well and correctly. a new nurse in making clinical decisions or judgments sometimes still seems hesitant and they cannot decide a decision in solving problems faced in health services, especially in hospitals. it is because they don‟t believe that to improve the quality of nursing services in the hospital needs a learning process (education and training) using clinical skills facilities. it provides an ideal place for the development of nurses' learning and self-confidence before entering the real world of work. self-confidence is a mental attitude possessed by an individual to judge something, thus, the individual can independently conduct something based on the ability they have (amal, 2016). considering about the challenge above, problem based learning is able to use simulation learning method or the practice based simulation model is a learning model that focuses on students developed to achieve effective and innovative simulation integrity, students in this case are new nurses expected to be able to be involved directly in the learning process based on constructive learning theory which confirms that knowledge is not passively transferred from students, but it is built by students through processing experiences and interactions with their environment (parker & myrick, 2009). nursalam (2011) states that simulation is learning method presenting learning using situation or real process. students are actively involved in interacting with the situation in their environment. simulation is a learning model seeking to bring real situations into lecture classrooms with maximum levels of similarity (johnston, coyer, & nash, 2017). simulation is an experience and interaction in making appropriate decisions in conductong nursing care (liaw et al, 2011). experience and interaction with environment can make new nurse to feel confidence in deciding and conducting a nursing action which will be carried out to the patient. mareno 2014 explains that self-confidence will influence the choice of an individual to make and feel about challenges and disputes. individuals with a high level of self-confidence will be able to strive to be stronger and successful in conducting their duties. self-confidence is a mental attitude owned by an individual to assess something. thus, an individual can independently carry out something based on the ability they have(afiatin, 1998). research conducted by (crimlisk et al., 2017) states that simulation can add knowledge, cooperate and enhance self-confidence of nurse. in the journal brown, 2010, it is explained that simulation is an effective teaching strategy in the preparation of health professionals and it is often used to evaluate the clinical judgment and competence of nurses. the same year the research conducted by (blum, 2010) said that simulations can increase the confidence of a nurse, although not as a whole. journal (omer, 2016)explains that using simulation methods as a strategy for clinical education can increase nurse „s confidence. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.132-142 134 objective the objective of this research was to literature review of the practice based simulation that may be expected to enhance new nurse‟s self confidence. methods inclusion criteria the following inclusion criteria were used to study selection for this literature review 1. research must be related to simulation method presented to nurse 2. this research must give information about the impact of simulation toward self-confidence. 3. the complete text of the study must be available in english and indonesia exclusion criteria it was unauthorized publications such as letters to editors, absences and editorials. data selection and analysis searching was conducted in december 2018 through database pubmed, google scholar, science direct database pubmed using key words of “self confidence” of 2.951 articles, using key word “self confidence” and practice based simulation of 38 articles, using key word of "self confidence" and practice based simulation + nursing new graduates of 27 articles.in searching the google scholar database using the keywords "self confidence" and practice based simulation + new nursing nursing there were 13,500 articles. in searching the science direct database using the keyword "self confidence", there were 1,287 articles, using the keyword "self-confidence" and practice based simulation obtained 1,831 articles, using the keywords" self-evidence "and practice based simulation + new graduates nursing of 348 article.in searching proquest database using the keywords "self confidence" and practice based simulation + new graduates nursing, there were 256 articles. from the entire database of 20,238 articles, there were only only 7 articles which fulfilled the inclusion criteria. results the main focus of this literature review was in the application of practice based simulation model of new nurse toward self confidence. to optimize this interpretation, first, review would clarify the result of some researches. table 1. process of searching the article article identified though pubmed database (n=3016 total (n=20.238) journals are screened through title (n=20.238) excluded by title (n= 11.172) replaced based abstract (n=8999) journals are assessed through abstracts for the feasibility (n=9066) journals are reviewed completely (n=67) journals are replaced because they don‟t fulfill the criteria (n=60) journals are included (n=7) article identified though database of google scholar (n=13.500) article identified though database of science direct (n=3466) article identified though database of proquest (n=256) identification screening eligbility journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.132-142 135 include journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.132-142 136 tabel 2. studi karakteristik n o source objective design sample instrument type of simulation number of sessions duration of sessions result 1 the effect of simulation learning on critical thinking and self-confidence when incorporated into an electrocardiogram nursing course (brown & chronister, 2009) demonstrate the effect of simulation activities on critical thinking and self confidence in an electrocardiogram nursing course correlational research 140 senior-level baccalaureate con = 70 treatmen =70 elektrocardio gram (ecg) slim test high fidelity human simulators 5 session treatment =70 minutes of lecture and 30 minutes of simulation activities weekly, weeks 2-6 control=100 week of lecture-format teaching during weeks 2-5 the treatment group did not show higher levels of critical thinking,self confidence than the control group 2 new graduate nurses' perceptions of the effects of clinical simulation on their critical thinking, learning, and confidence (kaddoura, 2010) explored the perceptions of new graduate nurses of how clinical simula-tion developed their critical thinking skills, learning, and confidence throughout their hospital clinical training exploratory descriptive 10 new baccalaureate nursing graduates student satisfaction survey clinical simulation not specified 8 hours the participants reported that simulation was benefi¬cial for the development of critical thinking skills in their specialized critical care units 3 implementing simulation training for new cardiothoracic intensive care unit nurses. (boling, hardin-pierce, jensen, & hassan, 2017) the objective of this article was to describe the process of designing and implementing a high-fidelity simulation training program as part of a new graduate nursing internship quantitative 12 new cticu nurses mannequin scenario of simulation 2 session 4 hours the focus for the initial pilot program simulation for new nurses was in the development of critical thinking, enhancement of learning, and improvement of confidence. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.132-142 137 4 evaluation of a high-fidelity simulation training program for new cardiothoracic intensive care unit nurses (boling, hardin-pierce, jensen, & hassan, 2016) evaluate the effect of a high-fidelity simulation training program on knowledge and confidence as part of a nursing internship in the cardiothoracic intensive care unit quantitative 10 nurse interns multiple-choi ce knowledge test (mckt), modified self-efficacy scale (mses), simulation effectiveness tool (set) high fidelity human simulators. 2 session 4 hours improving knowledge and confidence are 2 of the major goals of the orientation training of new nurses 5 new nursing graduates‟ self-efficacy ratings and urinary catheterization skills in a high fidelity simulation scenario (cason, atz, & horton, 2017) this study indicates that there is a need for validating competency in psychomotor skills,self confidence within the context of a simulated patient care situation a quantitative method with a descriptive correlational design 47 new graduate nurse (female 42, male 5) mannequin, clinical competency questionnaire (ccq) scenario, pre test, post test 3 session pre test 10 minutes, treatment 30 minutes, post test 10 minutes not spesific a new nursing graduate that is competent in psychomotor skills may develop higher level critical clinical judgment,cognitive abilities and self confidence 6 impact of interactive situated and simulated teaching program on novice nursing practitioners' clinical competence, confidence, and stress (chen, chen, lee, chang, & yeh, 2017) this work aimed to improve the clinical competence, promote the self-confidence, and reduce the number of work-related stressors of nnps (novice nursing practitioners) a randomized control design 31 nnps ((novice nursing practitioners) they were randomly allocated into an isst group (n = 16) and a control group (n = 15) nursing competency questionnaire (ncq) interactive situated and simulated teaching (isst) 1 session every day for 5 days 6 hours the isst program for nnps significantly improved their clinical competence and self confidence 7 emergency airway response team simulation training: a nursing perspective (crimlisk et al., an interprofessional simulation-based training program was developed to enhance emergency airway response team (eart) study interventions 63 nurse emergency protocol emergency air way response for aha video simulation 4 session 4-hour sessions were conducted during a 12-week period this project supports the use of simulation training to increase nurses" knowledge, confidence, and team dynamics in an eart response journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.132-142 138 2017) journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.132-142 139 discussion 1. type of simulation types of simulation used were large in 7 articles reviewed as follow; 2 (two) high fidelity human simulators (kaddoura, 2010) and (boling b, 2016), 1 (one) clinical simulation (sutton, 2014), 1 (one) scenario of simulation (bowling b, 2016), 1 (one ) scenario, pre test, post test (horton, 2017), 1 (one) interactive situated and simulated teaching / isst (chen, 2017) and 1 (one) video simulation (crimlisk et al., 2017). 2. instrument some instrument had been used to enhance self confidence of nurse, in article, it was reviewed as follow: 1 (one) used a mannequin (bowling b, 2016), 1 (one) used an electrocardiogram / ecg, slim test (chronister, 2009), 1 (one) used the student satisfaction survey (kaddoura, 2010), 1 (one) used multiple -coice knowledge test (mckt), modified self-efficacy scale (mses), simulation effectiveness tool (set) (boling b, 2016), 1 (one) used mannequin, clinical competency questionnaire / ccq (horton, 2017), 1 ( one) used the nursing competency questionnaire / ncq (chen, 2017), 1 (one) used the emergency air way response for ahas protocol (crimlisk et al., 2017). 3. effect a. it showed higher level of critical thinking and self-confidence (brown & chronister, 2009). b. simulations were useful for the development of critical thinking skills in special care units specifically for new nurses (kaddoura, 2010). c. simulation of new nurses was the development of critical thinking, increased learning, and increased self-confidence (boling b, 2016). d. it enhanced knowledge and self-confidence are 2 of the main goals of new nurse orientation training (boling b, 2017). e. new nursing graduates who were competent in psychomotor skills could develop high-level critical clinical assessments, cognitive abilities and self-confidence (horton, 2017). f. program of isst for nnp significantly improved clinical competence and self confidence of new nurse (chen, 2017). g. the application of simulation training was to increase knowledge, confidence, and dynamics of the nurse team in the eart response (crimlisk et al., 2017). 4. period and duration in article reviewed, research duration and session of simulation training were different. a. chronister, 2009, there were 70 minutes care and 30 minutes simulation. weekly activities were week 2-6 was control 100 weeks of teaching lecture format for weeks 2-5. b. kaddoura, 2010, the session used was not specific in the article, but the duration used for the simulation was8 hours. c. block b, 2016, the simulation method was conducted in 2 sessions in 4 hours. d. horton 2017, the session used was 3 sessions consisting of 10 minutes pre test, 30 minutes treatment, 10 minutes post test, but in this article the duration shown in the simulation was not specific. e. chen 2017, the simulation was conducted in 1 session every day for 5 days and the duration used is 4 hours. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.132-142 140 f. crimlisk et al., 2017, simulations conducted in 4 sessions were conducted in a 12-week period. self confidence of nurse could be built by having good ability or mental attitude. thus, it could take good, right and appropriate action or clinical assessment in accordance with the competencies they had (amal, 2016). clinical assessment was based on nurses' knowledge and experience and is an important component of effective and safe practice. new nurses currently face the challenges and roles of their new professionals in the increasingly complex environments in which they work in clinical assessment, decision making or decisions to act very important and strong for patient health and safety. the lack of self confidence of a nurse caused the lack of knowledge about patient specific conditions, technical skills, and clinical knowledge, thus it is endangering patient safety. self confidence is a mental attitude owned by an individual to assess something so that someone can independently do something based on the ability possessed (see, morrison, rothman, & soll, 2011). from 7 articles above, it can be considered that with different tools or instruments, time or duration in conducting different simulations, and the different type of simulation performed different, nurses can think critically and have self confidence in carrying out nursing care. therefore, nursing care can be carried out properly according to their abilities. with self-confidence, new nurses can also develop clinical assessments of nursing care to be carried out, critical high level, cognitive abilities that can increase self-confidence (cason et al., 2017) conclusion practice based simulation model is a learning model focusing on students, developed to achive effective and innovative integrity of simulation. students in this case are new nurses are expected to be able to be directly involved in the learning process based on constructive learning theory which confirms that non-passive knowledge is transferred from students, but built by students through processing experiences and interactions with their environment. simulation is conducted by considering the type of simulation used, time or duration and the instrument used during the simulation. with the simulation, it is expected that cognitive abilities, critical thinking and the confidence of a new nurse in clinical assessment to carry out nursing care at the hospital can be carried out properly, correctly and precisely. the review in this research of literature review is enhancing self confidence of new nurse in conducting clinical judgment or decision making on nursing care conducted at hospital. therefore, this literature review could be the basis for further research on simulation methods and the self confidence of new nurses to use a wider range of sources. limitation of the research in this literature review, researcher only reviewed researches in english with complete texts available in reviewed article journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 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(2011). the detrimental effects of power on confidence, advice taking, and accuracy. organizational behavior and human decision processes, 116(2), 272-285. https://doi.org/10.1016/j.obhdp.2011.07.006 https://doi.org/10.1111/j.1466-7657.2011.00915.x https://doi.org/10.1016/j.bbmt.2013.12.525 https://ners.unair.ac.id/materikuliah/buku-manajemen-2011.pdf https://files.eric.ed.gov/fulltext/ej1092418.pdf https://doi.org/10.1016/j.nedt.2008.10.012 https://doi.org/10.1016/j.obhdp.2011.07.006 journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 12 17 12 effect of education media video on improve stroke prevention behavior in continued age in wiyurejo pujon malang indun muslihati, yonas galang lisandi, ririn kasahan, hendry agustina winarko puskesmas pujon batu, malang, east java, indonesia corresponding author : indunmuslihati74@gmail.com abstract background: stroke is a disease caused by one of the pathological processes that affect the blood vessels of the brain. efforts to reduce mortality from stroke can be done by health education about stroke disease. purpose : the purpose of this research is to know the influence of media video education on the enhancement of prevention of stroke in elderly in wiyurejo village, pujon subdistrict, malang regency. methods : pre-experimental design research design with one group pre-post test design. population of all elderly (elderly) between 60-74 years in the village wiyurejo district pujon malang regency a number of 34 people. the sampling technique used was accidental sampling so that the sample was 32 people. data analysis using wilcoxon. result : the results showed that stroke prevention behavior before giving video media almost half of educational (46,9%) respondents have bad behavior. after being given an educational video media showed almost half of them with sufficient behavior (43.8%). conclusion : there is influence of educational video media to improving prevention behavior of stroke at elderly in wiyurejo village, pujon sub-district, malang regency. looking at the results of the study suggested that the provision of counseling about stroke prevention can be carried out repeatedly in the elderly so as to make efforts in preventing early keywords : media video education, behavior, elderly received: february 03, 2018; revised february 24, 2018; accepted march 10, 2018 how to cite: muslihati, i., lisandi, y.g., kasahan, r., & winarko, h.a. (2018). effect of education media video on improve stroke prevention behavior in continued age in wiyurejo pujon malang. journal of nursing practice. 1(2). 12-17 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 12 17 13 background according to who elderly (elderly) is a group of people aged 60 years or older. globally by 2013 the proportion of the population aged over 60 years is 11.7% of the world's total population and it is estimated that this number will continue to increase with increasing life expectancy. as the age increases there will be a decrease in the elasticity of the body system. in the elderly generally will also decrease the size of the organs of the body but not the heart. the heart of the elderly will generally grow. this leads to an epidemiological transition from infectious diseases to degenerative diseases that one of them is a stroke (fatmah, 2010). a stroke is an acute neurological disorder, caused by a blood circulation to the brain where suddenly (within a few seconds), or precisely (within a few hours) symptoms and signs appear in the focal area of the brain. stroke is a disease caused by one of the pathological processes that affect the blood vessels of the brain. stroke disease today tends to increase with a high mortality rate. stroke is the third leading cause of death after heart disease and cancer (arief, 2006). in the world, stroke is estimated to cause 7.5 million deaths or about 12.8% of total deaths. this accounts for 57 million of disability adjusted life years (daly). about 25% of adults in united state suffer from stroke in 2011-2012. there was no difference in prevalence between men and women but prevalence continued to increase by age 5% 2039 years, 26% age 40-59 years, and 59.6% for age 60 and older (akin, 2014). the prevalence of stroke in indonesia is based on the diagnosis of health workers by 7 per 1000 and based on the respondents' answers who have been diagnosed by health workers 12.1 per 1000 (basic health research, 2013). from the result of riskesdas of east java province in 2014, the prevalence of stroke in east java was 31.2% which increased according to age, so that above 55 years exceed 50%. from the data obtained, it is known that with the increasing age, more and more stroke, so over 65 years get more than 60%, or 6 out of 10 people in east java (moh, 2014). stroke is closely related to high blood pressure that affects the appearance of damage to blood vessel walls so that blood vessel walls are uneven. as a result, dissolved substances such as cholesterol, calcium and so on will settle on the vessel wall known as the narrowing of blood vessels. if the narrowing of blood vessels occur in a long time, will result in blood supply to the brain is reduced, even stopping the next cause a stroke (pudiastuti, 2011). the impact of a stroke is the disability and even death depending on the location where the blood supply disorder occurs. reduced blood supply causes neuron cell death, if lasting up to 72 hours can occur brain damage (corwin, 2009). further complications can be prevented with prompt and precise handling. preventive efforts and education to the public are also very important to reduce mortality and disability due to stroke. the role of nurses is not only in the prevention of complications and reduce the risk factors for stroke, but also provide information needed elderly in preventing stroke, and encourage families to more effective.dalammelaksanakanperannya.selain prevention efforts against stroke can be done with health education related to the stroke (smeltzer & bare, 2002). based on preliminary study conducted by researchers in wiyurejo village, pujon subdistrict, malang regency, the number of elderly between 60-74 years is 34 people. the results of interviews about stroke prevention of six elderly, all said that stroke occurs due to hypetensive disease. while the behavior in preventing stroke is not eating fatty foods. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 12 17 14 based on the above background then the researcher wanted to conduct a study entitled: "influence of media video education on improvement of prevention of stroke on elderly in wiyurejo village, pujon sub-district of malang regency". objective knowing the influence of educational video media to the enhancement of prevention of stroke in elderly in wiyurejo village, pujon sub-district. methods the research design used in this research is pre-experimental design with one group prepost test design. this study aims to determine the effect of media video education on the enhancement of prevention of stroke in elderly in wiyurejo village, pujon sub-district, malang regency. the population in this study is all elderly (elderly) between 60-74 years in the village wiyurejo pujon district malang regency a number of 34 people. the sample in this study is partially elderly (elderly) between 60-74 years in the village wiyurejo pujon district malang regency a number of 32 people. the sampling technique used in this research is accidental sampling. the independent variable in this research is educational video media. dependent variable in this research is stroke prevention behavior. statistical test using spss version 22.0 computation with wilcoxon formula. results table 1. behavior prevention of stroke in elderly before being given media video education in wiyurejo village pujon sub-district, malang regency no behavior f % 1 good 6 18,8 2 enough 11 34,3 3 lack 15 46,9 total 32 100 based on table 1 above can be seen that almost half (46.9%) of respondents less in the behavior of stroke prevention and a small (18.8%) of respondents both in the behavior of stroke prevention. table 2. behavior of prevention of stroke in elderly after being given media video education in wiyurejo village, pujon sub-district, malang regency. no behavior f % 1 good 11 34,3 2 enough 14 43,8 3 lack 7 21,9 total 32 100 based on table 4.7 above can be seen that almost half (43.8%) of respondents with adequate behavior in the behavior of stroke prevention and a small (21.9%) of respondents with less behavior in the behavior of stroke prevention based on the results of wilcoxon test with the help of spss showed ρ value of 0.037 less than α 0.05 so it can be concluded there influence of mediavideo education to enhancement preventative behavior of stroke in elderly village in wiyurejo sub pujon malang regency. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 12 17 15 discussion behavior prevention of stroke in elderly before being given media video education in wiyurejo village, pujon sub-district, malang regency. behavior of stroke prevention before giving educational video media showed almost half (46,9%) of respondents less in behavior of stroke prevention and a small part (18,8%) responder good in behavior of stroke prevention. stroke is a disease caused by one of the pathological processes that affect the blood vessels of the brain. stroke disease today tends to increase with a high mortality rate. stroke is the third leading cause of death after heart disease and cancer (arief, 2006). a stroke is an acute neurological disorder, caused by a blood circulation to the brain where suddenly (within a few seconds), or precisely (within a few hours) symptoms and signs appear in the focal area of the brain. stroke is a disease caused by one of the pathological processes that affect the blood vessels of the brain. prior to educating the respondents whose knowledge was made possible by the education of respondents, almost half of them (43.8%) responded with the last elementary school and a small portion (12.5%) respondents with the last education of sma / smea. respondent education influences behavior in acting. in accordance with table 4.9 that of 4 respondents with the last education sma / smea showed all 4 respondents with good behavior. higher education will affect the knowledge of respondents so as to apply the behaviors that have been obtained from the knowledge. in addition, with the education of respondents will have pengetahaun which increases about stroke. the respondent's experience can also influence his knowledge in stroke prevention. this is related to information obtained about stroke that most (59,4%) of respondents ever got information about stroke and almost half (40,6%) of respondents never get information about stroke. respondents who know in advance about the stroke will understand how to prevent it from being different from respondents who have never received information about stroke prevention. prior to educational research conducted by researchers, many of the respondents did not know how to prevent stroke, this is due to lack of information about stroke and prevention so that less knowledge leads to different behaviors. knowledge is able to change a person's behavior so that lack of knowledge will hinder to perform better behavior. behavior of prevention of stroke in elderly after being given media video education in wiyurejo village, pujon sub-district, malang regency the behavior of stroke prevention after being given educational video media showed almost half (43.8%) of respondents with sufficient behavior in the behavior of stroke prevention and a small (21.9%) respondents with less behavior in the behavior of stroke prevention good health education media is media that able to give information or health messages in accordance with the level of acceptance of the target, so that the target is willing and able to change the behavior in accordance with the message delivered (notoatmodjo, 2007). knowledge is the result of "knowing", and this occurs after people make sensations to a particular object. the realm of knowledge according to bloom (1994) is to sort the thinking skills in accordance with the expected goals. the thinking process describes the stage of thinking that must be mastered in order to be able to apply the theory in action. knowledge is the ability to mention or re-explain such as defining, compiling lists, naming, declaring, identifying, knowing, mentioning, framing, underlining, describing, matching, choosing. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 12 17 16 based on table that of 13 respondents who had received information on stroke prevention showed 10 respondents with good behavior, whereas in 19 respondents who have never received information shows only 1 respondent with good behavior. provision of extension methods caused the respondents to increase their knowledge so that understanding in preventing stroke also increased. this will cause the respondent to continue to find out how prevention of stroke. in addition, the work of respondents can also be connected where a small part (6.2%) of respondents as pensioners. respondents as retirees have a lot of information about strokes from their coworkers so that the information also increases. in contrast to respondents who are only at home which causes a lack of understanding in the application of stroke prevention efforts. increased behavior against efforts to prevent a stroke is done well after getting information about how stroke and prevention. provision of education can increase knowledge from respondents who previously did not know to know and understand so mmapu change behavior by applying in daily. influence of media video education on improvement of behavior of prevention of stroke at elderly in wiyurejo village, pujon sub-district, malang regency based on the results of wilcoxon test with the help of spss showed ρ value of 0.037 less than α 0.05 so that it can be concluded there is influence of media video education to increase behavior prevention of stroke in elderly in village wiyurejo sub pujon regency of malang regency several factors that influence health education according to notoatmodjo (2007) include extension factors, such as lack of preparation, lack of material to be explained, appearance less convincing target, the language used is less understandable by the target, the voice is too small and less able to be heard and the delivery of material counseling is too monotonous so boring. besides the target factors, such as the level of education is too low so difficult to receive messages conveyed, socioeconomic level is too low so not paying attention to the messages delivered because it is more concerned about the more urgent needs, beliefs and customs that have been embedded so difficult to change , the environmental conditions in which the target residence is unlikely to change behavior. respondents who were given counseling using educational methods so that will increase knowledge and can know and understand how the correct stroke prevention. supported by the results of research that is from 32 respondents before giving education showed 6 respondents with good behavior and 15 respondents with less behavior, after being given education showed 7 respondents with less behavior and 11 respondents with good behavior. provision of education such as giving counseling using image media such as video by the researchers is very helpful in efforts to increase knowledge, especially about stroke and handling. this is shown by some of the respondents who asked and were able to answer questions given by researchers. educational efforts can increase the information obtained so as to change the behavior to be better than before. conclusion behavior of stroke prevention before giving educational video media showed almost half (46,9%) of respondents less and a small part (18,8%) responder good in stroke prevention. behavior of stroke prevention after giving educational video media showed almost half (43,8%) of respondent enough and a small part (21,9%) respondents with behavior that less in stroke prevention journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 12 17 17 based on the results of t-test test with the help of spss showed ρ value of 0.037 less than α 0.05 so it can be concluded there is influence of media video education to enhancement preventative behavior of stroke at elderly village in wiyurejo sub pujon malang. references ananta. 2009. waspadai gejala penyakit mematikan. yogyakarta: nuha medika. arief. 2006. ilmu penyakit dalam. jakarta: media austacius azizah. 2011.keperawatan lanjut usia. yogyakarta: graha ilmu cahyono. 2008. gaya hidup dan penyakit modern. yogyakarta: kanisius corwin. 2009. pendidikan kesehatan, teori dan aplikasi. jakarta: media press depkes ri. 2012. promosi kesehatan dalam lingkup keperawatan. jakarta: promkes depkes ri. 2014. panduan pencegahan stroke secara dini. jakarta: promkes effendy. 2003. ilmu, teori dan filsafat komunikasi. bandung : citra aditya bakti fatmah. 2010. penangangan stroke. jakarta: media austacius mansjoer. 2006. kapita selekta kedokteran. jakarta: media austacius maryam. 2008. mengenal usia lanjut dan perawatannya. surabaya: salemba medika noorkasiani. 2009. kesehatan usia lanjut dengan pendekatan asuhan keperawatan. surabaya: salemba medika notoatmodjo. 2007. promosi kesehatan teori dan aplikasi. jakarta: rineka cipta nugroho. 2008. gerontik dan geriatrik.jakarta: egc. pudiastuti. 2011. penyakit pemicu stroke. yogyakarta: meha medika riset kesehatandasar.2013. upaya penanganan stroke secara dini. jakarta: promkes smeltzer & bare.2002. fundamental keperawatan.jakarta : penerbit buku kedokteran egc syafrudin. 2009. hubungan pengetahuan tentang stroke dengan perilaku terhadap pencegahan stroke di rs solo. skripsi. stikes wira husada solo wahyu. 2009. stroke. yogyakarta: bentang pustaka wiwit. 2010. stroke dan penanganannya. yoyakarta: kata hati journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.279-285 279 health education about clean and healthy living behavior (phbs) to increased knowledge of school age children: systematic review nur ridha sasmitha, hasnah, eny sutria. uin alauddin makassar, indonesia corresponding author: nurridhas@yahoo.co.id abstract background: in school-age children, the most common problem is clean and healthy living behavior, one way to improve clean and healthy living behavior by providing health education. purpose: this study aimed to identify and analyze available scientific evidence about the effectiveness of health education on improving the knowledge of school-age children. methods: this research method uses quantitative descriptive design with systematic review approach. literature search through database: google scholar, garuda portal, indonesian scientific journal database and international journal of social science and humanity with structured research questions using keywords using the pico method (patient, intervention, comparison of intervention and outcome). results: there were 83 articles identified, only 6 that met the inclusion criteria were analyzed using duffy's research appraisal checklist approach. conclusion: health education with the media is very effective in increasing the knowledge of school-age children about phbs, the media obtained from a variety of literature, namely education with snakes and ladders, quiz games, pocket book media, video media, poster methods, and dance video methods. health education with the media is very effective in increasing the knowledge of school-age children found in this review to be used as an intervention in health education. keywords: health education, knowledge of school age children, clean and healthy living behavior. received december, 29, 2019; revised february 10, 2019; accepted march 28, 2020 doi: https://doi.org/10.30994/jnp.v3i2.96 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:nurridhas@yahoo.co.id https://doi.org/10.30994/jnp.v3i2.96 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.279-285 280 background school-age children both preschool, elementary school, junior high school and high school are a child's age that is very different from adulthood. in this period there were many health problems that determine the quality of children in the future. school-age children are a critical age group because at that age they are susceptible to various health problems. health problems faced by school-age children are basically quite complex and varied (dewi, 2015). the most common problems of school-age children are clean and healthy living behaviors, developmental disorders, behavior disorders and learning disorders. then epidemiologically, children's health problems related to the spread of environmental-based diseases among school children, the risk of health problems in children due to environmental pollution from various development activities in indonesia is still high or increasing and the problem that must be considered is that shaping behavior in school-age children is usually related to personal and environmental hygiene such as good and proper brushing of teeth, habit of washing hands with soap and personal hygiene (annisa and nur, 2017). the inculcation of phbs (clean and healthy life behavior) values in primary schoolage children is very important, considering the health problems that often occur in primary school-age children are related to phbs (edyati, 2015). phbs in schools is a set of behaviors practiced by all school members on the basis of awareness as a result of learning, so as to prevent disease, improve health and play an active role in creating a healthy environment. according to who, every year around 2.2 million people in developing countries, especially children die from various diseases caused by lack of safe drinking water, poor sanitation and hygiene. in addition, there is also evidence that adequate sanitation services, safe water supplies, waste disposal systems and hygiene education can reduce mortality due to diarrhea by 65%, and other diseases by as much as 26% (moh ri, 2013). according to the ministry of health of the republic of indonesia, the regencies / cities that have a phbs policy nationally in 2018 amounted to 70.62%, which has exceeded the restra 2018 target of 70%. a total of 12 provinces have reached 100%, namely west sulawesi. gorontalo, central kalimantan, bali, banten, di yogyakarta, central java, dki jakarta, riau islands, kep. bangka belitung, lampung and bengkulu. while in the province of south sulawesi has not reached the target of 100% with a percentage of 95.83% (ministry of health, 2018). to improve hygiene and healthy behavior can be done by providing health education where education can improve health behavior and help prevent disease. education influences what will be done which is reflected in knowledge, attitudes and behavior. the level of education influences awareness of the importance of health for oneself and the environment that can drive the need for health services (nuraeni, 2012). school-age children are easily motivated and their competencies are enhanced including aspects of knowledge, attitudes and behavior in the health sector, so that they can potentially be agents of change. it is expected that with school-age children's health education they have sufficient knowledge so that they are accustomed to applying clean and healthy living behaviors in their daily lives (annisa and nur, 2017). the results of the study ridha abduh, et al (2016). about the effectiveness of comic media on knowledge and attitudes about washing hands in elementary school students reveals that for health education to be more interesting and easily understood by children, the role of the media in health education is very important. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.279-285 281 related research was also conducted by ratnaningsih, (2017). educational media are essentially educational aids. tools used by educators in delivering educational / teaching material. according to experts, the senses that channel the most knowledge into the brain are the eyes. approximately 75% to 87% of human knowledge obtained is channeled through the eyes. while the other 13% to 25% channeled through other senses. from this it follows that visual tools make it easier to convey and receive information or educational material (notoatmodjo, 2003). to increase knowledge about clean and healthy behavior (phbs), it must eliminate unhealthy behavior by providing a learning about clean and healthy living behavior by using media games that make children interested health education using the media is widely used to improve the knowledge of schoolage children, besides health education with the media is easy to do and interesting media and can be applied among school-age children, in this study, the author wants to discuss health education by using media to increase children's knowledge school age from various published literature. objective this study aimed to identify and analyze available scientific evidence about the effectiveness of health education on improving the knowledge of school-age children. methods journal search sources in this study are google scholar, garuda portal, indonesian scientific journal database and international journal of social science and humanity, articles published from 2015-2019, intervention journals that use health education media that can increase the knowledge of school age children, is an efficient intervention based on research results and easy interventions. results based on the results of a research article search, obtained several journals that discuss health education media that can increase school-age knowledge, research articles that fit the researcher's theme are 83 articles and based on inclusion criteria and the duffy's research appraisal checklist approach sheet, 6 journals obtained including the supporior paper category (score 205-306). the author takes the article in terms of the applicability of the intervention and in accordance with the inclusion criteria that have been set, namely articles in 2015-2019, fulltext articles that fit the topic, there are issn / doi or volume is a journal of health education intervention in school-age children, a journal about health education which uses media, methods or games for children that can improve the knowledge of school-age children, languages used in indonesian and english, journals published in southeast asia. health education includes education with snake ladder game media, education with game quiz, education with pocket book media, health education with video media, education with demonstration method with the help of poster media, and counseling with dance video media. intervention number of articles presentation (%) media snakes and ladders 1 16,67% media game quiz 1 16,67% pocket book media 1 16,68% video media 2 33,3% poster media 1 16,68% total 6 100% journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.279-285 282 discussion 1. health education with snake ladder game media the results obtained are 1 journal that uses health education about phbs with snake ladder media to increase the knowledge of school-age children conducted by annisa nurhidayati, nur hilal (2017). based on the results of health education research snakes and ladders game media that there is an increase in the average (mean) score of knowledge before and after being educated with snakes and ladders games with an average pretest score of 34.2 increased to 38.5 on the average score posttest. in line with the research of afif hamdalah (2016) proves that ladder snake game media is very effective in efforts to improve knowledge, attitudes and practices, on dental and mouth health, this is because snake and ladder games as educational media can increase the excitement in the learning process so that it does not cause effects bored. snakes and ladders media can be used in health education to increase students' knowledge about phbs. the snake ladder game model is basically the same as the regular snake ladder game, but the advantage of the snake ladder game as a health education media is that there is knowledge about phbs in schools through pictures on the board (beberan) as well as questions on the board and the answers on the answer cards as well as the meaning or meaning of the snake ladder media. for example in the picture of a ladder then a negative behavior or event changes into a negative behavior or event that changes into a positive behavior or event, if you do not want to suffer from stomach pain then you must wash your hands, as well as the meaning or the opposite meaning with the picture of a snake. (nurhidayati, 2017). 2. health education with game quiz there is 1 journal that uses health education with game quiz to improve the knowledge of school-age children conducted by tri ratnaningsih (2017). based on the research results obtained wilcoxon hypothesis test results obtained a significant value of 0.003 <0.05, which means that there is an influence of the game quiz on increasing knowledge about phbs in 4th grade elementary school students at sdn carat 1 gempol pasuruan, the results of the study were supported by research from mochammad setyo pramono and astridya paramitha (2011) using electronic games shows that, electronic game media can increase students' knowledge about clean and healthy behavior (phbs) with the results showing an increase in knowledge after being treated in the form of electronic games, the value of knowledge increases in unfortunate cities whose level of knowledge about phbs which used to be 88.51% to 97.81%. according to researchers game quiz is a form of game or mind where players (as individuals or in teams) try to answer questions correctly. interactive quiz game is an application that contains subject matter in the form of questions or questions that allow students to improve their insights and knowledge about learning material independently. game quiz acts as a source of information which according to notoadmodjo (2007) sources of information will affect the level of knowledge of someone who if a person gets a lot of information then he tends to have broader knowledge. 3. health education with pocket book media there is 1 journal that uses health education with pocket book media to improve the knowledge and behavior of clean and healthy living carried out by mutmainah farida hanif, mury ririyanty, iken nafikadhini (2018). based on the results of the study it was found that there were better knowledge differences when after the intervention of the phbs pocket book at school. in line with eliana and solikhah's journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.279-285 283 (2012) research on the influence of nutrition pocket books on the level of nutrition knowledge in grade 5 students of muhammadiyah dadapan, wonokerto village states that the effectiveness of the nutrition pocket book is based on the level of nutritional knowledge between before and after with the mean value before being given pocketbooks 71 , 33 and the mean after being given a pocket book 91,07 means that there is an influence of a pocket book on increasing nutritional knowledge in children. pocket book is one of the health promotion print media which has advantages which include long-lasting, covering many people, the cost is not high, can be taken anywhere, facilitating understanding and increasing the passion of learning kholid (2014). according to the author the use of media phbs pocket book is very good to use because it is practical in its use which is easy to carry anywhere. 4. health education with video media there is 1 research journal that uses health education with video media conducted by mulyadi, m.isra, warjiman, chrisnawati (2018) entitled the effectiveness of health education with video media on the level of knowledge of clean and healthy behavior, based on the results obtained 0.001 (p = 0.001 <0.01). this means that there is a significant influence before and after health education is given with video media to increase knowledge of clean and healthy behavior. this study is also in line with research conducted by edyati (2015) that counseling on personal hygiene health with video media has an influence on the knowledge and personal hygiene attitudes of sd 1 kepek students, this can be seen from the value of knowledge p of 0,000 (p = 0,000 <0,05). health education with video media is aired and captured by involving various senses, such as vision and hearing. the more senses are used, the easier it is to enter information. 5. health education with demonstrations with the help of poster media there is one journal that uses health education with demonstrations with the help of poster media conducted by dwi nurlailani, la dupai, putu eka maiyana erawan's research entitled the influence of public health in increasing knowledge, attitudes and behaviors of clean and healthy life of students in fifth grade of public elementary schools 12 poasia is based on the results obtained by researchers that there is evidence of differences in knowledge after being given an intervention for 21 days with health education provided by child health groups using demonstration methods with the help of poster media can increase knowledge. the research that has been conducted shows that the respondents who have received intervention in the form of phbs demonstrations by child health have increased from 74.5% to 95.7% which are included in the sufficient category. in line with fitriani's research (2011) on the influence of peer education on clean and healthy living behaviors (phbs), there were differences before and after being given peer education interventions on respondents' knowledge. based on the results of further analysis it can be concluded that there are significant differences in respondent knowledge after being given peer education better than before peer education was given to the intervention group (p value 0,000 alpha = 0.05). health education about phbs that has been provided through keli to respondents using the demonstration method influences changes in the attitude of the respondents so that they experience an increase before and after the intervention. the knowledge they gained was able to bring up an understanding of themselves that they needed and had to do clean and healthy life behavior both at school and at home. in addition, the journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.279-285 284 change in the attitude of the respondents after getting health education due to the demonstration method used is quite pleasant for the respondents so that it facilitates the process of receiving information about phbs. the existence of child health is sufficient to help respondents in determining attitudes so that some of the respondents were able to respond and appreciate what the child health teaching (peers) about phbs. for example, there were several respondents who said that they had started to invite and teach their younger siblings and friends both at home and at school about some phbs indicators such as hand washing and garbage disposal. 6. health education with dance video media there is one journal that uses health education with dance videos conducted by moh arip, cembun, desty emilyani's research on strategies to improve knowledge, attitudes and skills towards clean and healthy life, based on the results obtained that the average value of students' knowledge prior to intervention is 3.42 30-8 students, while students' knowledge after the intervention is 3.87 out of thirty-eight students. statistical analysis results obtained p <0.05, which means that there are significant differences in knowledge before and after counseling using "phbs kerasa video" on the habit of washing hands with soap " conventional counseling has been applied often to improve students' understanding of phbs but the results are not significant enough. in addition, one-way counseling tends to make students feel bored so that there are some students who still remember the counseling message. therefore, efforts that can be applied to improve students' understanding of phbs in sembung primary school in narmada are the traditional sasak dances called by rudat. rudat dance video is claimed to be able to increase students' understanding of phbs because it is a potential culture. it is also considered to be able to attract the attention of students so that it is expected to increase students' understanding of phbs counseling (culture & tourism, mataram agency, 2011). the dance in this video is a traditional dance from lombok called rudat. the potential of rudat dance as a medium of information for students is very large because its forms such as dance, music and one more person accompany with the lyrics about phbs, especially relating to handwashing with soap (ctps) then information what is delivered to students is very obtainable. in connection with rudat dance, it has the potential as a medium of information and counseling. conclusion based on the results of research from 6 articles it can be concluded that health education with the media is very effective in increasing school-age children's knowledge about phbs is education with snake ladder media, education with game quiz, education with pocket book media, health education with video media, education with the demonstration method with the help of poster media, and the dance video method. the sixth education is recommended for use because the technique is simple, does not require a lot of tools and materials, is easy to reach as well as interesting methods and media and can be applied among school age children. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.279-285 285 references annisa. (2017) pengaruh pendidikan kesehatan tentang phbs dengan media permainan ular tangga dan ceramah terhadap pengetahuan siswa sd negeri limpakuwus kabupaten banyumas 2017. dewi w.r,s., & muhibuddin, n (2015) pengaruh penyuluhan kesehatan dengan metode ceramah dan penggunaan leaflet terhadap pengetahuan dan perilaku hidup bersih dan sehat pada siswa sd. jurnal sain med vol. , no. 1, 30-35. departemen agama, ri. (2014). al-qur’an dan terjemahnya. departemen kesehatan, ri. (2013). riset kesehatan dasar (riskesdas 2013). jakarta departemen kesehatan. dwi nurlailani dkk. (2016). pengaruh kesmas cilik dalam meningkatkan pengetahuan, perlaku, dan sikap perilaku hidup bersih dan sehat murid kelas v sekolah dasar negeri 12 poasia kota kendari tahun 2016. jurnal ilmiah fakultas kesehatan masyarakat universitas halu oleo. edyati, l (2015). pengaruh penyuluhan kesehatan dengan media video terhadap pengetahuan dan sikap personal hygiene siswa sd negeri 1 kepek pengasih kulon progo. jurnal keperawatan stikes ‘aisyiyah. 3-19. fitriani, d. (2011). pengaruh edukasi sebaya terhadap perilaku hidup bersih dan sehat (phbs) pada agregat anak usia sekolah yang beresiko kecacingan di desa baru kecamatan manggar belitung timur kementrian kesehatan ri. (2018). profil kesehatan indonesia; jakarta. ketut swarjana (2017). ilmu kesehatan masyarakat konsep strategi dan praktik. andi: yogyakarta. kuswana, ws. (2013). taksonomi berfikir. bandung: pt remaja rosdakarya listyarini, a.d. (2017). penyuluhan dengan media audio visual meningkatkan perilaku hidup bersih dan sehat anak usia sekolah. jurnal stikes cendekia utama kudas. 112-117. mulyadi dkk. (2018). efektifitas pendidikan kesehatan dengan media vidio terhadap tingkat pengetahuan perilaku hidup bersih dan sehat. jurnal keperawatan stikes suaka insan. mutmainah f.h. (2018). efektivitas buku saku phbs di sekolah meningkatan periaku hidup bersih dan sehat. jurnal kesehatan. notoatmodjo, soekidjo. (2010). promosi kesehatan dan ilmu perilaku. jakarta : rineka cipta. nuraeni, a. (2012). hubungan penerapan phbs keluarga dengan kejadian diare balita di kelurahan tawangmas kota semarang. [tesis ilmiah]. depok: fakultas ilmu keperawatan. universitas indonesia. proferawati, rahmawati. (2012). perilaku hidup bersih dan sehat. yogyakarta: nuha media. pramono, mochamad setyo dan paramita, astridya. (2011). peningkatan pengetahuan anak-anak tentang phbs dan penyakit menular melalui teknik kie berupa permainan elektronik. shihab, m. quraisy. (2002). tafsir al-misbah : pesan, kesan, dan keserasian al-qu’ran. volume 6. jakarta : lentera hati tri ratnaningsih. (2017). efektivitas game quiz terhadap pengetahuan tentang phbs pada siswa kelas 4 sd. jurnal sain med journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.59-66 59 psycoeducation of the resilience of the family of patients with mental disorders in overcoming psychosocial problems in the transition of the covid-19 pandemic in the region buleleng regency of bali eka lutfiatus solehah1*, nyoman sri ariantini2 1,2 department of nursing, sekolah tinggi ilmu kesehatan rana wijaya singaraja, indonesia *corresponding author: ekasoleha2018@gmail.com abstract background: the covid-19 pandemic affects all aspects of human life, physically, economically and psychosocially. this pandemic situation also affects the mental state of the families of odgj patients. this situation not only threatens overall health but also threatens the resilience of the family in dealing with the situation. purpose: the study was to determine the effect of psychoeducation on the resilience of families of patients with mental disorders in overcoming psychosocial problems during the transition period of the covid-19 pandemic in the buleleng-bali regency area. methods: the methods uses a true experiment using a one group pre-posttest approach. this research activity was carried out in two stages, namely field activities and activities to provide counseling and education about odgj care during the transition period. results: this study indicate that before being given psychoeducation to families of odgj sufferers, most of the family toughness was in the less category as many as 57 respondents (57%) and after being given psychoeducation the family was mostly in the good toughness category as many as 67 respondents (67%). the results of the paired t test show the value of = 0.000 with = 0.05. the results of this test show that the value of < then h1 is accepted, meaning that there is an influence of psychoeducation on the resilience of the family of odgj patients in overcoming psychosocial problems during the transition period of the covid-19 pandemic in the buleleng regency –bali. conclusion: providing psychoeducation can help families become more resilient in dealing with psychosocial problems in treating dogj patients during the transition period of the covid-19 pandemic. keywords: family, mental disorders, psychoeducation received august 10, 2022; revised september 12, 2022; accepted october 3, 2022 doi: https://doi.org/10.30994/jnp.v6i1.277 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:ekasoleha2018@gmail.com https://doi.org/10.30994/jnp.xxxx.xxx journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.59-66 60 background the covid-19 pandemic not only has an impact on the physical and economic aspects, it also raises health problems that can interfere with mental and psychosocial health. this situation certainly requires integrated and comprehensive efforts in the management and handling of mental health and psychosocial cases that occur in the community due to the covid-19 pandemic (kementrian kesehatan, 2014). this situation has changed the order of people's lives to be able to adopt a new habit or rule in their daily activities (mawaddah et al., 2021). this uncertain and uncertain situation can lead to a psychological response for the individual. anxiety is a natural response when individuals are faced with psychosocial stressors, such as unpredictable situations, this situation will have more impact on families who have members who have mental disorders or odgj (pertiwi & syakarofath, 2020). some psychosocial problems that can arise during a pandemic include fatigue, low self-esteem, disability coping with family conflict, anxiety, depression and panic disorder. the family has a big role for individuals in conditions of psychological vulnerability because family support is a very powerful source of strength in order to maintain physical and mental health so that individuals can return to power (marleta et al., 2020). handling that can be done to improve the family's ability to deal with these psychosocial problems includes growing family resilience in dealing with these situations, including providing psychoeducation to families. psychoeducation is provided with the aim of increasing positive attitudes towards the various challenges of family life in dealing with these crisis situations so that families can properly handle problems that arise during the covid-19 transition period towards the care of odgj patients. according to the ministry of health's 2021 report, data on the increase in the number of people with mental disorders increased by 6.8% during covid-19. based on preliminary study data at the social service of buleleng regency, the number of people with mental disorders or odgj in kab. buleleng in january december as many as 45 people who were recorded in 2021, while the total people with mental disorders in bali amounted to 9000 people. the high number of odgjs in buleleng regency, bali, attracted the attention of researchers to conduct research on psychoeducation on the resilience of families of patients with mental disorders in overcoming psychosocial problems during the transition period of the covid-19 pandemic in the buleleng regency, bali. the purpose of this study was to determine the effect of psychoeducation on the resilience of families of patients with mental disorders in overcoming psychosocial problems during the transition period of the covid-19 pandemic in the buleleng-bali regency area. this research method uses a true experiment using a one group pre-posttest approach. this research activity was carried out in two stages, namely field activities and activities to provide counseling and education about odgj care during the transition period. the results of the study are expected to increase the family's resilience in carrying out and overcoming the psychosocial problems of odgj patients during the transition period of the covid-19 pandemic, so that families are able to recognize mental health problems, are able to overcome family problems independently or come to health workers to obtain appropriate treatment in accordance with health problems experienced by families and patients. objective the purpose of the study was to determine the effect of psychoeducation on the resilience of the family of patients with mental disorders in overcoming psychosocial problems during the transition period of the covid-19 pandemic in the buleleng-bali regency. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.59-66 61 methods this research method uses a true experiment using a one group posttest only design approach. odgj population in kab. buleleng numbered 45 people, assuming 1 odgj was cared for by 2 family members, so the sample in this study amounted to 90 people. the sampling technique in this study will use probability sampling, namely simple random sampling, which is sampling in the population that is carried out randomly without regard to the existing strata in the population. the inclusion criteria in this study were families who had odgj, domiciled in buleleng regency, bali, and were willing to be respondents. this research activity was carried out in two stages, namely counseling and education activities about the care of odgj in the covid-19 transition, the second was the evaluation phase of the implementation of psychoeducation for odgj families. data collection used instruments in the form of questionnaires and interview guidelines which were directly given to respondents. analysis of the data used in this study used the t test to determine the average increase in family resilience before and after psychoeducation. results a. general data 1. family characteristics table 1 frequency distribution of family characteristics in the district of buleleng – bali in august 2020 (n=100) care giver characteristics amount prosentase age of family 26-35 years 6 6 36-45 years 64 6 46-55 years 30 30 family education elementary school 1 1 junior high school 38 38 senior high school 49 49 university 12 12 working not work 27 27 work 73 73 source : primyary data process, 2022 based on table 1 above, it is known that the characteristics of respondents based on family age obtained data mostly aged 36-45 years as many as 64 respondents (64%). the educational characteristics of the respondents' families obtained data that almost half of them are high school graduates as many as 49 respondents (49%). the characteristics of the respondents' occupations showed that most of the respondents worked as many as 73 respondents (73%). the results showed that most of the families of odgj patients were still in the productive age category even though there were some who entered early elderly age, and had a secondary educational background and many of them still had jobs either as private employees, tradesmen, or entrepreneurs, so that the characteristics the respondent's family affects the respondent's knowledge and skills in caring for family members who suffer from odgj but sometimes this can be a psychological burden for the family. the characteristics of https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.59-66 62 this respondent indicate that the respondent can be said to be quite able to understand information about the care that must be carried out on family members who experience odgj so that families can carry out proper care even in the current pandemic condition, so that family resilience can be further improved and maintained properly. 2. characteristic of odgj patients tabel 2 frequency distribution based on odgj patient characteristics in the district of buleleng –bali in august 2020 (n=100) odgj patient characteristics amount prosentase age of patient 26-35 years 62 62 36-45 years 31 31 46-55 years 7 7 education of patients elementary school 5 5 junior high school 35 35 senior high school 58 58 university 2 2 source : primyary data process, 2022 based on table 2 above, it is explained that based on the age of the patients, most of them are 26-35 years old as many as 62 respondents (62%). based on patient education, most of them have high school education background as many as 58 respondents (58%), the results of this study indicate that most odgj patients are still of productive age with patient education background including higher education. b. special data 1. resilience of the family tabel 3 frequency distribution based on resilience of the family before and after giving pyschoeducation in the district of buleleng –bali in august 2020 (n=100) resilience of the family before after amount prosentase amount prosentase less resilience 57 57 33 33 good resilience 43 43 67 67 amount 100 100 100 100 source : primyary data process, 2022 based on the results in table 3, it shows that before being given psychoeducation to families of odgj sufferers, most of the family toughness was in the less category as many as 57 respondents (57%) and after being given psychoeducation the family was mostly in the good toughness category as many as 67 respondents (67%). the results of this study indicate that the provision of psychoeducation increases the resilience of the families of odgj patients in overcoming psychosocial problems during the covid-19 pandemic transition period in the buleleng regency – bali. 2. result of statistics tabel 4 the results of the paired t test psychoeducation of resilience in families of people with odgj in overcoming psychosocial problems during the pandemic transition covid-19 in the district of buleleng –bali in august 2020 (n=100). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.59-66 63 paired differences t df sig. (2tailed) mean std. deviati on std. error mean 95% confidence interval of the difference lower upper pair 1 resilience of family pretest resilience of family postest .240 .429 .043 .325 .155 5.591 99 .000 source : primyary data process, 2022 based on the results in table 4 shows that the value of = 0.000 with = 0.05. the results of this test show that the value of < then h1 is accepted, meaning that there is an influence of psychoeducation on the resilience of the family of odgj patients in overcoming psychosocial problems during the transition period of the covid-19 pandemic in the buleleng regency – bali. discussion based on the results in table 3, it shows that before being given psychoeducation to families of odgj sufferers, most of the family toughness was in the less category as many as 57 respondents (57%) and after being given psychoeducation the family was mostly in the good toughness category as many as 67 respondents (67%). the results of this study indicate that the provision of psychoeducation increases the resilience of the families of odgj patients in overcoming psychosocial problems during the transition period of the covid-19 pandemic in the buleleng regency –bali. based on the results in table 4 shows that the value of = 0.000 with = 0.05. the results of this test show that the value of < then h1 is accepted, meaning that there is an influence of psychoeducation on the resilience of the family of odgj patients in overcoming psychosocial problems during the transition period of the covid-19 pandemic in the buleleng regency –bali. family as caregiver plays a very..important role..in assisting people with mental disorders and living their daily lives. so many problems faced by families in caring for family members who experience mental disorders. family resilience is the ability of the family to protect themselves from various life threats that come from their own family and from outside the family such as the environment, society and the state; the ability to adapt to conditions that are always changing dynamically and have a positive attitude towards the challenges of family life (budi wijoyo et al., 2021). family psychoeducation program is a family mental health care program with an educational approach. the purpose of this family psychoeducation is to increase family knowledge about health problems, teach techniques that can help families recognize the symptoms of behavioral deviations and increase support for other family members (cahyaningtyas et al., 2016). the psychoeducation program provided in this community activity is family resilience psychoeducation in overcoming psychosocial problems that occur due to the covid-19 pandemic. towards a strong family during this pandemic, it is necessary to start by https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.59-66 64 strengthening personal resilience first which can then strengthen other family members. this community service activity aims to increase participants' knowledge about mental health problems or psychosocial problems and increase their ability to face various difficulties during the crisis as a result of the covid-19 pandemic that occurred. based on the results of the research above, it shows that before psychoeducation was given, many families felt less capable, less confident and also not ready to face psychosocial problems because of the stigma and public perception of odgj patients. the family's lack of resilience creates feelings of tiredness and despair in caring for their family members who have odgj. in addition, families feel burdened in caring for their family members with mental disorders. lack of knowledge and insight possessed by the family in caring for odgj patients, especially in dealing with psychosocial problems, causes the family to feel heavy and uncomfortable in carrying out the treatment. besides that, with the need for care and daily needs which sometimes become difficult to fulfill because the process of treating patients with mental disorders takes a long time and also because of the impact of the covid-19 pandemic which destroys the community's economy. based on the characteristics of the family age of odgj patients in table 1, the data obtained are mostly aged 36-45 years as many as 64 respondents (64%). according to bandura in solehah, (2021) state one of the factors that affect a person's ability and belief in doing something is age. abilities and beliefs are formed through a social learning process that can take place throughout life. older individuals tend to have more time and experience in dealing with things that happen when compared to younger individuals, who may still have less experiences and events in their lives. older individuals will be more able to overcome obstacles in their lives compared to younger individuals, this is also related to the experiences that individuals have throughout their life span. the results of this study indicate that the respondent's age includes late adulthood where at that age the respondent will find it easier to understand the information received, especially about health education provided by officers regarding the management of odgj patient care, especially in dealing with family psychosocial problems in the transition period of the covid19 pandemic. so that many families who before the provision of psychoeducation had less resilience turned into more resilient after being given psychoeducation. based on family education, the data in table 1 shows that almost half of them are high school graduates as many as 49 respondents (49%). according to bandura in kusumawaty et al., (2020) states that abilities and beliefs are formed through a learning process that can be accepted by individuals at the level of formal education. individuals who have higher levels usually have higher abilities and beliefs, because basically they learn more and receive more formal education, in addition, individuals who have higher levels of education will have more opportunities to learn in overcoming problems. -problems in life. according to the researcher's assumption, the respondent's educational background is secondary education so that they are quite capable of understanding and receiving explanations from officers on how to deal with psychosocial problems that occur during the family's care for odgj patients during the transition period of the covid-19 pandemic. this happens because with an explanation from the respondent's health officer they can explain how to https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.59-66 65 manage the stress they face when caring for odgj patients, especially in dealing with psychosocial problems that arise during the transition period of the covid-19 pandemic, so many respondents have high family resilience after being given psychoeducation. the results of this study indicate that providing psychoeducation can help families become more resilient in dealing with psychosocial problems in treating dogj patients during the transition period of the covid-19 pandemic. with the provision of psychoeducation, the family feels that they can determine appropriate coping strategies to adapt to the current situation, where families usually feel worried and anxious so that they cannot adapt well, but after being given psychoeducation about family stress management, they are able to control the anxiety they experience. so that they can be calmer in taking care of family members who have mental disorders. conclusion 1. before being given psychoeducation to families of odgj sufferers, most of the family's toughness was in the poor category as many as 57 respondents (57%) and after being given psychoeducation, most of the family members were in the good toughness category as many as 67 respondents (67%). 2. the results of this test show that the value of < then h1 is accepted, meaning that there is an influence of psychoeducation on the resilience of the family of odgj patients in overcoming psychosocial problems during the transition period of the covid-19 pandemic in the buleleng regency –bali. references budi wijoyo, e., yoyoh, i., hastuti, h., & mulyawan, a. (2021). intervensi psikoedukasi keluarga untuk merawat orang dengan gangguan jiwa (odgj) : literature review. in edu masda journal (vol. 5). http://openjournal.masda.ac.id/index.php/edumasda. cahyaningtyas, a., tenrisana, as. a., triana, d., prastiwi, d. a., nurcahyo, e. h., jamilah, & tiwa, v. d. (2016). pembangunan ketahanan keluarga 2016 (edisi satu). cv. lintas khatulistiwa. kementrian kesehatan, i. (2014). undang-undang republik indonesia nomor 18 tahun 2014 tentang kesehatan jiwa. kusumawaty, i., yurike, & pastari, m. (2020). pendampingan psikoedukasi : penguatan caring oleh caregiver keluarga terhadap orang dengan gangguan jiwa. medikes (media informasi kesehatan), 7(1). marleta, j. r., setiyawati, d., matulessy andik, jaya, e. s., kembaren, l., hidayati, n. e., gamayanti, i. l., daulima, n. h. c., windarwati. heni dwi, hermantyo, a. i., airlangga, p. d. s., apriany, f., & santoso, d. h. (2020). panduan kesehatan jiwa pada masa pandemi covid-19 : peran keluarga sebagai pendukung utama. satgas covid-19. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.59-66 66 mawaddah, n., sari, i. p., fatmawati, a., suhartanti, i., & prasetya, a. (2021). psikoedukasi ketangguhan keluarga mengatasi masalah psikososial di masa pandemi covid-19. community development journal, 2(3), 998–103. pertiwi, r. e., & syakarofath, n. a. (2020). family strength model dalam upaya meningkatkan ketangguhan keluarga di situasi krisis. altruis: journal of community services, 1(2), 91–98. https://doi.org/10.22219/altruis.v1i2.12283. solehah, e. l. (2021). pengaruh psikoedukasi tentang manajemen stres dalam meningkatkan self efficacy keluarga merawat odgj di wilayah kerja puskesmas balowerti kota kediri. jurnal medika usada |, 4(2), 1–8. https://thejnp.org/ journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 18 25 18 effectiveness of socialization of immunization of pentavalen continued by health persons to mother's compliance batita in working center health center community beji malang, east java agus sutikno 1 , ana ifa nurul haida 2 , dian yovita sari 3 1 public health center beji, batu, malang, east java, indonesia 2 rst soepraoen, malang, east java, indonesia) 3 rsu karsa husada batu, malang, east java, indonesia corresponding author : agusedo.sutikno@gmail.com abstract background: pentavalent vaccine has several types of diseases, namely diphtheria, pertussis, tetanus, hepatitis b, inflammation of the brain and pneumonia. however.forhalalisasi socialization and provision of immunization pentavalen. purpose : this study aims to find out how the effectiveness of socialization pentavalen immunization by health workers to toddlers in the working area beji puskesmas kota batu. methods : this research was analytic observational with cross sectional approach (one group pre test post test design) was done to mrs. batita in working area bejipuskesmas town of batu in may to june 2017. respondents were selected in total sampling and conducted questionnaire by using observation sheet before and after further pentavalen immunization socialization for measurement of batita mother in immunization implementation. data collection using using pre-post observation sheet and the result in analysis by using paired sample t-test, the significant level used is 95% with value α 0, 05. result : the result of the research shows that before the implementation of pentavalen socialization on 17 batitae 17 respondents (30,9%) and the last socialization of pentavalen to ibubatita as many as 45 respondents (81,8%), there is significant correlation between effectivity of pentavalent immunization socialization by health worker against batita housewife in working area beji puskesmas kota batu p value = 0.000 and α = 0,05. conclusion : in this study the implementation of immunization socialization. ibubatita will increase awareness and awareness of ibubatita to immunize her baby in posyandu or other health services that serve immunization. keywords : socialization, maternal mother compliance, immunization received: february 03, 2018; revised february 24, 2018; accepted march 10, 2018 how to cite: sutikno, a., haida, a.i.n., & sari, d.y. (2018). effectiveness of socialization of immunization of pentavalen continued by health persons to mother's compliance batita in working center health center community beji malang, east java. journal of nursing practice. 1(2). 18-25 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 18 25 19 background based on data of achievement of continued pentavalen immunization beji health center in 2016 get 50,11% have implement pentavalen from coverage target that is 90%. the result shows that mother immunization has not fulfilled uci (universal coverage immunization) that is complete immunization coverage at least 80% equally in infants in 100% of villages / sub districts in 2010 (proverawati & andhini, 2010) should be done by the health office in order to improve the compliance of parents to immunize their baby (azizah, et al, 2011). efforts are made to improve compliance and knowledge of mother batita is by way of socialization related to immunization pentavalen include understanding, type of immunization, immunization schedule, excellence of vaccine and immunization way. it is hoped that with this socialization ibu batita mothers will be more understanding and obedient to immunize their children in posyandu and other health services. from the preliminary study conducted on march 10, 2017 in torongrejo village, there are 4 posyandu located in beji health center, it is known that from 10 respondents who have immunized data that 7 toddlers (70%) did not do pentavalen immunization continued while 3 toddlers (30%) have advanced pentavalent immunizations. the results of interviews with 10 mothers who have the toddler majority stated that as many as 8 mothers (80%) were less understood and less aware that there is a government program in the form of advanced pentavalent immunization for infants aged 18 months to 36 months. they assumed no more immunizations after complete primary immunization at 9 months of age. as we know today the government (ministry of health) has issued a policy of using new pentavalen vaccine for immunization target in indonesia. previously the combination vaccine has been successfully used with dpt-hb vaccine type (combination of 4 types of vaccine in one feeding). as the name implies, penta (five) valen consists of a combination of 5 types of vaccine in a single gift. the five types of vaccine include dpt-hb vaccine plus hib. the pentavalent vaccine serves to prevent diphtheria, whooping cough or 100 days of cough, tetanus, hepatitis b, and inflammation of the brain (meningitis) and pneumonia (pneumonia) caused by hib (haemophylus influenza type b). the advantage of giving pentavalent vaccine is to provide better protection for children against the above diseases so that it will grow healthier. the pentavalent vaccine is given by children aged 2,3 and 4 months. then resumed when the child is 1.5 years old, with one continuous injection (booster). advanced immunization ensures maximum immunity. so, apart from 3 times before the 1-year-old child, make sure the child gets advanced immunization once again at the age of 1.5 years. immunization is estimated to prevent 2.5 million cases of child deaths per year worldwide can be prevented by immunization. diseases that can be prevented by immunization (pd3i), such as tuberculosis (tb), diphtheria, pertussis (respiratory disease), measles, tetanus, polio and hepatitis b. immunization programs are essential to achieve population immunity (probandari et al, 2013). a review of the regional review of immunization (who / searo) in new delhi and the indonesian national immunization advisory group on immunization (itagi) expert in 2010 recommended that the hib vaccine be integrated into the national immunization program to reduce morbidity, mortality and infant and toddler defects caused by pneumonia and meningitis. this is in line with the new vaccine introduction plan contained in the 2010-2014 comprehensive multi years plan (cmyp) in order to journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 18 25 20 accelerate the achievement of the millennium development goals (mdgs) (dinkes prov jateng, 2013). in order to socialize the use of pentavalen vaccine will be done counseling and socialization of mother batita to know the benefits of further pentavalen vaccine includes the content and purpose of providing additional pentavalen immunization for their children. immunization program absolutely requires the support of all parties to move the target, especially the baby mothers and toddlers to posyandu, puskesmas or other health facilities. immune immunization is not only related to individual immunity, but community immunity. if in a community there are some infants and toddlers who have not been immunized, then the risk of transmission of diseases that can be prevented by immunization is still high. immunization pentavalen can be obtained free of charge at all posyandu, puskesmas or other government health facilities. from the above description it can be concluded that the socialization of pentavalen immunization is very necessary that is to provide knowledge for the mother, especially batita mother that there is a continuous pentavalent immunization given to her child aged 18 months even if her child has been given routine pentavalent immunization at age 2.3 and 4 months to increase his child's immunity. the regular and supplementary pentavalent immunization program is a new program conducted in june 2015 (central java provincial office 2015), so that many infant and toddler mothers do not yet know about advanced pentavalent immunization, based on this the researcher attempts to raise the issue of "the effectiveness of pentavalen immunization socialization continued by health personnel against compliance mother of batita dwo working area of beji town health center ". objective knowing the effectiveness of the continued implementation of pentavalent immunization by health personnel to mother batita compliance in beji puskesmas working area batu kota. methods this research was analytic observational with cross sectional approach (one group pre test post test design) was done to mrs. batita in working area bejipuskesmas town of batu in may to june 2017. respondents were selected in total sampling and conducted questionnaire by using observation sheet before and after further pentavalen immunization socialization for measurement of batita mother in immunization implementation. data collection using using pre-post observation sheet and the result in analysis by using paired sample t-test, the significant level used is 95% with value α 0, 05. results figure 1. identify compliance of mother of toddler before socialization of continued pentavalen immunization in torongrejo village working area of pukesmas beji kota batu 17 45 0 20 40 60 kepatuhan sebelum sosialisasi journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 18 25 21 based on the figure known 45 respondents that prior to the implementation of pentavalen advanced socialization of mother of child under 3 years as much as 17 respondents (37.77%). figure 2. identify compliance of mother of toddler after socialization of continued pentavalen immunization in torongrejo village working area of pukesmas beji kota batu based on figure known 45 respondents that after the implementation of advanced pentavalen socialization of mother of child under 3 years as much as 28 respondents (62.22%). figure 3. effectiveness socialization of continuous pentavalent immunization against obedience of mother of child under 3 years in torongrejo village working area of beji town health center batu based on figure shows that respondents with compliance before the implementation of immunization of advanced pentavalent immunization coming to immunize as many as 17 respondents (37.77%). and after the implementation of immunization of advanced pentavalen immunization coming to immunize as many as 28 respondents (62.22%) discussion compliance mother of the child under three years prior to continued immunization of pentavalent immunization. the results of the research conducted in may 2017 at 4 posyandu in torongrejo village before the socialization of advanced pentavalen immunization showed that the majority of respondents were obedient in providing advanced pentavalent immunization of 17 batita (37.77%). febriastuti (2013) states that compliance means a person's behavior to follow medical or health advice in accordance with the provisions given. a good and deep understanding of these factors is beneficial for parents and health workers to improve 28 45 0 10 20 30 40 50 kepatuhan sesudah sosialisasi 17 28 45 0 20 40 60 distribusi kepatuhan journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 18 25 22 adherence to advanced pentavalent immunization so that therapeutic effectiveness can be monitored. compliance the mother of the under-three child in the administration of advanced pentavalent immunization is influenced by the level of education of the respondent, this is with the good formal education can influence a person in making decisions and behave, with education one can increase intellectual maturity so as to make decisions in acting. the higher a person's education will be the more knowledge and technology (notoatmojo, 2012). kadir, et al (2014) stated that the education level of respondents is one of the aspects that influence the mindset in determining the compliance of immunization, because the higher the education level one can think better related to the health of the toddler. and vice versa those who are lowly educated, rather difficult and take a relatively long time to make changes. notoatmojo (2012) states that adherence affects the awareness of respondents to bring the baby immunization. mothers who are not willing to immunize their babies can be caused by not understanding properly and deeply about basic immunization. in addition, less attention in bringing the baby immunization on schedule. a lack of awareness will affect mothers in obtaining information about immunization. after realizing the importance of immunization benefits, mothers can take their babies for basic and advanced immunization on schedule. compliance of the mother of the child under three years after the socialization of advanced pentavalent immunization the results of the research conducted in june 2017 at 4 posyandu in torongrejo village after the socialization of pentavalen immunization continued showed that the majority of respondents were obedient in providing advanced pentavalent immunization of 28 batita (62.22%). the advantage of giving pentavalent vaccine is to provide better protection for children against the above diseases so that it will grow healthier. the pentavalent vaccine is given by children aged 2,3 and 4 months. then resumed when the child is 1.5 years old, with one continuous injection (booster). advanced immunization ensures maximum immunity. so, apart from 3 times before the 1-year-old child, make sure the child gets advanced immunization once again at the age of 1.5 years. immunization is estimated to prevent 2.5 million cases of child deaths per year worldwide can be prevented by immunization. diseases that can be prevented by immunization (pd3i), such as tuberculosis (tb), diphtheria, pertussis (respiratory disease), measles, tetanus, polio and hepatitis b. immunization programs are essential to achieve population immunity (probandari et al, 2013). after further socialization of pentavalent immunization in three-year-old mother who consisted of 45 respondents who came to immunize 28 batita (62,22%), this was because the socialization of pentavalen immunization resulted in an understanding of the benefits and advantages of providing advanced pentavalent immunization for his son. from the above data can be assumed that the implementation of immunization of pentavalen continued immunization influence on mother batita obedience to come and immunize her child in posyandu. journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 18 25 23 the influence of continued immunization of pentavalent immunization by health workers on the obedience of the mother of the child under three years from paired sample t-test test get significant value, result of research show that there is meaningful influence between effectiveness socialization of pentavalen immunization continued by health worker to obedience of mother of child under 3 years with p value (0,0017 <0,05). the results of this study support previous research from hindriyawati, et al (2012) that there is a relationship between the level of knowledge of mothers in the provision of basic immunization. mulyani (2009) in his research also states that there is influence between mother's knowledge level about immunization with maternal obedience in giving measles immunization. mardiansyah (2009) that there is a relationship between the mother's knowledge of basic immunization against immunization compliance in infants. maternal compliance in pentavalent immunization means that respondents already know the benefits of pentavalent immunization. according hayana, et al (2013) that the provision of immunization in children has a purpose for the body immune to certain diseases. immune can also be affected by several factors including high levels of antibody at the time of immunization, antigen potential injected, and time between immunization. the effectiveness of immunization depends on the factors that influence it so that the immunity can be expected in the child. this is in accordance with the statement from ismet (2013) that one of the factors affecting compliance is the level of knowledge, the higher one's knowledge of immunization, allowing the person to apply his knowledge in this case to fully immunize the toddler. information is one of the organ of knowledge-forming. the more a person gains, the easier it receives the information, the better the knowledge, the better one's knowledge, the easier it is to receive information. this is in accordance with notoatmojo (2007), that when the acceptance of new behavior or behavior adoption is based on knowledge, positive awareness and attitude then the behavior is permanent. conversely, if the behavior is not based on knowledge and awareness will not last long. arifin (2011) in his research stated that a well-informed mother would be easier to understand about anything related to immunization so mother would be obedient in bringing the child to be immunized. conclusion after pentavalen immunization implementation implementation was carried out on the compliance of ibu batita in torongrejo village in beji kota health clinic work area because the paired sample t-test test was significant 0.000 (p ≤ 0,05). references arifin, (2011).hubungan tingkat pengetahuan ibu tentang pentingnya imunisasi dasar dengan kepatuhan melaksanakan imunisasi di bps hj.umi salamah di desa kauman, peterongan, jombang, tahun 2011. prosiding seminas competitive advantage,vol 1,no.2 astinah; hasbulalah, s ; muzakir. h (2013). faktor-faktor yang mempengaruhi kepatuhan ibu pada pemberian imunisasi dasar di posyandu teratai 11b di wilayah journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 18 25 24 kerja puskesmas tamamaung makasar. e-library stikes hasanudin makasar.vol 2 no 6. azizah, n; suyati, rahmawati , ve. (2011). hubungan pengetahuan ibu tentang pentingnya imunisasi dasar dengan kepatuhan melaksanakan melaksanakan imunisasi di bps hj. umi salamah di desa kauman, peterongan, jombang : prodi d-iii kebidanan fik unipdu. dinas kesehatan provinsi jawa tengah (2013).petunjuk teknis introduksi imunisasi dpthb-hib(pentavalen).pada bayi dan pelaksanaan imunisasi lanjutan pada anak balita.semarang:dinkes jateng febriastuti, n, arif, ys; kusumaningrum,t.(2013). kepatuhan orang tua dalam pemberian kelengkapan imunisasi dasar pada bay1 1-11 bulan.surabaya: progam studi s1 pendidikan ners fakultas keperawatan universitas airlangga. fidadan maya. (2012). pengantar ilmu kesehatan anak. yogyakarta :d-medika, ismet,f. (2013). analisis faktor-faktor yang berhubungan dengan imunisasi dasar lengkap pada balita di desa batu barani kec.kabila bone kab.bone bolango.jurnal keperawatan ung. fakultas ilmu-ilmu kesehatan dan keolahragaan,universitas negeri gorontalo. kadir,l; fatimah dan hadia 2014. (2014).pengetahuan dan kepatuhan ibu pada pemberian imunisasi dasar bagi bayi. journal of pediatric nursing vol.1(1),pp.009-013. kementrian kesehatan ri (2013).menkes luncurkan vaksin pentavalen dan progam imunisasi lanjutan bagi batita, diakses melalui depkes.go.id tanggal 20 januari 2015 kinanti , an. (2013). imunisasi pentavalen ,vaksin “kombinasi” terbaru untuk anak indonesia. diakses melalui http://health.detik.com, tanggal 20 januari 2015. lestari,ri dan masruroh. (2012).hubungan pengetahuan ibu tentang imunisasi dasar lengkap dengan praktik imunisasi dasar lengkap bayinya di wilayah kerja puskesmas pegandon kec.pegandon kab.kendal.jurnal ilmiah kesehatan akbid uniska kendal.edisi ke-2 tahun 2012. marfiah, s (2014). imunisasi dasar dengan vaksin pentavalen ,diakses dari http://sitimarsifah.com, tanggal 20 januari 2014. mulyadi, yad. 2012. panduan sosiologi sma kelas x. jakarta timur: yudhistira. niven. (2012). psikologi kesehatan : pengantar untuk perawat dan profesional kesehatan lain.jakarta : egc notoatmodjo, 2012.promosi kesehatan dan perilaku.jakarta : rineka cipta journal of nursing practice http://jurnal.strada.ac.id/jnp issn: 2614-3488 (print); 2614-3496 (online) vol.1 no.2 april 2018. hlm 18 25 25 probandari,an; handayani,s; laksono, njd. (2013). ketrampilan komunikasi.modul field lab. surakarta: fakultas kedokteran universitas sebelas maret surakarta. proverawati&andhini. (2010). imunisasi danvaksinasi.yogyakarta :nuha medika. ranuh, dkk (2011).pedoman imunisasi di indonesia. jakarta: badan penerbit ikatan dokter anak indonesia. setyono, budhi. 2011. bahas total matematika, fisika, biologi, kimia, ekonomi, geografi, dan sosiologi sma kelas x ipa. jakarta selatan: kawah media. journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.130-136 130 the importance of discharge planning in stroke patients: literature review anie tri indiartinie1*, eppy setiyowati2, yurike septianingrum3, abdul muhith4, ima nadatien5, umdatus soleha6, rusdianingseh7 1 student master of applied nursing at nahdlatul ulama university, surabaya, indonesia 2,3,4,5,6,7 department of nursing and midwifery, nahdlatul ulama university, surabaya, indonesia *corresponding author: indiartinie@gmail.com abstract background: stroke causes neurologic disturbances that can cause changes in quality of life. quality of life is mental, physical, social health and regardless of disease. in order to achieve a good quality of life, there must be a role for health workers. discharge planning in stroke patients is preparing patients for treatment in healing and improving the health status of stroke patients. purpose: the purpose of the literature review is to find out the importance of discharge planning in stroke patients. methods: the research stage is to make a selection by paying attention to the year of publication and with full text. furthermore, articles and journals that are considered less relevant are excluded. literature was obtained from 10 articles relevant to google scholar, indonesia one search, doaj, and garuda with the keywords discharge planning, quality of life and stroke. results: after reviewing the selected articles, it was found that discharge planning has a good impact on increasing family readiness in caring for patients, as well as improving the quality of life of stroke patients, namely being able to increase rehabilitation activities, prevent disease complications and adherence to taking medication and routine control. conclusions: improving the quality of life of stroke patients, which can improve rehabilitation activities, prevent disease complications and comply with taking medication and routine control. keywords: discharge planning, patient, stroke received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.301 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:indiartinie@gmail.com https://doi.org/10.30994/jnp.v6i2.368 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.130-136 131 background stroke is a permanent neurological disorder due to disruption of blood circulation to the brain, which occurs for about 24 hours or more. this clinical syndrome occurs suddenly and is progressive, causing acute brain damage with clinical signs that occur in a focal or global manner. stroke is a loss of brain function caused by the cessation of blood supply to the brain. stroke can cause neurologic disturbances that depend on the location of the lesion (clogged blood vessel), the size of the area of inadequate perfusion and the amount of collateral blood flow (secondary or accessory) (carod-artal & egido, 2010). stroke is ranked 2nd in the world as a non-communicable disease that causes death after heart disease. every year more than 2 million people experience a stroke and an increase of 6.7% annually. based on who (word health organization) data, stroke is the 5th cause of death in america, reaching 129 thousand people per year. stroke patients in the united states aged between 55-64 years as much as 11% have silent cerebral infarction, the prevalence increases to 40% at the age of 80 years and 43% at the age of 85 years (mahyuvi & nursalam, 2020). the prevalence of stroke in indonesia has increased from 7% in the 2018 riskesdas to 10.9% in 2020. the prevalence of stroke in east java province is ranked 3rd in indonesia, reaching 302,987 sufferers (mahyuvi & nursalam, 2020). quality of life is a person's assessment of his life. research results (abdullah, 2017)said that there is a significant relationship between functional status and quality of life in the acute phase after stroke, patients with poor functional status tend to have a poor quality of life. individual quality of life is influenced by several factors, namely physiological factors, symptom status, functional status, general health perceptions, individual characteristics and environmental characteristics. clinical manifestations of stroke include motor loss, loss of communication, reception disturbances, namely the inability to interpret sensations, impaired cognitive function and psychological effects where patients show symptoms of limited attention, difficulty in understanding, forgetfulness and lack of motivation so that patients experience frustration in healing treatment so that adaptations are needed which are arranged in discharge planning. providing discharge planning can increase patient knowledge, the effectiveness of hospital care, reduce repeat visits to the hospital and can reduce treatment costs (sitompul et al., 2020). in the advanced phase or follow-up care, appropriate treatment is needed because it can prevent complications from occurring in stroke patients. stroke patients when they return from the hospital, post-stroke patients still experience sequelae, for example with the condition; motor loss (hemiplegia/hemiparese) or patients who go home with a state of total bedrest, loss of communication or difficulty speaking (dysatria), impaired perception, impaired cognitive function and psychological effects, so that it will have an impact on activities of daily life in fulfilling basic human needs. providing good care services at the hospital will speed up the healing process of stroke patients. the minimum standard length of care for stroke patients is an average of 2 to 4 weeks. after that the stroke patient will perform outpatient treatment. the condition of patients who are medically allowed to go home has improved but in fulfilling needs and nursing is still very limited (kurniati et al., 2022), improving the quality of life is the main goal expected in the care of post-hospitalized stroke patients. efforts to improve a good quality of life after a stroke are very dependent on the quality of management and care so that the participation of health workers in the stroke team is needed, in this case the health workers are also involved and the family has an understanding of the disease process, knows how to handle it and the continuity of care in the rehabilitation phase and adaptation arranged in a discharge planning. discharge planning is an effort made by families and health workers to prepare patients to get continuity of care both in https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.130-136 132 the healing process and maintaining their health status until the patient feels ready to return to his environment and must start from the time the patient comes to the health service. discharge planning can improve health development and help patients achieve optimum quality of life after the patient is discharged, discharge planning can also have a significant effect in reducing disease complications, preventing relapse and reducing mortality (prick et al., 2022). as the main implementation of discharge planning is the provision of health education to patients and families which aims to increase knowledge and understanding as well as support for the patient's health condition and follow-up that must be carried out after returning home. discharge planning for stroke patients is very important considering the period of care and recovery to the level of disability and the sequelae that are caused are quite severe and require a long time. giving discharge planning aims to influence patient behavior as an effort to improve quality of life and prevent recurrent stroke attacks (permata sari, 2022). methods this article is a literature review. a review study includes a summary of previous findings in a review of the research literature on a specific topic. the existence of a lot of information is an opportunity, a systematic review method is needed so that the information can be used as needed by the researcher to complete this research. the literature search was carried out by the researchers themselves. extracted documents are reviewed by other researchers independently to include documents that are relevant and appropriate in this study. the search took place in the google scholar database with the keywords discharge planning, quality of life and stroke. the search for articles started on 10 october 2022 to 17 october 2022 with keywords determined by the researchers, namely, discharge planning, quality of life and stroke. finally, there are 10 journals and articles that the author has obtained which are then reviewed to get the gist of the discussion and some important points in each reference. lastly is the process of writing articles (nursalam, 2020). results search reviews were identified and filtered according to the variables used. then the feasibility test was obtained and 10 journals were then selected according to the specified criteria so that 10 journals were obtained. the journal search engines used in this study were google scholar, indonesia one search, doaj, and garuda. title, author and year research result discharge planning of stroke patient in regional general hospital ungaran writer:(eva rayanti & yoel, 2020) the conclusion of this study is that nurses have already conducted discharge planning for stroke patients at the hospital, but nurses need to optimize their role in the implementation of discharge planning. the effect of discharge planning implementation on stroke patients in indonesia writer :(adhitya et al., 2020) by carrying out discharge planning, especially for stroke patients, a good influence is obtained for the patient or family in the hope that problems that may occur can be handled so that the patient's health status can improve after a stroke and carrying out discharge planning can improve the quality of nursing care in indonesia. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.130-136 133 title, author and year research result the effect of discharge planning on the quality of life of ischemic stroke patients writer : after administering discharge planning to stroke patients, it turns out that they will have a greater chance of life to have a good quality of life compared to those without discharge planning. the effect of discharge planning on families' ability in post-stroke care at home writer :(yaslina et al., 2019) there is an effect of providing discharge planning on the family's ability to care for post-stroke at home the effect of discharge planning on the readiness of stroke patients to face discharge in the neurology inpatient room writer :(permata sari, 2022) the results showed that the average prior to the discharge planning readiness of respondents was 24.60 with a standard deviation of 3.299. while the average after discharge planning the readiness of respondents was 31.50 with a standard deviation of 0.889. visible differences between the mean readiness to face the return stroke patients before and after discharge planning is 6.90 with an ap value of 0.000. the effectiveness of implementing discharge planning using a structured method on family readiness in providing early mobilization in cerebro vascular attack patients in rs. surabaya islam writer :(damawiyah & ainiyah, 2017) the results of statistical tests with mann whitney obtained a value of p = 0.001 (p <0.05) meaning that there was an effect before and after the application of discharge planning with a structured method was given to family readiness in providing early mobilization in cerebro vascular attack patients in the treatment group. development of a patient decision aid for discharge planning of hospitalized patients with stroke writer :(prick et al., 2022) the developed ptda was found acceptable and usable by patients and hcps and is currently under investigation in a clinical trial to determine its effectiveness effect of a design discharge planning program for stroke patients on their quality of life and activity of daily living writer :(said taha & ali ibrahim, 2020) applying a design discharge planning program had statistically significant improvement on knowledge, quality of life and activity of daily living for studied patients the effect of discharge planning on the quality of life of stroke patients write(sitompul et al., 2020) the effect of discharge planning is very good, as well as family support will have an impact, namely improving the quality of life of stroke patients, namely increasing activity, preventing disease complications and patient adherence in taking medication and routinely carrying out disease control. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.130-136 134 title, author and year research result the effect of discharge planning combines audiovisual with the family centered nursing preparedness caring for acute post stroke patients writer :(kurniati et al., 2022) the first phase of the study produced a cadp module for families of stroke patients, the second phase based on the wilcoxon sign rank test showed that there was an effect after the intervention and the mann whitney test showed a significant difference in mean between intervention and control during eh (0.000; 0.000), during treatment (0.000;0.000), before lh (0.000;0.000) discussion providing discharge planning affectsfamily readiness to care for stroke patients before leaving the hospital. families and patients who receive discharge planning after having a stroke are more enthusiastic about undergoing rehabilitation after discharge and families experience fewer psychological disorders in caring for patients (yaslina et al., 2019). in increasing the readiness of patients and families in the planning process before discharge from the hospital by facilitating discussion and providing education on practical issues relevant to their illness and problems that often arise when care is carried out at home. giving discharge planning has a positive impact on how patients and families rated their level of self-confidence after discharge from the hospital. so that by providing discharge planning education consistently with material that is gradual and continuous it has an impact on patient and family acceptance and understanding responses to be easier (kurniati et al., 2022). there are several factors that influence the implementation of discharge planning in hospitals, one of which is the role of the family in carrying out discharge planning. the role of the family cannot be denied as a support system that is very helpful, especially when the patient is at home. patients will feel motivated to adhere to treatment to speed recovery. the role of nurses in hospitals is to work as health service providers in a professional manner because nurses act as case managers and executors of patient care. before going home, nurses provide services in the form of care before going home, namely discharge planning stroke by providing information and teaching families about how patients help move from bed to chair, help with dressing, bathing and washing, how to give medicine properly, when giving medicine comes to control at home sick on time and others. providing discharge planning is able to increase the readiness of families to care for patients because usually nurses are used to giving patient control sheets when they go home and most nurses explain activities that are allowed and activities that are prohibited as well as the nutritional needs of patients after being at hom (afni rodearni purba et al., 2022). increased family readiness to care for stroke patients can occur due to discharge planning interventions that are provided about complete education regarding preparations that families must know before leaving the hospital, namely when to control, when to take medication, rehabilitation activities and patient nutrition at home. patient behavior can be changed by providing discharge planning, namely through information given to patients so that it becomes a stimulus that can increase knowledge, influence awareness to behave as expected. stroke patients have different abilities and responses to the stimulus given, so the behavior and ability of patients to carry out independent care are also different (permata sari, 2022). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.130-136 135 conclusion providing discharge planning to families and stroke patients has a good impact in increasing family readiness in caring for patients, as well as improving the quality of life of stroke patients, which can improve rehabilitation activities, prevent disease complications and comply with taking medication and routine control. references abdullah, e. (2017). pengaruh discharge planning terhadap kualitas hidup pasien stroke ishkemik. jurnal keperawatan, 7(1). adhitya, s., basit, m., & widodo, h. (2020). the effect of discharge planning implementation on stroke patients in indonesia. proceeding of sari mulia university nursing national seminars. afni rodearni purba, s., susyanti, d., & yuda pratama, m. (2022). discharge planning pada pasien stroke iskemik. jurnal keperawatan flora, 15(2). carod-artal, f. j., & egido, j. a. (2010). quality of life after stroke: the importance of a good recovery. cerebrovasc disease. https://doi.org/doi: 10.1159/000200461. damawiyah, s., & ainiyah, n. (2017). efektivitas penerapan perencanaan pulang dengan metode terstruktur terhadap kesiapan keluarga dalam memberikan mobilisasi dini pada pasien cerebro vaskuler attack di rs. islam surabaya. jurnal ilmiah kesehatan (journal of health science). eva rayanti, r., & yoel, l. j. (2020). discharge planning of stroke patient in regional general hospital ungaran. jurnal keperawatan respati yogyakarta, 7(2), 94–98. http://nursingjurnal.respati.ac.id/index.php/jkry/index. kurniati, n., nursalam, n., & kartini, y. (2022). the effect of discharge planning combines audiovisual with the family centered nursing preparedness caring for acute post stroke patients. interest : jurnal ilmu kesehatan, 154–165. https://doi.org/10.37341/interest.v0i0.345. mahyuvi, t., & nursalam, n. (2020). the effect of social cognitive theory-based psychoeducation towards depression and blood pressure of ischemic stroke patients. journal for quality in public health, 4(1), 202–207. https://doi.org/10.30994/jqph.v4i1.140. nursalam. (2020). metodologi penelitian ilmu keperawatan (edisi 5). salemba medika. permata sari, y. (2022). pengaruh discharge planning terhadap kesiapan pasien stroke menghadapi pemulangan di ruangan rawat inap neurologi. real in nursing journal (rnj), 5(2). https://ojs.fdk.ac.id/index.php/nursing/index. prick, j. c. m., van schaik, s. m., deijle, i. a., dahmen, r., brouwers, p. j. a. m., hilkens, p. h. e., garvelink, m. m., engels, n., ankersmid, j. w., keus, s. h. j., the, r., takahashi, a., van uden-kraan, c. f., van der wees, p. j., van den berg-vos, r. m., van schaik, s. m., brouwers, p. j. a. m., hilkens, p. h. e., van dijk, g. w., … schut, e. s. (2022). development of a patient decision aid for discharge planning of hospitalized patients with stroke. bmc neurology, 22(1). https://doi.org/10.1186/s12883-022-02679-1. said taha, a., & ali ibrahim, r. (2020). effect of a design discharge planning program for stroke patients on their quality of life and activity of daily living. international journal of studies in nursing, 5(1), 64. https://doi.org/10.20849/ijsn.v5i1.724. sitompul, o. h., faridah, i., & afiyanti, y. (2020). literatur review pengaruh discharge planning dengan kualitas hidup pasien stroke. jurnal ilmu kesehatan indonesia (jiksi) e-issn, 1(2), 1. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.130-136 136 yaslina, maidaliza, & itra hayati. (2019). pengaruh pemberian discharge planning terhadap kemampuan keluarga dalam perawatan pasca stroke di rumah. perintis’s health journal. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.75-83 75 the analysis of services quality and satisfaction of bpjs patient at x public health center counter kediri city mohamad as’ad efendy1*, elon bora bili2 1,2 department of nursing, institut ilmu kesehatan strada indonesia, indonesia *corresponding author: surel.asad@gmail.com abstract background: there are still many people who do not know about the national health insurance itself, the ease of treatment using the national health insurance has not been fully successful, because of the length of bureaucracy and the lack of facilities and infrastructure to support the national health insurance program. purpose: the purpose of this study was to see correlation between services quality and satisfaction bpjs patients. methods: a correlational study methodology was used with a group of bpjs patients. to obtain 30 individuals, a consecutive sampling procedure was used. the data was analyzed using the spearman rho statistical test, with a significance threshold of = 0.05. results: the data revealed that, of the 30 respondents, the majority, 26 respondents (80 percent), stated that the services quality was good, and the majority had adequate satisfaction, 25 respondents (83 percent ). the results of the analysis of the spearman rho test obtained a p-value = 0.000 which is less than the value of alpha (0.05) so it can be concluded that h0 is rejected, meaning that there is a relationship between the services quality and the satisfaction of bpjs patients at x public health center kediri city. conclusion: based on the study's findings, it is possible to conclude that there is a link between the services quality and the satisfaction of bpjs patients. the study's findings also suggest that services quality can increase satisfaction because patient will have loyalty if public health center can ensure services quality to bpjs patient. keywords: bpjs, satisfaction, services quality received august 10, 2022; revised september 12, 2022; accepted october 3, 2022 doi: https://doi.org/10.30994/jnp.v6i1.294 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:surel.asad@gmail.com https://doi.org/10.30994/jnp.v6i1.294 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.75-83 76 background one of the health problems faced by indonesian people today is is that there are still many people who do not know about the national health insurance alone, convenience treatment with use guarantee health national even not yet fully successful, due to the length of the bureaucracy and the lack of supporting facilities and infrastructure the national health insurance program (yustisia, 2019). in running the service program guarantee health national the, bpjs health cooperate with various facility health services such as puskesmas, posyandu, and hospitals to provide health services for the community, especially those with low incomes in the hope of being able to provide service health which worthy and quality because limitations financial (thabrany, 2020). service health quality is factor which important in reach satisfaction patient. satisfaction patient is feeling patient which arise as consequence from performance service the health he gets after the patient compares with what what he expected (department of health, 2020). factors which cause patient dissatisfaction bpjs among them a lot patients who must be served at the first provider (ppk 1) causes the queue to become longer, the examination is carried out quickly and seems rushed so that the patient feels that it is not enough time to consult a doctor (muninjaya, 2019). restricted drug administration makes patients are not comfortable, because bpjs health participants have to queue back and forth for treatment again. by using a tiered referral system, patients feel that the referral process takes longer (alamsyah, 2019). giving referrals is also not as easy as when it was askes or jamsostek or jamkesmas. limited service time or practice hours at family doctors also cause complaints from patients related to the tiered referral system (bustami, 2018). satisfaction bpjs participants on the quality of hospital services really need to be monitored. because if the patient bpjs participants did not get satisfaction, so it is not impossible that people who have not registering as a bpjs service participant will not want to register himself. until the program government will also be difficult to realize (purwanto, 2018). in this case reviewing from the goal the government from the bpjs health program above to improve hospital services that maximum and could realize registered whole people indonesia in program. in repair facility service health very need existence survey satisfaction patient (supartiningsih, 2017). patient satisfaction is one of the standard measures that have been set for measure succeed or whether or not service health (arsepta, 2018). satisfaction patient becomes part integral from activity guarantee quality service health. that is, the measurement of the level of patient satisfaction must be an activity that cannot be separated from patient satisfaction measurement of the quality of health services. dimensions of patient satisfaction become one dimension of quality service health which very important (kurnia, 2018). quality service which good will cause satisfaction on customer or user service service (bpjs) (wahyuni, 2019). with holding system guarantee health national (jkn) expected satisfaction patient could increases along with the increase in the quality of health services (irawan, 2018). objective the objective of this study was to see correlation between services quality and satisfaction bpjs patients. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.75-83 77 methods the research design used in this study is a correlational study with cross sectional approach. the sampling technique used is consecutive sampling which meet the inclusion and exclusion criteria. the population is 1,662 with a sample of 30 people. in this study the independent variable is service quality and the dependent variable is satisfaction in counter public health center x on patient bpjs. test statistics which used is spearman rank with score ️ = 0.05. results data general age frequency percentage (%) < 25 year 7 23 25-35 year 19 64 > 35 year 4 13 amount 30 100 type sex frequency percentage (%) man 10 33 woman 20 67 amount 30 100 education frequency percentage (%) sd 5 17 junior high school 10 33 senior high school 14 47 diploma/pt 1 3 amount 30 100 work frequency percentage (%) farmers/irt 9 30 entrepreneur/trade/entrepreneur 14 47 employee private 6 20 employee country civil (pns/tni/polri) 1 3 amount 30 100 based on table on showing that age respondent is known part big respondent with age 25-35 year that is as much 19 (64%) respondents. type sex it is known that most of the respondents are female, as many as 20 (67%) respondents. education respondent is known almost half from respondent with level education senior high school that is as much 14 (47%) respondents. work respondent is known almost half of respondent work as trader that is as much 14 (47%) respondents. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.75-83 78 data special no quality service frequency percentage (%) 1 not enough 1 3 2 enough 3 10 3 well 26 87 amount 30 100 no satisfaction at the counter public health center x on patient bpjs frequency percentage (%) 1 very not satisfied 1 3 2 not satisfied 1 4 3 satisfied 3 10 4 very satisfied 25 83 amount 30 100 based on table on showing that quality service counter registration in puskesmas x is known to almost all respondents as many as 26 (87%) respondents in the good category. satisfaction at the counter public health center x on bpjs patient almost known whole respondent as much 25 (83%) respondent in category very satisfied. analysis data results test statistics spearman rank variable level significance quality service 0.00 0 satisfaction in counter public health center x on patient bpjs the results of data analysis show that the significance level is 0.000 < = 0.05 so that h0 rejected and h1 is accepted thus there is a relationship between service quality and satisfaction in counter public health center x on patient bpjs. discussion quality service counter registration in public health center x based on results study is known that quality service counter registration in puskesmas x is known to almost all respondents as many as 26 (87%) respondents in the good category. this is in accordance with the results of the questionnaire that the officer at the registration counter is always there time of service, officers at the counter to serve patients quickly and uncomplicated, always polite in providing service, have a sympathetic attitude and understand the wishes patient, no give attention which special to patient, officer in counter look skilled, careful, and thorough in providing services, always recording identity patient, give convenience in service registration, officer in counter registration look neat and room wait in counter registration clean and comfortable. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.75-83 79 department of health (2021), explain that quality service could interpreted as level perfection of health services in accordance with standards required service by the community to meet patient demands. the more obedient officers (profession) to standard service, so the more quality also service health which given. quality health care is meeting and exceeding customer needs and expectations through continuous improvement over the entire process (wijono, 2020). customers include patients, family, and other which come for get service doctor, employee. quality health services are assessed from 5 dimensions, namely reliability (ability to fulfill promises), responsiveness (response in give service), assurance (ability give guarantee service), empathy (ability understand desire customer), and tangibles (physical view of the service). these five dimensions of service quality are the concept of service quality is a measuring tool for the quality of health services (tjiptono, 2020). factors related to the quality of health services is a predisposing factor (predisposing) factors) include demographics (age, gender, socioeconomic status), social structure (ethnic, race, culture, occupation, education), beliefs (belief in disease, doctors, health workers). enabling factors include the quality of health services, service distance, socioeconomic status, service needs (needs), tariffs or fees, facilities, personnel services, location, speed and ease of service, information, decisions to utilise service health. according to opinion researcher that quality service public health center very important, because affect patient satisfaction. the quality of good health services can create a sense of satisfied on self every patient. satisfaction customer which low will impact to decline amount visit patient which will influence profitability facility health. in addition, the important role of each system is to ensure service quality given health. with increasing attention to quality improvement health services, understanding of the approach to health service quality assurance is becoming increasingly important. so it can be said that the better the quality of health services given by the registration counter officer, the level of satisfaction will also increase patients on the quality of services provided. on the other hand, the lower the service quality health services provided by the health center then it will be lower satisfaction patient against quality service service which given. satisfaction in counter health center x pada patient bpjs based on the results of the study, it was found that satisfaction at the puskesmas x counter at bpjs patients are known to almost all of the respondents as many as 25 (83%) respondents in the category very satisfied. this is in accordance with the results of the questionnaire that the physical facilities of the registration counter (building, living room) waiting time, room temperature, etc.) that the patient received at the puskesmas was satisfactory, the patient also felt satisfied with the performance of the registration officer at the registration counter, the counter officer is not favoritism in providing health services and the counter staff is always on time in carrying out registration, patients feel comfortable during the registration process at the registration counter and service in units registration always get impression which good. irawan (2020), explains that patient satisfaction is a feeling of pleasure and satisfaction because hope and his wish achieved after accept service which given. satisfaction patient is a patient's feeling that arises as a result of poor health service performance got it after patient compare it with what which he hoped. level satisfaction patient bpjs in on quality service in public health center could becomes reject measuring the success of the bpjs program specifically at the health center which is the guard front for serve the community. the bpjs program itself is still in its journey of many shortcomings and complaints from bpjs participants include, bpjs patient inpatient rooms are often full, referral problems make it difficult for critical patients, lack of socialization about the bpjs https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.75-83 80 program, slow work system and verification claim action which slow (tjiptono, 2020). the more tall level quality health services, the greater the perceived patient satisfaction and vice versa, the more low level quality service health so the more small satisfaction patient which felt. quality service health is size evaluation thorough on a level good health services. while patient satisfaction will be known before after the patient feels the results of the quality of health services received which is influenced by also by hope previously and needs will service health that (department of health, 2021). in the opinion of researchers that health workers can maximize performance in service and pay attention to things that can help the patient's problems and all meet customer needs, it is possible to increase the level of customer satisfaction that can increase customer confidence in the services provided give. in addition, officers must always be polite and master the knowledge and skills skills which needed for handle every question or problem customer. in addition, the researcher assumes that the registration counter clerk must: more discipline in carry out tasks, especially those related to health so that things do not happen wants and misunderstandings between patients and healthcare workers. in addition, the health center provide means and infrastructure like corner read for patient which wait and complete akat health in because means and infrastructure very important in increase quality service so that creation satisfaction patient. officer officer counter registration is also not allowed to be favoritism and must show empathy in giving service to patients. this the registration counter officer has a very important role important in service because it is the door or the front line to the patient get service health. the relationship between service quality and satisfaction at the x health center counter for patients bpjs. the results of data analysis show that the significance level is 0.000 < = 0.05 so that h0 rejected and h1 is accepted thus there is a relationship between service quality and satisfaction in health center counter x for bpjs patients. the quality of service is in good category so that satisfaction at the puskesmas x counter for bpjs patients is known to almost all respondents as many as 25 (96%) respondents in the category of very satisfied. according to the opinion of related researchers the difference between the preliminary study data and the results of the research obtained, it is known that the number of bpjs patients who visit puskesmas x in very large numbers and where in the distribution of questionnaires also not to patients who were interviewed when researcher take the initial data so that possible interview results obtained not in accordance with the results of research that has been carried out by researchers. besides that too the service quality of the counter staff is also related to the period of service, because of the good experience owned in give service is wrong one factor in increase patient satisfaction. the patient's perception of the length of work or tenure of the officer, where the patient will satisfied to performance officer counter registration. bpjs participants' satisfaction with the quality of hospital services really needs to be monitored. because if the bpjs participant patient does not get satisfaction, then it is not impossible people which not yet register as participant service bpjs no will want to register himself. so that government programs will be difficult to materialize. in this case review from the government's goal of the bpjs health program above to improve services maximum hospital and can realize the registration of all indonesian people in the program. in repair facility service health very need existence survey patient satisfaction (supartiningsih, 2017). patient satisfaction is one of the standard measures which has set for measure succeed or whether or not service health (singh, 2018). satisfaction patient becomes part integral from activity guarantee quality service health. that is, measuring the level of patient satisfaction must be an activity that cannot be separated from the measurement of the quality https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.75-83 81 of health services. dimensions of patient satisfaction are wrong a very important dimension of the quality of health services. good service quality will cause satisfaction on customer or user service service (bpjs). (wahyuni, 2019). conclusion based on the results of the study, it can be concluded that the service quality of the registration counter in puskesmas x, it is known that almost all respondents as many as 26 (87%) respondents in the good category. almost all of the satisfaction at the puskesmas x counter for bpjs patients is known respondents as many as 25 (83%) respondents in the category of very satisfied. the results of data analysis show that the significance level is 0.000 < = 0.05 so that h0 is rejected and h1 is accepted therefore there is a relationship between service quality and satisfaction at the x health center counter for bpjs patients. it is recommended that health workers can improve health services and be able to assess at a time determine solution best for reach satisfaction patient participant bpjs in counter optimal registration by improving the quality of health services. for respondents to can provide information and knowledge about the quality of health services and patients bpjs users can participate to provide constructive criticism and suggestions for health services at puskesmas x kediri city. for further researchers, it is hoped that can be used as input and basic data for further research and can examine factors other factors such as officer communication factors, work experience, length of service at the registration counter relate with satisfaction in counter public health center x on patient bpjs. references a. aziz, alimul hidayat. 2017. nursing research methods and data analysis techniques. jakarta : publisher. salemba medicine. alamsyah, d. 2019. management service health. yogyakarta : muha medicine. arsepta, a, a. 2018. factors relating to service quality towards patient satisfaction of outpatient commercial insurance participants at syafira hospital. pekanbaru : thesis stikes hangtuah. azwar a. 2020. maintaining the quality of health services application of the solving circle principle problem. jakarta: ray library hope; 2020. burhanuddin, n. 2019. the relationship between health service quality and patient satisfaction hospital sheikh yusuf gowa. journal mkmi, 12 (1), 41–46. http://journal.unhas.ac.id/index.php/mkmi/article/view/552/377. bustami, 2018. guarantor quality service health & accept the stability. field : erlangga. dervish, s. d. 2017. method research. jakarta : egc. ministry of health ri. 2021. health profile of indonesia 2021 : towards a healthy indonesia 2020. jakarta : department health ri. emi ellia astutic, ahmad efrizal amrullah, said madijanto, 2020. connection quality health services with patient satisfaction bpjs outpatient participants. journal health dr. soebandi vol. 8, no. 2 http://journal.stikesdrsoebandi.ac.id/ publisher : lp3m stick dr. soebandi jember. etilidawati, e., & handayani, dy 2018. the relationship of the quality of health service quality with satisfaction patient participant guarantee health national. designing, 15 (3), 142–147. https://doi.org/10.30595/medesigns.v15i3.2078. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.75-83 82 hanna pearl, diana mayasari, eliza techa fattima, cynthia saputri, 2018. relationship quality service with satisfaction patient participant bpjs in room treat stay internal medicine rsud dr. h abdul moeloek. jk unila | volume 2 | number 1 | february 2018 | 31. irawan, handi, 2020. satisfaction customer . jakarta : pt gramedia. references. irawan h. 2018. the principle of customer satisfaction. edition 8. jakarta: elex media komputindo; 2018. kurnia, s., hastuti, w., mudayana, a. a., & nurdhila, a. p. 2018. connection quality services with patient satisfaction bpjs participants at regional general hospitals yogyakarta. 11 (2), 161–168. https://doi.org/10.12928/kesmas.v11i2.7260. marian tonic, ricky wiranata, 2020. connection quality service health with satisfaction of inpatients of bpjs health participants at selasih hospital, pangkalan kerinci, pelalawan regency in 2015. journal of hospital administration and management vol 1, no. 1, june 2020. maulina, l., madjid, ta, & chotimah, i. 2019. patient satisfaction of bpjs participants in unit treat stay public health center cibungbulang regency bogor year 2019. journal student health society, 2 (2), 130–136. minister of health of the republic of indonesia, 2019. the legal basis for the implementation of the bpjs program. muninjaya, 2019. quality management of health services. jakarta: egc; 2019. notoatmodjo, soekidjo. 2017. methodology study health. jakarta : rineka create. nursalam, 2017. draft and application methodology study knowledge nursing. jakarta : salemba medika. nursalam, 2017. satisfaction customer. jakarta : pt gramedia. libraries, 2018. pohan, 2019. factor factor which influence search service health. salemba medicine. 2019. purwanto, s. 2018. satisfaction patient to service home sick, http://permatabunda.co.id/index.php/article-kesehatan/85-kepuasan?format=pdf,. in access day monday 27 april 2018, o'clock 11:35 am. purwoastuti, e. & walyani, e, s. 2020. quality service health & midwifery. yogyakarta: pustakabarupress. patience, 2019. draft satisfaction. grammar indonesia : jakarta. sari, 2020. quality in goetsh and davis. service quality. indonesian gramedia : jakarta. sugiyono, 2017. qualitative research methods and r&d ( revised edition ). bandung : cv. alphabet. thabrany, h. 2020. national health insurance. jakarta : pt rajagrafindo persada. tjiptono, 2020. dimension quality service. print second. surabaya : airlangga universitypress. wijono, d. 2020. management quality service health. theory, strategy and application. volumes.1. print second. surabaya : airlangga university press. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.75-83 83 wolper, laurence. 2020. administration service health principle, practice, submission. jakarta : publisher book medical egc. yustisia v. 2019. guide official get guarantee health from bpjs. edition i. jakarta: visimedia; 2019. zeitham and berries in tjiptono, 2019. aspect aspect satisfaction patient. jakarta : pt grammar. references. https://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.268-278 268 occupational therapy in children with special needs: systematic review ulul azmi asya, huriati, andi adriana amal, arbianingsih uin alauddin makassar, indonesia corresponding author: aulul828@gmail.com abstract background: children with special needs are children who are significantly different from other children, they are physically, psychologically, cognitively and socially obstructed in achieving their goals and potential to the fullest such as autism. purpose: this study aimed to determine the provision of effective occupational therapy in children with special needs. methods: this research uses a quantitative descriptive design. search for research articles in several databases using certain keywords in the period 2015-2019. results: search results obtained 1396 articles using occupational therapy, there were only 10 articles that met the inclusion criteria analyzed using the duffy's research appraisal checklist approach and the 10 articles included in the superior paper category so that it was good for further analysis. based on the results of systematic review shows that effective occupational therapy is given to children with special needs (autism). occupational therapy given is very varied, namely drawing, collage technique, buttoning clothes, remembering pictures, sensory oral motor stimulation. motor skills acquisition training, equine-assisted therapy / eat, sensory integration therapy / sit. conclusion: from the analysis of the article shows that all occupational therapy can help improve both physical and mental development in children with autism so that children with autism can carry out daily activities like children in general and improve their quality of life. occupational therapy found in this review can be used as an intervention in overcoming developmental problems in children with autism due to simple techniques using daily activities. keywords: children with special needs, autism, occupational therapy. received december, 29, 2019; revised february 10, 2019; accepted march 28, 2020 doi: https://doi.org/10.30994/jnp.v3i2.95 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:aulul828@gmail.com https://doi.org/10.30994/jnp.v3i2.95 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.268-278 269 background children with special needs are children who are significantly different from other children, they are both physically, psychologically, cognitively and socially obstructed in achieving their goals and potential optimally such as speech disorders, disability, mental reterdation and emotional disorders. the existence of children with special needs (abk) in indonesia can not be ignored, given the number of those who continue to grow in recent years because it is easier to find children with developmental disorders both physically, intellectually, emotionally, and socially in the middle of society (mangunsong, 2009). the number of children with special needs (abk) in indonesia from year to year continues to increase. the united nations (united nations) estimates that at least 10 percent of school-age children have special needs. the number of school-age children in indonesia with special needs, which is 5-14 years, there are 42.8 million people. if you follow these estimates, it is estimated that there are approximately 4.2 million indonesian children with special needs (desiningrum, 2016). according to the latest data, the number of children with special needs in indonesia has reached 1,544,184 children, with 330,764 children (21.42%) in the age range of 5-18 years. of this amount, only 85,737 children with special needs are attending school, there are still 245,027 children with special needs who have not received education at school, either special schools or inclusive schools. the number of children with special needs in 2011 was recorded at 356,192 children, but those who received new services were 86,645 children and in 2012 only 105,185 children, in 2014 the government targeted at least 50% of children with special needs to be accommodated (desiningrum, 2016). the application in educating children with special needs requires therapy that is useful to help them develop more physically and mentally. the therapy provided is expected to be able to stimulate the physical development of children well in order to be able to do things as done by children their age and be able to change the disruption of communication, social, and behavior development that occurs in children so as to produce positive behavior and be able to become an independent child (irawan, 2016). therapy is used for children with special needs by applying occupational therapy or often called occupational therapy. apart from being used for children with special needs, this therapy can also be given to children / adults who have learning difficulties, motor disabilities (injuries, strokes, traumatic brain injuries), autism, sensory processing disorders, down syndrome, attention deficit hyperactivity disorder (adhd), genetic disorders, asperger's syndrome, speech delay, developmental disorders (cerebal palsy), pervasive developmental disorder (pdd) and those with psychiatric disorders. children with special needs usually have difficulty doing things that other children have no difficulty doing, for example writing or cutting. occupational therapy can be used as an option to work to improve children's physical and mental abilities to participate in activities involving gross and fine motor children so that children can be independent and can be developed and accepted in the community occupational therapy aims to assist children in developing strength and coordination of the brain, and helps children who have problems with fine motor skills (e kosasih, 2012). in this study, researchers want to explain further how the effectiveness of occupational therapy given to children with special needs by using systematic review as an analysis tool. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.268-278 270 objective this study aimed to determine the provision of effective occupational therapy in children with special needs. methods this research uses a quantitative descriptive design with a systematic review approach. the total number of journals obtained totaled 1396 journals, the source of the journals in this study using the google scholar database with 475 journals, emerald with 255 journals, garuda portal with 14 journals, oxford with 515 journals, and ijsr with 155 journals, using keywords: in choosing a research journal, the inclusion criteria are articles published in the last 5 years, 2015-2019, fulltext articles that fit the research objectives, namely occupational therapy in children with special needs, there are issn, doi or volume, and limits of experimental research for children with special needs (autism) then all of the articles were selected according to the inclusion and exclusion criteria and then the relevance was selected using duffy's research appraisal checklist approach. only 10 who met the inclusion criteria were analyzed using the duffy’s research appraisal checklist approach and 10 of the articles included in the superior paper category (205-306). results 1. characteristics of respondents tabel 1. characteristics of respondents occupational therapy age gender pre school school male female draw √ √ √ collage technique √ √ √ put on shirt buttons √ √ √ remembering figs √ √ √ acquisition skills training √ √ √ oral motor sensory √ √ √ sensory integration stimulation √ √ √ √ equine-assisted therapy √ √ 2. occupational therapy obtained a. of the 10 articles found 3 articles that use occupational therapy drawing on children with special needs in this case autistic. b. of the 10 articles obtained 1 article that uses occupational therapy collage techniques in children with special needs in this case autistic. c. of the 10 articles obtained 1 article that uses occupational therapy considering drawing in children with special needs in this case autistic. d. of the 10 articles obtained 1 article that uses occupational therapy buttoning clothes on children with special needs in this case autistic. e. of the 10 articles obtained 1 article that uses occupational therapy acquisition skills training in children with special needs in this case autistic. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.268-278 271 f. of the 10 articles obtained 1 article that uses oral sensory stimulation motor occupational therapy in children with special needs in this case autism. g. of the 10 articles obtained 1 article that uses occupational therapy sensory integration therapy / sit in children with special needs in this case autistic. h. from 10 articles obtained 1 article that uses equine-assisted therapy occupational therapy in children with special needs in this case autistic 3. occupational drawing therapy a. the duration of occupational therapy draws 30 minutes during one therapy b. the procedure for providing occupational therapy is drawing the first step to measure the level of development (motor and independence) before being given occupational therapy. then given occupational therapy drawing and coloring pictures that have been made. furthermore, measurement of the level of development of autistic children is repeated. 4. occupational therapy collage techniques a. the duration of occupational therapy with a collage technique is around 15-20 minutes b. the procedure for providing occupational therapy with a collage technique with stages, first: maintaining the comfort and privacy of children. second: provide intervention by having the child tear the colored paper (origami) and stick it on a predetermined image. the third stage, the evaluation stage by observing the results that have been done by children in terms of sticking colored paper in a predetermined image 5. occupational therapy remembering images a. the duration of occupational therapy is given a picture of 20-25 minutes b. the procedure for providing occupational therapy is to remember the picture, which is to first measure the level of cognitive development before giving occupational therapy. then given occupational therapy given the picture. after that, measuring the level of cognitive development in autistic children is repeated. 6. occupational therapy buttoning a shirt a. the duration of occupational therapy buttoning the shirt is about 15-20 minutes b. the procedure for giving occupational therapy buttoning a shirt is to first measure the level of fine motor development before being given occupational therapy. then the occupational therapy buttoned the shirt with props of one buttoned shirt. after that, the level of fine motor development in the autistic child is measured again. 7. occupational therapy acquisition skills training a. the duration of occupational therapy acquisition skills training is 1 hour 15 minutes in 1 therapy session. the number of sessions given was 36 sessions in a week given 3 sessions. b. the procedure for providing occupational therapy for acquisition skills training is to provide acquisition interventions. after data collection, the test is carried out using the test of gross motor development (tgmd-2) 8. oral motor occupational sensory stimulation therapy a. the duration of oral occupational therapy of motor sensory stimulation is for 20 minutes to 25 minutes. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.268-278 272 b. the procedure for providing oral motor sensory stimulation occupational therapy is to first use the repetitive behavior scale revised (rbs) measurement, then to be given oral motor sensory stimulation occupational therapy. after that the measurement of rbs was performed again on the child. 9. occupational therapy sensory integration therapy / sit a. the duration of occupational therapy for sensory integration therapy / sit is 45 minutes with an additional 15 minutes devoted to providing education to parents. b. the procedure for providing occupational therapy with sensory integration therapy / sit, which is screening first using sensory profile (sp), is used to assess sensory problems. after that the sensory integration therapy / sit occupational therapy intervention was given. then a measurement using the short child occupational profile (scope) is used to compare the two groups in terms of changes in their work performance. 10. equine-assisted therapy occupational therapy a. the duration of equine-assisted therapy is 60-70 minutes b. procedure for providing occupational therapy with equine-assisted therapy with each subject evaluated at 30 days before the start of the eat session using the vineland adaptive behavior scale (vabs) and within 30 days after the end of the eat session using tower of london (tol) measurements discussion 1. draw based on the results of the analysis of occupational therapy drawing proved effective in increasing gross motor skills in children with special needs in this case autistic. based on research results prove that drawing occupational therapy can improve gross motor skills thereby increasing the quality of life in children with autism. the drawing function for autistic children physically (motor) can help the process of controlling the hands and fingers and train the muscles of the hand, sensory help focus visual attention respond to sensory input, communication can help the development of expression and emotion, cognitive can help stimulation mental and problem-solving abilities for example in the selection of color images, and socially and emotionally can help self-confidence to complete tasks and adjust actions and feelings in an image expression (safaruddin, 2015) one of the factors that influence the fine motor skills of children is the pattern of parenting and family, such as the family environment is very important in providing guidance to children in carrying out daily actions so as to be able to express the desires they have in an attempt to heal someone with mental disorders. and can provide an active activity by providing therapy that exercises subtle movements of the hand and integration of basic movements that have been mastered through drawing (sugiono, 2003). 2. collage technique based on the results of the analysis of occupational therapy, collage techniques have proven to be effective in increasing fine motor skills in children with special needs, in this case autism. in this article assessing fine motor skills by observing the activities of journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.268-278 273 children with autism glue members in the picture, taking grain and sticking grain in the image then proceed with the activity of filling the picture. this is in line with research herviani (2017) which says that three-dimensional collage activities can be applied in improving fine motor skills in children with autism. collage according to muharrar and verayanti (2013) is a technique of sticking various elements into one frame so that it produces new works of art. one of the benefits of collage technique is to train a child's motor skills, the activity of collage emphasizes the activities of hand movements, where it is able to train to develop children's fine motor skills. individuals with autism disorder find it easier to obtain information visually. seeing the learning characteristics of autistic children who tend to visual learning, then in the treatment of using three-dimensional collage activities that in the process of demonstrating or modeling directly to students, so students can directly pay attention and afterwards practice according to what children see (nirahma & yuniar, 2012 ). 3. buttoning the shirt based on the results of occupational therapy analysis buttoning the clothes proved effective in increasing gross motor skills in children with special needs in this case autistic. based on the results of research prove that occupational therapy buttoning a shirt can improve fine motor skills thereby increasing the quality of life in children with autism. the above research results are in accordance with research conducted by (marginingsih, 2012) someone who has good fine motor skills will facilitate activities in school, home and daily work such as fishing clothes, holding spoons and forks, the more mature development of the nervous system regulate muscles. the benefits of fine motorbutton buttons training include training the ability of fingers, coordination between hands, eyes and brain (anna, 2011). with the practice of buttoning a child, children can enjoy the exercise and mastery of many skills in a sense of calm, concentration, cooperation, discipline and confidence in oneself (sadisah, 2012). 4. remembering pictures based on the results of occupational therapy analysis, remembering images have proven to be effective in increasing cognitive abilities in children with special needs, in this case autistic. when occupational therapy is given the therapist trains the child's skills in a pleasant atmosphere while inviting children to play so as to arouse interest in practicing. the therapy is given not too long but often and the therapist will stop it if the child looks bored. an autistic child has a characteristic in learning that is easy to understand and remember various things that are touched (visual learner or visual thinking), easy to understand various things that he experiences (hands on learner) therefore the use of assistive devices using visual strategies (assistive devices) visual) can be used in teaching communication skills. this is in agreement with gemah (2004) who said that many children with autism get better results when learning by using visual (vision). journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.268-278 274 visual learning makes it easy for children with autism to be able to concentrate and understand things, one of which is by seeing concrete objects, color photos, images or symbols. one visual strategy that can be used in bridging the communication limitations of autistic children is with occupational therapy considering images. remembering images can also be a method used in helping non-verbal autistic children communicate. remembering the image emphasizes the understanding and communication skills of children with autism through images. the images used are simple images, designed to follow general standards, do not differentiate between sexes, one image can be used for several functions and is easy to understand. the use of occupational therapy, remembering pictures as a method or visual strategy is expected to help children with autistic verbal communication so that they can communicate and even help them to speak or use sound. 5. acquisition skills training based on the results of occupational therapy analysis acquisition skills training proved to be effective in increasing gross motor skills in children with special needs in this case autistic. based on research results prove that occupational therapy acquisition skills training can improve gross motor skills thereby increasing the quality of life in children with autism. acquisition training is a procedure in training motor skills, motor development and motor control. the process that allows a child to solve movement problems to complete daily functional tasks in the fields of self care, school, play, mobility and communication. this research is supported by the effects of movement education programs by using movement patterns to develop basic motor skills in children, (waffa abd elhafez abd elmaksoud ghaly, 2010). acquisition skills training amounted to 36 sessions consisting of various activities namely balance activities, jumping and prancing, hand and eye coordination, core strength, general strength, planning and sensory motor. 6. sensory motor oral stimulation based on the results of the analysis of occupational therapy sensory motor oral stimulation proved effective in self-biting behavior in autistic children. based on research results prove that occupational therapy sensory motor oral stimulation can stimulate oral motor in children with autism so as to prevent autistic children from biting themselves in expressing their emotions. sensory oral motor stimulation is a technique used to increase stimulation of the tongue and lips to prevent children from biting themselves. biting yourself is a way for children with autism to get a stimulus and express their emotions. as we all know biting is a way of self-seeking stimulus and expressing emotions for children with autism. this strange behavior at times can be self-injured and repetitive. there are various other behavioral problems that can arise over time such as irritation, anger and tantrums. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.268-278 275 this is in accordance with research melisa (2009) who evaluated "the effect of sensory integration interventions on reducing maladaptive behavior in high school students with autism. he chose a 16 year old student. sensory integration interventions were given 20 to 60 minutes, 3 times a week at 2 week interventions the results show that there is a reduction in maladaptive behavior through sensory integration interventions. 7. sensory integration therapy / sit sensory integration therapy / sit is a type of therapy that prioritizes the organization of sensations. the purpose of this therapy is so that the brain can integrate information that comes from the senses so that the body can act and respond in accordance with the environmental situation at hand and with a purposeful manner. in sit therapy in addition to direct intervention for children, therapists also provide strategies that target the sensory needs of children for caregivers or for the parents by providing information about approaches to interact with children. sensory integration therapy is widely used for the management of children with developmental, learning, and behavior disorders as in the research of rusiana states that the application of the sensory integration approach can minimize hyperactive behavior in autistic children in slb putra mandiri surabaya (rusiana.e, 2013). as well as fitri's research (2018) which analyzes the integration sensory therapy carried out in single children to see the function of the five senses (sight, smell, hearing, taste, and touch) through the involvement of parents and the environment states that there are changes in the development of independence salama following sensory integration therapy . sensory integration therapy as a form of occupation and treatment in children with certain conditions is often used as a way to make improvements, both to repair developmental disorders or learning disorders, social interaction disorders, and other behaviors. the purpose of holding sensory integration therapy is to restore the function of the five senses (sight, smell, hearing, taste, touch) and proprioceptive and vestibular. with the return of the five senses and the proprioceptive and vestibular functions, children can conduct self-development activities independently and reduce their sense of dependence on others (idai (indonesian pediatrician association), 2011). 8. eat / equine-assisted therapy eat / equine-assisted therapy or more commonly called therapeutic riding is a therapy specifically for children with special needs (abk) who use horses in therapeutic activities to bring about improvements in cognitive, physical, emotional, and social well being someone with disabilities (pathintl) .org) at this eat children are encouraged to follow instructions given by the therapist and to interact with the horse both verbally and not verbally. the usual activities carried out every one therapy session are usually divided into three parts; pre on horse, on horse, post on horse. before riding or riding a horse the child is guided for grooming or journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.268-278 276 cleaning and preparing the horse. in this section children are expected to form strong bonding with their horses. riding programs are known to be able to build self-confidence, self-esteem, and selfawareness when someone with disabilities has the motivation to ride and they have a feeling of pride in the activities carried out. in therapeutic riding therapy, horses help abk physically and mentally by 'challenging' them to achieve something that seems impossible for someone with a disability to do. this is one reason why this therapy can build a child's confidence. apart from horses, other pets also make children dare to start new relationships, increasing the desire to join a group. in addition, it is also known from a study that children who have pets are better at introducing themselves to others, providing better information, and giving more response if invited to interact. the relationship that occurs between children and pets can foster empathy and sympathy in children (etika, 2017). this occupational therapy is very helpful in developing independence, as well as increasing the focus or concentration of children with autism in learning. the goal of occupational therapy for children with autism spectrum disorders is to improve their quality of life, both at home and at school. conslusion based on the results of systematic review shows that effective occupational therapy is given to children with special needs (autism). occupational therapy given is very varied, namely drawing, collage technique, buttoning clothes, remembering pictures, sensory oral motor stimulation. motor skills acquisition training, equine-assisted therapy / eat, sensory integration therapy / sit. from the analysis of the article shows all occupational therapy can help improve both physical and mental development in children with autism so that children with autism can carry out daily activities like children in general and improve their quality of life occupational therapy found in this review can be used as an intervention in overcoming developmental problems in children with autism because the technique is simple using daily activities. suggestion based on the results of the systematic review that has been done about occupational therapy in children with special needs this therapy should be used as therapy to improve the physical and mental abilities of children with autism. it is also necessary to do training and guidance on occupational therapy for child nurses to have new skills to develop and socialize to the community. references anna, lusia kus. (2011). latihan motorik halus dengan mengancingkan baju. di unduh pada tanggal 13 agustus 2019 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.268-278 277 http://health.kompas.com/read/2011/05/02/10070730/latih.motorik.halus.dengan .mengancingkan.baju.. borgil, marta, dkk. (2015). effectiveness of a standardized equine-assisted therapy program for children with autism spectrum disorder. usa: springer science+business media new york. desiningrum, dinni ratri. psikologi anak berkebutuhan khusus. yogyakarta: psikosain. (2016). etika, nimas mita. (2017). terapi anak autismen dengan hewan peliharaan. diunduh pada tanggal 14 agustus 2019 https://hellosehat.com/pusat-kesehatan/autisme/terapianak-autisme-dengan-hewan-peliharaan/. evi & tri riska. (2015).terapi okupasi perkembangan motorik halus anak autisme. jurnal ipteks terapan. sekolah tinggi ilmu kesehatan fort de kock. herviani, vivi kurnia. (2017).kegiatan kolase tiga dimensi terhadap kemampuan motorik halus anak autis di tk. universitas negeri surabaya (unesa): jurnal pendidikan khusus. idai (ikatan dokter anak indonesia). (2011) pedoman pelayanan medis ikatan dokter anak indonesia (1st ed.). indonesia: badan penerbit ikatan dokter anak indonesia. https://www.academia.edu/9082974/ikatan_dokter_an ak_indonesia_2011_pedoman_pelayanan_medis_ik atan_dokter_anak_indonesia_edisi_ii .2011. iqbal, dkk. (2018). efektivitas pemberian terapi okupasi dalam meningkatkan kemandirian makan pada anak usia sekolah dengan autis. universitas riau: jurnal keperawatan sriwijaya. irawan, ria dewi. (2016).terapi okupasi (occupational therapy) untuk anak berkebutuhan khusus (down syndrome) (studi kasus pada anak usia 5-6 tahun di balai pengembangan pendidikan khusus semarang. semarang: unnes. jay, dkk. (2015). effectiveness of sensory motor oral stimulation for reducing the self biting behavior in children with autism. jkkmmrf college of occupational therapy, komarapalayan: ijsr. jordiono, dkk. (2016). pengaruh terapi okupasi menggambar terhadap kemampuan motorik halus anak autis di slb negeri semarang. jurnal ilmu keperawatan stikes telogerejo semarang. komariah, fitri. (2018).program terapi sensori integrasi bagi anak tunagrahita di yayasan miftahul qulub. jurnal of disability studies. vol. v, no. 1, januari-juni 2018, h. 45-72. uin sayarif hidayatullah. kosasih, e. (2012).cara bijak memahami anak berkebutuhan khusus. bandung: yrama widya. nirahma, choirunisa. (2012).metode dukungan visual pada pembelajaran anak dengan autisme. jurnal psikologi klinis dan kesehatan mental. vol 1, no. 02, juni 20. mangunsong. (2009). f. psikologi dan pendidikan anak berkebutuhan khusus jilid i. jakarta: lembaga pengembangan sarana pengukuran dan pendidikan psikologi (lpsp3) kampus baru ui, depok. muharrar, syakir & sri verayanti. (2013).kreasi kolase, montase, mozaik sederhana. jakarta: esensi. http://health.kompas.com/read/2011/05/02/10070730/latih.motorik.halus.dengan.mengancingkan.baju http://health.kompas.com/read/2011/05/02/10070730/latih.motorik.halus.dengan.mengancingkan.baju https://hellosehat.com/pusat-kesehatan/autisme/terapi-anak-autisme-dengan-hewan-peliharaan/ https://hellosehat.com/pusat-kesehatan/autisme/terapi-anak-autisme-dengan-hewan-peliharaan/ https://www.academia.edu/9082974/ikatan_dokter_an%20ak_indonesia_2011_pedoman_pelayanan_medis_ik%20atan_dokter_anak_indonesia_edisi_ii%20.2011 https://www.academia.edu/9082974/ikatan_dokter_an%20ak_indonesia_2011_pedoman_pelayanan_medis_ik%20atan_dokter_anak_indonesia_edisi_ii%20.2011 https://www.academia.edu/9082974/ikatan_dokter_an%20ak_indonesia_2011_pedoman_pelayanan_medis_ik%20atan_dokter_anak_indonesia_edisi_ii%20.2011 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.268-278 278 r. renuchitra, dkk. (2016).effect of motor skils acquisition training on gross motor skilis of autistic children. india: research scholar, department of rehabilitation sciences, hollycross collage. renetal. watling, jean dietz. (2007). immediate effect of ayres’s sensory integration– based occupational therapy intervention on children with autism spectrum disorders. the american journal of occupational therapy journal volume 61, number 5. rusiana.e. (2013). pendekatan sensori integrasi untuk meminimalisasi perilaku hiperaktif pada anak autis. jurnal pendidikan khusus, 3, 1–10. safaruddin, muhammad sigid. (2015). terapi menggambar buat anak spesial. diunduh pada tanggal 21 agustus 2019 https://www.kompasiana.com/sigid/5500b0d8813311491bfa7cb6/terapimenggambar-buat-anak-special-autis wafaa abd elhafez abd elmaksoud ghaly. (2010).the effect of movement education program by using movement pattern to develop fundamental motor skills for children pre-school. world journal of sport sciences 3. https://www.kompasiana.com/sigid/5500b0d8813311491bfa7cb6/terapi-menggambar-buat-anak-special-autis https://www.kompasiana.com/sigid/5500b0d8813311491bfa7cb6/terapi-menggambar-buat-anak-special-autis journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.137-144 137 the effectiveness of mirror therapy in stroke patients: a systematic review zahrotul jannah1*, yurike septianingrum2, raden khairiyatul afiyah3, imamatul faizah4 1 master of applied nursing, faculty of nursing and midwifery, nahdlatul ulama university of surabaya 2,3,4 department of nursing and midwifery, nahdlatul ulama university of surabaya *corresponding author: 1130016076@student.unusa.ac.id abstract background: stroke is a global problem and the second cause of death in the world. purpose: to find out the effectiveness of giving mirror therapy in stroke patients. methods: there are five databases used, namely science direct, sage journal, emerald, proquest and pubmed to search for mirror therapy and post-strokes. the inclusion criteria used are for publications for the last 5 years from 2017 to 2022, full-text articles and in english, according to the title, and rct research or experimental studies. results: of the total 7 articles submitted for this systematic review after quality assessment, this included 3 randomized controlled trials and 4 experimental studies. all muscle strength studies in post-stroke patients after being given mirror interventions experienced an increase in muscles in parts of the body that experienced hemiperation, thereby increasing independence in patients. from the results of all studies, it was found that the optimal time in starting the therapy is in the chronic stage, and the therapeutic dose is given with the same intensity (at least five sessions per week) and duration (at least 30 minutes to 90 minutes). conclusion: mirror therapy proved to be an effective and viable approach to rehabilitate poststroke survivors in acute, sub-acute, and chronic phases of the stroke, despite the long-term effects. keywords: humans, incidence, mirror therapy received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.307 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ https://meshb.nlm.nih.gov/record/ui?ui=d000088762 https://doi.org/10.30994/jnp.v6i2.368 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.137-144 138 background stroke is a non-communicable disease which is one of the problems around the world. (kosasih, solehati, dan purba 2018) the prevalence of stroke in indonesia increases with age, stroke cases the highest diagnosed were aged 75 years and over (50.2%) and the lowest was in the age group 15-24 years (0.6%) sex was more male (11.0%) compared to female (10.9%). based on the place of residence, the prevalence of stroke in urban areas is higher (12.6%) compared to rural areas (8.8%). (riskesdas 2018). one of the problems of a physically prominent stoke is weakness, even paralysis of the limbs. this condition causes the patient stroke to have limitations in performing its functions as in daily activities. stroke patients experience a decrease in doing daily activities independently compared to someone of the same age who did not have a stroke (kosasih, solehati, dan purba 2018). interventions for healing that can be done in stroke patients in addition to medical therapy, namely mirror therapy rehabilitation therapy. mirror therapy is therapy rehabilitation which depends on and practices the patient's motor imagery/imagination, where the mirror will provide visual stimulation to the brain (cerebral motor nerves i.e. ipsilateral or contralateral to hemiparesis of limb movement. (usman 2019). the purpose of this systematic review is to determine the effectiveness mirror therapy in stroke patients. methods the method used in the analysis of this evidence-based practice is a systematic review by selecting articles using the picos guide. article searches are carried out on electronic databases including sage journal, science direct, emerald, proquest and pubmed. selected article inclusion criteria 1) published in 2017-2022 2) full-text3) article in english 4) according to the title 5) rct research or experimental studies. keywords that are used is "stroke patient" and "mirror therapy” and “motor recovery” and “rct research” or “studies experiment” these keywords help in searching the database by using bolemians to maximize retrieval of the most relevant articles by using and displaying through the prisma diagram. table 1 search terms used to identify relevant articles picos related keywords population stroke patient intervention mirror therapy comparison outcome motorcycle recovery study design rct research or studies experiment results an initial literature search yielded 10,086 articles (1 from pubmed, 205 from sage journal, 300 from science direct, 9,579 from proquest and 1 from emeralds). after reviewing in terms of research, the selected article is 5 the last year (2017-2022) totaled 399 articles were selected there are 703 articles that must be excluded because it does not meet the criteria. types of articles included article type full-text research articles there are 288 selected while those who were issued there are 415. the suitability of the title of the selected article is 36, the choice of the full-text is available selected 17 articles and rct https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.137-144 139 research or experimental studies there are 7 articles for review, as shown in figure 1. figure 1: search flowchart using the prisma method. the studies in this systematic review are heterogeneous, 7 articles using a control group and intervention group in the study. a number of including articles also use interventions mirror therapy which has combined. the results of the 7 articles showed the effectiveness of mirror therapy carried out with different concepts and different combinations. quality assessment. this systematic review uses guidelines to analyze quality reporting among selected studies. the guidelines used are with critical appraisal skills program tools/casp. casp instruments include a randomized controlled trial checklistas many as 13 questions include questions 1–6 relate to the internal validity of the study, 7–8 relate to the validity of the results and questions 9-13 relate to the relevance of practice/external validity (casp, 2017). in a quasi-experimental design the quality of the experiment was assessed using the jbi instrument critical appraisal checklist for quasi-experimental studies. this instrument contains 9 questions related to a quasi-experimental study with the aim of this assessment is to assess the methodological quality of a study and to determine the extent to which a study has addressed possible bias in its design, behavior and analysis. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.137-144 140 the results of this assessment can then be used to inform the synthesis and interpretation of research results (institute 2016). bias risk the risk of bias in this systematic review is carried out by determining data extraction including the similarity of studies both in terms of study design, objectives research as well as outcome resulting from the included studies and assessing the quality of the studies reviewed later. data extraction for this study, a data extraction tool was designed to guide information from the records in accordance with the purpose of the study. extracted data on each inclusive study includes last 5 years publications from 2017 to 2022, full-text articles in english, according to the title, and research rct or experimental study. furthermore, the data that will be extracted in the section results are: publication of the last 5 years from 2017 to 2022, full-text article in english, as appropriate, and rct research or experimental studies. synthesis of results data synthesis was carried out qualitatively by the author and 3 authors companion by discussing to analyze the selected study. synthesis the results are shown in table 2. table 2 risk assessment of bias using the jbi critical assessment checklist no author, year critical appraisal rct the jbi critical appraisal checklist (the joanna briggs institute, 2017) % quality evaluation 1 (hung et al. 2022) 85% (11/13) strong 2 (wei et al. 2022) 50% (7/13) low 3 (miclaus et al. 2021) 66.6% (6/9) currently 4 (palomo-carrión et al. 2021) 66.6% (6/9) currently 5 (noureen et al. 2022) 66.6% (6/9) currently 6 (hsieh et al. 2020) 100% (9/9) strong 7 (gandhi et al. 2020) 85% (11/13) strong https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.137-144 141 table 3: characteristics of included-studies author(s) study design participants' profile details of the intervention outcome type session length frequency intervention length (hung et al. 2022) rct 37 chronic spastic hemiplegia stroke patients treatment combined robot assisted training, mirror therapy, and active control treatment 75 min 3 days/ week 8 weeks the findings of this study showed that each treatment (rt, mt, and ac) was effective in treating motor function after bont-a in stroke patients who also had ue spasticity. this study demonstrated that the three combined treatments induced beneficial effects on motorcycle recovery and spasticity as assessed by the fma and mas at post-treatment and follow-up. (wei et al. 2022) rct 32 strokes patients group (vrmt) and group (ravrmt) 20 min/day 1 day 4 weeks rat and vrmt are both highly effective for treatment in improving upper limb motor cycle dysfunction in stroke patients by activating brain networks associated with movement and circuitry. (miclaus et al. 2021) study experiment 59 patients post stroke reality therapy virtual (vr) and mirror therapy (mt) exercises physiotherapy classic and rehabilitation 70 min 2 weeks the mann-whitney results show that vr and mt as therapeutic interventions have good results better than standard physiotherapy in range of motion (p < 0.05, cohen's d 0.693), muscle strength (p < 0.05, cohen's d 0.924, lower limb function (p < 0.05, cohen's d 0.984) and postural balance (p < 0.05, cohen's d 0.936). our study shows that mt-associated vr therapy can be successfully replaced classical physiotherapy in lower extremity rehabilitation after stroke. (palomocarrión et al. 2021) study experiment patients stroke hemiplegia (number of respondents note mentioned) mirror therapy and observation therapy 1 hour/day 5 sessions/ week 4 weeks increased activity of the muscles of the affected hand and increased grip strength. (noureen et al. 2022) study experiment 36 stroke patients routine physical therapy and mirror therapy 35 min/day 5 days/week 4 weeks mirror therapy combined with routine physical therapy is a useful approach and shows better results in reducing phantom limb pain and in psychosocial adjustment to prostheses than routine physical therapy alone. (hsieh et al. 2020) study experiment 20 strokes sub acute mirror therapy and observation therapy 60 min/day 5 days/week 3 weeks the mirror therapy group improvement in fma among the other groups https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.137-144 142 author(s) study design participants' profile details of the intervention outcome type session length frequency intervention length (gandhi et al. 2020) rct stroke chronic (number of respondents note mentioned) mirror therapy and rehabilitation 20-90 min/day 3-5 sessions/ week 4 weeks the role of mirror therapy in acute and chronic stroke rehabilitation (which suggest a better functional prognosis), its long-term effects, and improved quality of life discussion optimal time to start therapy the trend in studies shows that mt appears to be beneficial for participants with chronic stroke, but more evidence is needed for this. no conclusions can be drawn to support effectiveness mt for patients in the acute and sub-acute stages. seven studies (hung et al. 2022); (wei et al. 2022); (miclaus et al. 2021); (palomo-carrión et al. 2021) (noureen et al. 2022) (hsieh et al. 2020) (gandhi et al. 2020) in this review have included participants in the chronic stage and acute but the majority of them consisted of one lowquality rct (wei et al. 2022) and 3 experimental studies (miclaus et al. 2021); (palomocarrión et al. 2021) (noureen et al. 2022) and two high-quality rcts (hung et al. 2022) and (gandhi et al. 2020) and 1 high-quality experimental study (hsieh et al. 2020), furthermore, all case studies used a combination of interventions. remember the lack of high-quality evidence, it is difficult to conclude that the chronic stage is the optimal time to use this approach. as well as, only two studies involved participants in the acute stage, and recovery motor skills after treatment are often confused with spontaneous recovery in this group. high-quality rct (hung et al. 2022) and (gandhi et al. 2020) using mt with participants in the acute stage. both give a clear description of their research protocol and have provided adequate follow-up. nonetheless, both of them show variations key in the types of participants recruited. therapeutic dose and degree of damage due to the heterogeneity of the studies, no definite conclusions can be drawn regarding the optimal therapeutic dose. however, a conclusion can be drawn about some possible recommendations for further research the results of all studies showed that the therapeutic dose was given with an intensity of the same (at least five sessions per week) and duration (at least 30 minutes up to 90 minutes). all high-quality rcts included in this review have therapy. confused by variation in studies because all three rcts high quality (hsieh et al. 2020), (gandhi et al. 2020), (hung et al. 2022) involved participants in three different stages of stroke (i.e., acute, subacute, and chronic). based on research conducted by (hung et al. 2022) where the number of samples is 37 people and carried out 8 weeks with a frequency of every 3 days and the implementation time is 75 minutes. research result demonstrated that rat and vrmt are both highly effective for the treatment of improve upper extremity motor dysfunction in stroke patients with activated brain networks associated with movement and circuitry. this is too relevant to the study (wei et al. 2022) the number of samples is 32 people carried out for 4 weeks, with a frequency of once a day and the implementation time is about 20 minutes. the results showed that ravrmt can improve upper extremity motor dysfunction after stroke better and explored its central mechanism using fmri. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.137-144 143 based on the research that has been done (miclaus et al. 2021) where the number of samples is 59 people which will be carried out for 2 weeks with an execution time is 70 minutes. the results showed that vr. therapy associated with mt can successfully replace classical physiotherapy in lower extremity rehabilitation after stroke. it is also relevant to research (palomo-carrión et al. 2021) the number of samples according to the criteria inclusion of children aged 6-12 years, implementation of interventions carried out for four weeks (1 hour per/day; 5 sessions per/week). the results showed that there was an increase in the activity of the hand muscles which impact and increased grip strength. based on research conducted by (noureen et al. 2022) samples were obtained from 36 people, with 4 weeks of implementation carried out in 35 minutes. the results of the study found that mirror therapy combined with routine physical therapy showed better results in reducing phantom limb pain and in psychosocial adjustment to prostheses rather than routine physical therapy alone. this is relevant to research (hsieh et al. 2020) the number of samples of 20 people was carried out for 3 weeks with 60 minutes execution time. the results of this study were obtained that the mirror therapy group resulted in the least increase in amf in among other groups. other relevant research by (gandhi et al. 2020) with an inclusion sample of acute and chronic stroke patients whose implementation done 4 weeks with a frequency of 3-5 sessions per week with a time of 20-90 minutes. it was found that the role of mirror therapy in acute stroke rehabilitation and chronic conditions show a better functional prognosis), long-term effects length, and improved quality of life. muscle strength in post-stroke patients before being given mirror intervention therapy based on the articles reviewed in this review (hung et al. 2022); (wei et al. 2022); (miclaus et al. 2021); (palomo-carrión et al. 2021); (noureen et al. 2022); (hsieh et al. 2020); (gandhi et al. 2020), reported muscle strength in post-stroke patients before being given mirror therapy intervention post-stroke patient's muscle strength is still experiencing hemiparesis. meanwhile muscle strength in post-stroke patients after being given a mirror therapy intervention has increased muscle in the part of the body that has hemiperasis thereby increasing the patient's independence (hung et al. 2022); (wei et al. 2022); (miclaus et al. 2021); (palomo-carrión et al. 2021); (noureen et al. 2022); (hsieh et al. 2020); (gandhi et al. 2020), thus mirror therapy can increase muscle strength in poststroke patients. conclusion this review provides evidence that mirror therapy is effective to increase muscle strength in post-stroke patients. this review has implications in clinical practice, especially in patients who experience post-stroke. mirror therapy can be an easy and effective option to improve muscle strength in post-stroke patients. through this study, intervention with mirror therapy in the practice of rehabilitation therapy of stroke patients that targets the presence of muscle strength. it is hoped that these results will be useful in establishing mirror therapy as an intervention program. the intervention in this article can be a reference for other researchers to be researched further, and as an additional literature in making systematic reviews for students. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.137-144 144 references gandhi, dorcas b.c., albert sterba, himani khatter, dan jeyaraj d. pandian. 2020. “mirror therapy in stroke rehabilitation: current perspectives.” therapeutics and clinical risk management 16: 75–85. https://doi.org/10.2147/tcrm.s206883. hsieh, yu wei, yu hsuan lin, jun ding zhu, ching yi wu, yun ping lin, dan chih chi chen. 2020. “treatment effects of upper limb action observation therapy and mirror therapy on rehabilitation outcomes after subacute stroke: a pilot study.” behavioural neurology 2020. https://doi.org/10.1155/2020/6250524. hung, jen wen, chu ling yen, ku chou chang, wei chi chiang, i. ching chuang, ya ping pong, wen chi wu, dan ching yi wu. 2022. “a pilot randomized controlled trial of botulinum toxin treatment combined with robot-assisted therapy, mirror therapy, or active control treatment in patients with spasticity following stroke.” toxins 14 (6). https://doi.org/10.3390/toxins14060415. institute, joanna briggs. 2016. “critical appraisal tools for use in jbi systematic reviews checklist for prevalence studies.” adelaide, sa: joanna briggs institute. kosasih, cecep eli, tetti solehati, dan chandra isabela purba. 2018. “pengaruh edukasi kesehatan terhadap pengetahuan pasien stroke dan keluarga: peran, dukungan, dan persiapan perawatan pasien stroke di rumah.” media kesehatan politeknik kesehatan makassar 13 (2): 8. https://doi.org/10.32382/medkes.v13i2.662. miclaus, roxana steliana, nadinne roman, ramona henter, dan silviu caloian. 2021. “lower extremity rehabilitation in patients with post-stroke sequelae through virtual reality associated with mirror therapy.” international journal of environmental research and public health 18 (5): 1–14. https://doi.org/10.3390/ijerph18052654. noureen, ayesha, ashfaq ahmad, arooj fatima, kashif siddique, dan zain ul abbas. 2022. “effects of routine physical therapy with and without mirror therapy on phantom limb pain and psychosocial adjustment to amputation among prosthesis users.” physiotherapy quarterly 30 (2): 8–14. https://doi.org/10.5114/pq.2021.108680. palomo-carrión, rocío, juan carlos zuil-escobar, myriam cabrera-guerra, paloma barredamartínez, dan carmen belén martínez-cepa. 2021. “mirror therapy and action observation therapy to increase the affected upper limb functionality in children with hemiplegia: a randomized controlled trial protocol.” international journal of environmental research and public health 18 (3): 1–10. https://doi.org/10.3390/ijerph18031051. riskesdas. 2018. “laporan riskesdas 2018 kementrian kesehatan republik indonesia.” laporan nasional riskesdas 2018. http://www.yankes.kemkes.go.id/assets/downloads/pmk no. 57 tahun 2013 tentang ptrm.pdf. usman, andi mayasari. 2019. “efektifitas pemberian mirror therapy pada klien post stroke : a literature review.” efektifitas pemberian mirror therapy pada klien post stroke: a literature review 4 (2): 52–56. wei, dong, xu yun hua, mou xiong zheng, jia jia wu, dan jian guang xu. 2022. “effectiveness of robot-assisted virtual reality mirror therapy for upper limb motor dysfunction after stroke: study protocol for a single-center randomized controlled clinical trial.” bmc neurology 22 (1): 307. https://doi.org/10.1186/s12883-022-028366. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.43-52 43 the analysis of verbal abuse within socialization ability of preschoolers in playproup al fattah malang prima dewi kusumawati1*, nadya risky aini nasution 2 1,2 department of nursing, institut ilmu kesehatan strada indonesia, indonesia *corresponding author: primadewiku17@gmail.com abstract background: preschoolers are children with a phase of developing and learning new things quickly. the development phase begins with interacting with family and socializing with playmates in the social environment. the social environment can affect the development process of pre-school age children, for example the occurrence of verbal abuse in the social environment that has an impact on children's social development. purpose: the purpose of this study was to determine the relationship between verbal abuse and the socialization ability of preschool children. methods: the research design was cross sectional study and the sampling method was carried out by the total sampling method. the sample in this study was all 50 students of playgroup al fattah malang. data analysis used spss program with chi square test. results: it was found that 46% of children received verbal abuse in the low category, 38% in the medium category and 16% received verbal abuse in the high category and 76% of children had good socialization skills and 24% of children had poor socialization skills and through chi square test analysis with in the spss program, the value of asymptotic significance (2-sided) = 0.001 < 0.05, it means that h1 is accepted, or it is clear that there is a relationship between verbal abuse and the socialization skills of preschoolers in playgroup al fattah malang. conclusion: it can be concluded that verbal abuse can result in barriers and disruptions to the socialization development of preschool children. parents and teachers are expected to provide the right parenting to improve socialization skills in preschool age children. keywords: preschoolers, socialization ability, verbal abuse received august 10, 2022; revised september 12, 2022; accepted october 3, 2022 doi: https://doi.org/10.30994/jnp.v6i1.290 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ https://doi.org/10.30994/jnp.v6i1.290 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.43-52 44 background verbal harassment or verbal abuse is defined as violence in the form of yelling, refusing children, insulting, humiliating children, cursing and frightening by using inappropriate words. verbal abuse can occur when children ask for attention, cry and don't want to be silent, children who continue to talk so that parents will verbally abuse their children (lestari and titik (2015) in indrayati (2019). preschool age children are a period when children are vulnerable to behaving inappropriately). selfish, stubborn, resisting and rebelling from the rules given by parents with the aim of gaining freedom and curiosity, this situation can make parents feel that their children are difficult to manage and consciously or unconsciously abuse their children. there are still many who do not know that children have rights regulated in the law of the republic of indonesia number 35 of 2014 concerning child protection. law of the republic of indonesia number 35 of 2014 article 1 paragraph 15a states that violence is any act against children that results in misery or suffering physically, psychologically, sexually, and/or neglect, including is a threat to commit acts, coercion, or deprivation of liberty against the law. children have the right to survival, growth and development (indrayati, 2019). data from the agency for women's empowerment, child protection and family planning shows that the number of women and children who became violent in 2014 was 104 victims; in 2015 it increased to 111 victims. in 2016, there were 27 cases; all of the victims were children. the incidence of violence against children in indonesia continues to increase, until mid-march 2018, the ministry of women's empowerment and child protection (pppa) has received around 1,900 reports (saiful munir, 2018). data from the national commission for child protection (komnas pa) shows an increase in violence against children during the covid-19 period, both verbal and physical. based on the facts found by komnas pa, mentioning physical or mental violence is 11%, while verbal violence is 62% (listyarti, 2020) the results of a preliminary study in 2022 conducted at ta al-fattah in the sukun malang area, it was observed that there were some children who rarely played with friends, were shy to greet friends, were more often alone, were less able to collaborate as many as 15 children and from the results of interviews with the teachers who teach at playgroup al fattah say that the child lives in a family environment that takes care of their child of their own free will including the use of harsh words to punish the child, without regard to the impact that will result from the upbringing. based on the results above, violence against children is very common. violence against children has not received special attention from the government and the health team because everything parents do to their children is a matter of their own family. new problems will arise when children experience the effects of violence both physically and emotionally. playground is one of the places to train children's socialization skills after family, because by playing children can interact and learn to work together to establish a relationship so that the child's personality will emerge by itself, and the child's personality is different sometimes children are happy to be friends, cheerful, and friendly and there are also children who are shy, quiet, and careful. parents should respect their child's personality, the goal is to have a successful interaction and make the interaction as comfortable as possible. the development of habits or culture in our society is actually not appropriate in educating children, namely by often speaking dirty, cursing, and yelling at children with inappropriate and threatening words. this phenomenon often occurs in the family, school and children's playground. this can interfere with and hinder the process of child growth and development, especially on emotional development which affects the child's adjustment, both personally and socially. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.43-52 45 a gentle attitude towards children by still providing certain boundaries or being firm which does not mean being fierce and always yelling at children when they make mistakes. that way the child will feel protected and appreciated, so that the child will listen to the words of the parents and obey them. as a parent, you should take preventive action before your child makes a mistake, so that parents can minimize verbal abuse of their child. efforts made by parents to prevent acts of violence against children in the family include solving and discussing any problems that arise in the family, setting a good example for children and being calm in dealing with child delinquency (syamsu, 2018). with the support of theory, observation and research conducted, the authors are interested in digging deeper into analyzing verbal abuse with socialization skills in preschool children. objective the study was to determine the relationship between verbal abuse and the socialization ability of preschool children. methods the research design used in this study used an analytic cross sectional research design. cross sectional research design is a research using determination of exposure or cause and result or effect simultaneously on each object of research. the cross-sectional research design is appropriate to use to explain the relationship between phenomena at one point in time (mubarok, 2021). the design of this study was used to determine the effect of verbal abuse on the socialization ability of preschool-aged children, where the relationship between verbal abuse (independent variable) and the socialization ability of preschool-aged children (dependent variable) was seen and measured once at the same time. results this chapter will describe the results of sampling in august 2022 regarding the analysis of verbal abuse with the socialization ability of preschool age children in playgroup al fattah malang. 1. frequency distribution of respondents' gender in playgroup al fattah. gender frequency percentage male 25 50.0 female 25 50.0 total 50 100.0 source: 2022 frequency data from the results of table 1, it is found that the ratio between men and women is equal, namely 25 men (50%) and 25 women(50%). 2. frequency distribution of respondents' age in playgroup al fattah. age frequency percentage 4 years 5 10.0 5 years 14 28.0 6 years 31 62.0 total 50 100.0 source: 2022 frequency data from the results of table 2, it is found that most of the respondents in playgroup al fattah are 6 years old (62%). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.43-52 46 3. distribution of respondent characteristics based on verbal abuse in playgroup al fattah. verbal abuse frequency percentage light 23 46.0 mild 19 38.0 heavy 8 16.0 total 50 100.0 source: 2022 frequency data from the results of table 3, it is found that most of the respondents in ta al fattah experienced mild verbal abuse as many as 23 respondents (46%). 4. frequency distribution of respondents based on socialization ability in playgroup al fattah. socialization ability frequency percentage good 38 76.0 less 12 24.0 total 50 100.0 source: 2022 frequency data from the results of table 4, it is found that most of the respondents in playgroup al fattah have good socialization skills as many as 38 respondents (76%). 5. cross table of verbal abuse supervision with socialization ability in playgroup al fattah. verbal abuse socialization ability total less good n % n % n % light 0 0% 23 46% 23 46% mild 5 10% 14 28% 19 38% heavy 6 12% 2 4% 8 16% total 11 22% 39 78% 50 100% source: 2022 frequency data from the results of cross-table 5, it is found that most of the respondents in playgroup al fattah who experienced mild verbal abuse and had good socialization skills were 23 respondents (46%). 6. analysis of the relationship of verbal abuse with the socialization ability of preschool age children in playgroup al fattah. chi-square test value df asymptotic significance (2-sided) pearson chi-square 16.334a 2 .000 likelihood ratio 15.983 2 .000 linear-by-linear association 14.995 1 .000 n of valid cases 50 cells (33.3%) have expected count less than 5. the minimum expected count is 1.92. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.43-52 47 based on the output table above, the asymptotic value is known. sig. on the chi square test is 0.000 < 0.05, then based on the basis of the decision above, it can be concluded that h1 is accepted and h0 is rejected. thus it can be interpreted that there is a relationship between verbal abuse and the socialization ability of preschoolers in playgroup al fattah malang. discussion identification of verbal abuse in preschool children in playgroup al fattah from the results of the identification of verbal abuse in preschool children, it was found that most children in playgroup al fattah experienced verbal abuse in the mild category with a total of 23 children (46%),. while 16% of children in ta al fattah experienced verbal abuse in the severe category with a total of 8 children, and children more often received verbal abuse from their parents by being scolded for no reason by their parents. in this study, figure 4.4 shows that the verbal abuse that is often received and heard by children is scolding for no reason, namely as many as 34 children. nurfina's opinion (2019) is in line with the results of this study, she revealed that the first emotional response that parents often do to their children is scolding their children, this is done because parents do not know compromise in their communication and are only one-way and parents do not need feedback. return from the child to understand about the child. according to indrayati (2019), verbal abuse by parents against their children is caused by several things, for example, parents have minimal knowledge about verbal abuse, because so far parents yell at their children, saying stupid children are considered normal and natural. parents think that the impact of verbal abuse is not too heavy when compared to physical violence. this is also in accordance with what was stated by kemenpppa (2018), violence against children in indonesia has become entrenched so that cases of violence against children continue to increase. parents have the view that children belong to their parents or the view that children must obey their parents so that they become a means of justification for acts of violence against children. children who are negligent, fussy, disobedient, and against the will of their parents will receive sanctions or punishment, which then they can become violent. children, who often receive verbal violence from their parents such as being insulted, ignored, scolded, called with bad calls, are often scared, threatened and yelled at. the child will grow up with fear, so that when in the community and school the child tends to be less active, looks quiet, does not dare to ask questions, does not dare to come forward in class, children cry easily, are not independent, do not answer when asked and do not dare to be with others. identification of socialization skills in children in playgroup al fattah based on the results of data processing in figure 4.4, it can be concluded that 76% of children in playgroup al fattah malang have good socialization skills, while 24% of children have poor socialization skills. this happens because children who enter preschool age (4-6 years) have good socialization skills. preschoolers begin to try to get to know other people without shyness and doubt, so preschoolers are easier to establish a relationship with others. as shown in figure 4.2, all children in ta al-fattah malang are 4-6 years old or entering preschool age. according to erikson (2000) (in emiliza, 2019) preschoolers enter a phase of https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.43-52 48 initiative versus guilt development, where children begin to explore unfamiliar territory and learn to get to know new people. with a child's high curiosity, the child can get the initiative for an action taken to establish interaction with other parties. however, a small proportion of preschoolers have not yet reached that phase and tend to be in the phase of independence versus shyness and doubt that usually occurs at toddler age (1-3 years). this happens because of a developmental disorder that causes children not to develop according to their age. children who are often criticized and scolded will tend to have low self-esteem (inferior). low selfesteem is a big barrier to socializing, because children lose self-confidence. in fact, selfconfidence is the main capital so that children can be successful in life. preschool children in their socialization skills are easier to get along with and make friends with peers because of the child's desire to interact and establish a relationship with other people. in accordance with figure 4.5 which shows that the highest socialization ability behavior or often done by preschoolers is number 5, which is easy to get along with / make friends with a number of 39 children who do it. this is in line with the opinion of sahri (2010) (in muhajaroh, 2018) that in the development of socialization in preschool children, children will hang out more often and make friends to establish a relationship with peers. through these interpersonal relationships, children will learn to value themselves and assess their position in the group. hurlock (2017) supports this and argues that preschoolers will learn to make social relationships and get along with people outside the home, especially with their peers. associating with peers will be done by children every time they try to establish relationships with other parties so that the more often children do this, the ability to get along with peers will be better. relationship of verbal abuse with socialization ability of preschool age children in playgroup al fattah malang from the results of the chi square test, and the results of the analysis of the relationship between verbal abuse and the socialization ability of preschoolers in ta al-fattah malang, it states that the h1 hypothesis is accepted and it can be said that there is a relationship between verbal abuse and the socialization ability of preschoolers in playgroup al fattah, poor. this study can draw a conclusion that the lower the exposure to verbal abuse by parents to preschool children, the better the child's socialization skills, this statement is supported by research conducted by miftakhul fitroh (2014) with the title the relationship between parental stimulation and children's socialization and independence skills. the preschool at playgroup al fattah said that the better the stimulus from parents, the better the child's ability to socialize. a good stimulus in the family environment, especially parents in the form of warmth and affection, will have a positive effect on the social development of children both in the family and in the community. verbal abuse will interfere with the development of the socialization skills of preschoolers because it will inhibit curiosity to establish relationships with other parties. from the results of this study, it was found that 46% of children exposed to verbal abuse were in the low category (23 children), and of the 23 children, all children had good socialization skills. for respondents who were exposed to moderate verbal abuse as many as 19 children (38%) of the total respondents. among them, 6 children (12%) have the lack ability of socialization and https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.43-52 49 14 children (28%) have good socialization skills. meanwhile, there were 8 children exposed to severe verbal abuse from the total respondents. among them, 6 children (12%) had poor socialization skills and 2 children (4%) had good socialization skills. this is in accordance with the opinion of santoso (2018) that the impact of verbal abuse can interfere with the health and well-being of children, which causes trauma to children. so that verbal abuse can affect the social life of children. children will be more quiet, withdrawn, and afraid of other people. this opinion is also supported by surya (2019), namely verbal abuse can be fatal to children, which can lead to traumatic experiences because the words are always remembered by children. so that verbal abuse can change the feelings, way of thinking, reactions and behavior of children. children become more sensitive and always feel suspicious. according to anapratiwi (2018) about the impact of verbal abuse also has an impact on a child's personality, the child will become paranoid, low self-esteem, passive and have excessive anxiety. the environment has a lot of impact on children's development, including who the child hangs out with, and the influence of close people. the relationship between parents and children through good quality interactions must also be supported by good quality with the closest people in the family environment. this is effective in supporting children's development because children also learn through social relationships with other people. researchers agree that parents who verbally abuse their children by scolding, yelling, punishing, and comparing children with their friends will cause anxiety in children which results in children's apathy towards their environment; children are not sensitive to stimuli so that the process of capturing information as material children's learning both from the family environment and the school environment is disrupted. the researcher argues that children who have good socialization and independence skills have the ability to adjust to their social environment well, are more independent, do not always depend on their parents and children will also be easily accepted by members of their social groups, can control themselves, have good relationship with friends and cooperative with others. preschool-aged children who get verbal abuse will experience problems in their social development, the lighter verbal abuse they experience, the better their social skills, and vice versa. conclusions based on the results of the research that has been done, the following conclusions can be drawn: 1. the results of the identification of verbal abuse showed that 8 children or 16% of all preschool children in playgroup al fattah malang were exposed to severe verbal abuse. this happens because of the wrong parenting style in educating children. if the parenting style supports and is in line with the child's development, then violence against children can be avoided. 2. the results showed that the socialization skills of preschoolers in playgroup al fattah malang almost all had good socialization skills. this is because the child receives social development support from his parents such as providing parenting in accordance with the child's development, namely verbal abuse. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.1. october 2022. page.43-52 50 3. the results of the study stated that there was a relationship between verbal abuse and the socialization ability of preschool children in playgroup al fattah malang. suggestions for parents and the community about verbal abuse are that people are expected to know the impact of verbal abuse on children's socialization skills and can change parenting patterns to avoid the impact that will occur if they still apply the wrong parenting pattern. especially parents who meet their children more often, parents must be able to be good examples and figures for their children to emulate. for schools as research sites and other schools, it is hoped that they can determine policies in an effort to prevent and overcome the occurrence of verbal abuse in playgroup al fattah and other kindergartens in the sukun area, malang by holding counseling and parenting classes for parents about the impact of verbal abuse on children's socialization skills. the school must have early detection of verbal abuse as a preventive measure. references anapratiwi, d., handayani, s. s., & kurniawati, y. 2018. hubungan antara kelekatan anak pada ibu dengan kemampuan sosialisasi anak usia 4-5 tahun (studi pada ra sinar pelangi dan ra al iman kecamatan gunungpati, semarang). jurnal belia vol, 2. no, 1. hal 23-30. aprilia, lika. 2020. kenali dampak trauma fisik dan mental akibat kekerasan terhadap anak. hello sehat. diakses dari https://hellosehat.com/dampakkekerasanterhadapanak/. tanggal 25 april 2022. arikunto, s. 2019. prosedur penelitian. jakarta: rineka cipta. armiyanti, iin., aini, khusnul., & apriana, rista. 2017. pengalaman verbal abuse oleh keluarga pada anak usia sekolah di kota semarang. jurnal keperawatan soedirman (the soedirman journal of nursing). fitriani, wahidah., & erniwati. 2020. faktorfaktor penyebab orang tua melakukan kekerasan verbal pada anak usia dini. jurnal pendidikan anak usia dini. fitroh, miftakhul. 2014. hubungan stimulasi orang tua dengan kemampuan sosialisasi dan kemandirian anak prasekolah di tk al-irsyad dawuhan situbondo. umm. hadijah, dkk. 2018. literature review : verbal abuse orangtua terhadap perkembangan kognitif anak usia sekolah. tanjungpura journal of nursing practice and education. hidayat. a. aziz. 2017. metode penelitian keperawatan dan teknik analisis data. jakarta: salemba medika. huraerah, abu. 2018. kekerasan terhadap anak, bandung: nuansa. hurlock, elizabeth b. 2014. perkembangan anak. jakarta : erlangga. indrayati, novi. 2019. gambaran verbal abuse orangtua pada anak usia sekolah. jurnal ilmu keperawatan anak. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 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2614-3496 (online) vol.6 no.1. october 2022. page.43-52 52 supariasa, i.d.n. dkk. 2017. penilaian status gizi (edisi revisi). jakarta: penerbit. buku kedokteran egc. surya, hendra. 2019 kiat membina anak agar senang berkawan: sebuah solusi mengatasi kesulitan bergaul pada anak. jakarta : pt elex media komputindo. syamsu, yusuf. 2018. psikologi perkembangan anak dan remaja. pt. remaja rosdakarya. ulfah, meidheana marlia., & winata, widia. 2021. pengaruh verbal abuse terhadap kepercayaan diri siswa. jurnal instruksional. wijayanti, vera dinda. 2017. hubungan verbal abuse terhadap perkembangan kognitif anak usia prasekolah di kelurahan reban kabupaten batang. jurnal undip semarang. yuni, farida arsih. 2010. kekerasan kata-kata (verbal abuse) pada remaja. diakses pada 15 april 2022. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.155-162 155 spiritual benson relaxation in reducing stress in patients undergoing hemodialysis tata mahyuvi1*, noer istiqomah2, yuly peristiowati3, katmini4, joko prasetyo5, indasah6, hari prasetyo umar7 1,7 student doctoral at institut ilmu kesehatan strada indonesia 2 nurse dyalysis at islamic hospital of surabaya, indonesia 3,4,5,6 institut ilmu kesehatan strada indonesia, kediri, indonesia *corresponding author: mahyuvi1922@gmail.com abstract background: patients with chronic kidney failure experience various changes in their lives, starting from their diet, exercise, blood sugar control, urea, creatinine and renal function replacement therapy that must be carried out throughout their lives, causing long stress for the patient. purpose: the purpose of this study was to analyze the effect of spiritual benson relaxation on reducing stress in patients undergoing hemodialysis. methods: this research design uses quasi-experimental approach with a pre and post control group design. the population of all patients with chronic kidney failure who underwent dialysis in the hemodialysis unit of the surabaya islamic hospital a. yani was 70 people. the sample size is 32 respondents. the sampling technique is purposive sampling. the intervention group was given spiritual benson relaxation and the control group were given intervention according to hospital standards. the analysis used the wilcoxon with a significant value of . < 0.05. results: the results showed that the stress level p value 0.001 in the intervention group and the control group p value 0.035 which means that there is an effect of spiritual benson relaxation on reducing stress in patients undergoing hemodialysis. conclusion: spiritual benson relaxation is effective in reducing stress in patients undergoing hemodialysis and the technique is easy to do. keywords: benson relaxation, hemodialysis, spiritual, stress received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.300 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:mahyuvi1922@gmail.com https://doi.org/10.30994/jnp.v6i2.300 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.155-162 156 background kidney failure is a clinical condition characterized by irreversible or irreversible decline in kidney function, at a certain degree requiring permanent kidney replacement therapy in the form of dialysis or kidney transplantation (nursalam et al., 2020). patients with chronic kidney failure experience various changes in their lives, starting from their diet, exercise, blood sugar control, urea, creatinine and hemodialysis therapy that must be carried out throughout their lives, causing long stress for the patient. the patient said that the stress he experienced was due to seeing the tubes that were flowing with blood, the costs that had to be incurred each time he underwent therapy, the stress of being stabbed, and the uncertainty of healing. at the beginning of hemodialysis, the patient's response seemed to be unable to accept the loss of kidney function, angry with the events, feeling sad, stressed, depressed, and wanting to try to commit suicide with the events he experienced, thus requiring a long adjustment to the environment. who are new and must undergo hemodialysis at least twice a week. this becomes a physical stressor that affects various dimensions of the patient's life which includes biology, psychology, social and spiritual which can lead patients to stress, anxiety and even depression. the prevalence of chronic kidney failure in the world reaches 661,648 people and is a global health threat. study results (anisah & maliya, 2021) as many as 83% of hemodialysis patients experience stress. data indonesian renal registry/ irr (2018) states that there are 66,443 chronic kidney failure patients who are actively undergoing hemodialysis therapy. riskesdas data (2018) states that patients with chronic kidney failure in the east java province at 5 years reached 113,045 people. patients with chronic renal failure who undergo hemodialysis therapy for a long time will feel stress caused by situational crises, threats. this makes hemodialysis patients susceptible to protracted stress. the psychological consequences felt by patients often need special attention by doctors and nurses. in general, treatment in hospitals is focused on recovering physical conditions but must pay attention to the patient's psychological conditions such as anxiety, stress and depression (alfikrie et al., 2020). the results of the study (ramadhan & nurhayati, 2018) stated that patients with chronic kidney failure are very susceptible to suffering from psychological disorders, namely stress. where stress is an individual's response in general to the demands on the body. the demand is the necessity to adapt and therefore the balance of the body is disturbed. stress will begin with an alert reaction to a threat that is marked by automatic body processes, in this case the result of chronic kidney failure. the consequences that arise when chronic kidney disease patients experience stress include aggressiveness, frustration, nervousness, boredom, boredom, loneliness, drinking alcohol, smoking, overeating, sexual deviations, weak thinking power, unable to make decisions, not concentrating, increased pressure blood pressure, heart rate and blood sugar (nursalam et al., 2020). coping with stress can be done by means of pharmacological therapy/drugs or non-pharmacological interventions. one of the interventions in dealing with stress can use spiritual benson relaxation. methods quantitative research using a quasi-experimental with a preand post-test control group design. independent variable spiritual benson relaxation and the dependent variable is stress. the sampling technique used in this research is purposive sampling. the number of respondents is 34 people. the research was conducted at rsi surabaya a. yani. the study was conducted in april-may 2022. the statistical test of the research results used the wilcoxon test. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.155-162 157 results the research results obtained by the researchers are as follows: table 1. distribution of respondents' age, gender, education and occupation data characteristics interventions control n % n % gender male 10 62.5% 9 56.3% female 6 37.5% 7 47.8 % total 16 100 % 16 100 % age adult (18-40 years) 3 18.8% 1 6.3% middle adult (41-60 years ) 11 68.8% 14 67 ,5 % elderly adults (>60 years) 2 12,5 % 1 6,3 % total 16 100 % 16 100 % education elementary school junior high school 1 6,3 % 6 37.5% senior hight school 9 56,3 % 6 37.5% college 6 37.5% 4 25 % total 16 100 % 16 100 % employment working 5 31.3 % 4 25 % not working 11 68.8 % 12 75 % total 16 100 % 16 100 % based on table 1. the gender of the respondents was mostly male in the intervention group 62.5% and gender in the control group 56.3%. most of the respondents in the intervention group were middle adults (41-60), namely 68.8% and 67.5% in the control group. the education level of the respondents in the intervention group was mostly high school (56.3%) and in the control group, almost half of the respondents (37.5%) were junior high and high school educated. in the intervention group most (68.8%) did not work and in the control group (75%) respondents did not work. table 2. distribution of stress level analysis of patients undergoing hemodialysis at the surabaya islamic hospital a. yani before and after being given spiritual-based benson relaxation in the intervention and control groups pre post wilcoxon test frequency (f) % frequency (f) % intervention ρ value = 0.001 no stress 10 62,5 % mild stress 2 12,5 % 4 25 % moderate stress 4 25 % 2 12,5 % severe stress 8 50 % very severe stress 2 12.5% total 16 100 % 16 100 % https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.155-162 158 control ρ value = 0.035 no stress mild stress 2 12.5% 8 50 % moderate stress 6 37.5% severe stress 6 37.5% 7 43.8% very severe stress 2 12.5b% 1 6.3% total 16 100 % 16 100 % based on table 2. above shows that before being given spiritual-based benson relaxation, the respondent failed chronic kidney disease half of the respondents (50%) in the intervention group experienced severe stress and after being given the intervention most (62.5%) were not stressed/normal. in the control group before being given the intervention, almost half (37.5%) experienced moderate and severe stress and after being given the intervention, severe stress increased to (43.8%). based on the results of statistical tests using wilcoxon signed ranks test value = 0.001 in the intervention group and in the control group 0.035 then the hypothesis is accepted, meaning that there is a spiritual effect of benson relaxation on reducing stress in patients undergoing hemodialysis. discussion stress levels of patients undergoing hemodialysis before being given spiritual benson relaxation the results of the study before being given spiritual benzene relaxation showed that half of the respondents (50%) in the intervention group experienced severe stress and in the control group before being given the intervention almost half (37.5%) ) experienced moderate stress and almost half (37.5%) had severe stress. this is because the patient has only taken hemodialysis several times so that he is stressed seeing the tubes that are flowing with blood, the costs that must be incurred each time he undergoes therapy, the stress of being stabbed, the patient still does not accept the fact that hemodialysis therapy will be carried out for the rest of his life and the uncertainty of recovery. this is in line with research (ramadhan & nurhayati, 2018) which states from the results of the study it is known that patients with chronic kidney failure who undergo hemodialysis experience stress with a small percentage who do not experience stress, namely 7 people (17%), almost half of them have mild stress. people (31%), almost half of them were under moderate stress 14 people (33%), and a small part of severe stress was 8 people (19%). it is also supported by the results of a literature review journal by (tarigan, 2020) which states that chronic kidney failure patients undergoing hemodialysis experience stress and anxiety. it is also supported by research (lemba et al., 2020) showing that, of the 60 respondents of chronic kidney failure patients undergoing hemodialysis, there were 4 patients (6.7%) in the non-stress category, while 4 patients (6.7%) in the non-stress category. mild stress, 38 patients (63.3%) in the moderate stress category, 12 patients (20.0%) in the severe stress category, and only 2 patients (3.3%) in the very severe stress category. there are 38 patients (63.3%) in the category of moderate stress. stress is a physical and psychological reaction to any demands that cause tension and disrupt the stability of daily life (iswari, 2019). stress is the body's response to the surrounding environment, so it can become a self-defense system that can protect us (syahrizal et al., 2020). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.155-162 159 stress is a condition or state of the body that is disturbed due to psychological pressure and stress is usually associated with psychological diseases. however, it is more because a person's mental problems then result in physical illnesses that can arise due to weakness and low body resistance in stressful conditions (safitri et al., 2017). stress affects many aspects of human life, especially patients with chronic kidney failure undergoing hemodialysis. in the cognitive aspect, stress causes disturbances in cognitive function by decreasing or increasing attention to something. in the emotional aspect, stress can cause fear which is a common reaction when individuals feel threatened, creates feelings of sadness or depression, and triggers anger, especially when individuals experience situations that are dangerous or frustrating (sumarsih et al., 2019). stress is a phenomenon that affects all dimensions in a person's life, whether physical, emotional, intellectual, social and spiritual (yunitasari et al., 2020). people who experience stress will experience muscle tension, decreased endurance, nervousness, difficulty sleeping, nausea and so on. this will indirectly affect a person's life satisfaction which will also have an impact on that person's quality of life (tarigan, 2020). most of the respondents experienced moderate stress due to hemodialysis. according to the researchers, chronic kidney failure patients undergoing hemodialysis experience stress because some have undergone hemodialysis for a long time so that some patients are used to all the changes that occur in themselves, although sometimes complications from chronic kidney failure often make patients experience various problems and problems. if the patient's coping mechanism is not good in responding to stressors, it will have an impact on the patient's stress level. stress arises when a person makes adjustments to an event or situation. there are two factors that cause a situation or event to cause stress, namely those related to the individual itself and those related to the situation experienced by the individual. situations or events related to individuals can be in the form of certain conditions in the environment that damage tissues in the body, such as excessive heat / cold, injury or disease. the state of illness causes the emergence of demands on the individual's biological and psychological systems, where the degree of stress that will arise due to these demands depends on the seriousness of the disease and the age of the individual. meanwhile, those related to situations experienced by individuals can be in the form of increasing family members, divorce, death in the family, work and environmental conditions (rahayu et al., 2018). chronic kidney failure patients undergoing hemodialysis experience stress, this is because patients feel anxious because chronic kidney failure cannot be cured and must experience various complications, both physical and mental. life, not to mention the economic aspect because patients have to incur transportation costs, and cannot work as usual when undergoing hemodialysis, so that they experience tension, anxiety, stress and depression that are different for each individual which has a negative impact on their quality of life and health (mahyuvi, 2021). stress level of chronic kidney failure patients undergoing hemodialysis after being given spiritual benson relaxation the results of the study after being given spiritual benson relaxation showed that patients with chronic kidney failure in the intervention group were mostly (62.5%) not stressed/normal and in the control group severe stress increased to (62.5%) 43,8%. based on the results of the research above, it proves that there is a change in the stress of patients with chronic kidney failure, before and after being given spiritual-based benson relaxation. the above is supported by research (ningsih et al., 2018) which states that spiritual therapy can reduce stress levels in patients with chronic kidney failure undergoing hemodialysis. it is also https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.155-162 160 supported by the results of research (aprilliam & abdillah, 2021) which states that benson relaxation can reduce stress levels. spirituality is one way to minimize stress that acts as a positive psychological factor (free from stress and anxiety) through the functional limbic system that can lead to positive coping mechanisms (wisnusakti, 2018). spirituality can significantly assist patients in adapting to changes caused by chronic kidney disease. spiritual intervention is believed to reduce stress optimally because it can be carried out independently, anytime and anywhere, is inexpensive and non-toxic (yusuf et al., 2020). the relationship between man and the creator is the first element in spirituality. getting closer to god is a coping strategy that is most often used by patients to cope with the stress of chronic kidney failure patients. according to the researcher, nurses in this study used it as a stimulus to reduce stress, through a spiritual-based benson relaxation method. benson's spiritual-based relaxation technique is a technique that is easy to do because the patient only needs to take a deep breath and then exhale accompanied by saying a word or sentence formula that is believed by the respondent so that it can increase comfort and reduce stress levels. this spiritual-based benson relaxation technique can be done independently or guided by health workers or families. when a person feels anxious, the body's system will work extra by increasing the sympathetic nervous system in response to stress. after being given spiritual-based relaxation, benson will inhibit sympathetic nerve activity which can reduce oxygen consumption by the body and then the muscles of the body become relaxed, causing a feeling of calm and comfort (otaghi et al., 2016; suwardianto, 2021). spiritual benson relaxation that is carried out will stimulate the brain area, namely the prefrontal cortex which is the center of emotion regulation and judgment to instruct emotional reactions which then the body will respond by feeling accepting and non-judgmental, while the hippocampus and amygdala areas for regulating emotions as well as areas of openness, suppression, and reinforcement that will provide instructions to open up more so that individuals are able to disengage themselves in awareness, refrain from internal reactivity and be able to increase self-acceptance so as to reduce stress, not only physically, psychologically, socially but also mentally healthy spiritual (vijayanti, 2019). humans as whole creatures respond to conditions that occur due to health problems, and have coping mechanisms to adapt to environmental changes, so that individuals always interact by using positive and negative coping (ningsih et al., 2018). during the benson spiritual relaxation process, chronic kidney failure patients will feel calm, increase their level and love for themselves, there is an attachment to spirituality, increased awareness of health and self-care and surrender to god almighty so that the patient's stress level decreases and even becomes less stressed. or normal. benson relaxation spiritual effect analysis on reducing stress in patients undergoing hemodialysis based on the results of statistical tests using wilcoxon signed ranks test value = 0.001 in the intervention group and in the control group 0.035 then the hypothesis is accepted, meaning that there is a spiritual benson relaxation on reducing stress in patients undergoing hemodialysis. spiritual benson relaxation is a relaxation technique that can relax the mind and body through a process that will progressively release muscle tension in each body with deep breaths while saying in the heart sentences of motivation, gratitude and resignation. benson's spiritualbased relaxation was carried out as many as 2 interventions in 1 week before the patient underwent hemodialysis therapy. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.155-162 161 these sentences want to regulate emotions by decreasing the activation of the amygdala, then the stimulus is sent to the prefrontal cortex in the form of a learning process (a careful learning process through the process of selection, organization, and interpretation of the stressor it receives) will then produce a change in self-perspective in the form of awareness to take wisdom and self-acceptance to the conditions experienced at this time. awareness in taking wisdom and self-acceptance will increase tolerance to stress and reduce muscle tension which will then change the individual's spiritual cognitive and emotional response, as a result, it can reduce corticotropin releasing factor (crf). furthermore, crf stimulates the pituitary gland to secrete or release endorphins as neurotransmitters that affect the mood to relax, maintain positive emotions, namely self-acceptance, increased confidence and motivation to stay healthy. this will lead to positive effects, including an increase in concentration, body and mind awareness. this situation will also increase the patient's self-awareness of the current situation, so that the patient can accept his condition without criticizing or blaming himself and his environment. furthermore, it will increase motivation for health and a feeling of well-being in chronic kidney failure patients undergoing hemodialysis therapy. patients who have been able to accept their situation feel more comfortable and relaxed, so that they can reduce patient stress and stabilize the body's hemodynamics. conclusion 1. before being given spiritual benson relaxation of patients undergoing hemodialysis half of the respondents in the intervention group and almost half of the control group experienced severe stress 2. after being given spiritual benson relaxation patients undergoing hemodialysis in the intervention group were mostly not stressed and in the control group almost half experienced severe stress. 3. there is an effect of spiritual benson relaxation on reducing stress in patients undergoing hemodialysis. references alfikrie, f., purnomo, a., & selly, r. 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(2019). efek kombinasi relaksasi benson dan dzikir terhadap kecemasan pada pasien hemodialisa di rsud panembahan senopati bantul. universitas alma ata yogyakarta. wisnusakti, k. (2018). the relationship between levels of spiritual welfare and anxiety in elderly. jurnal pendidikan keperawatan indonesia, 4(2), 91–96. https://doi.org/10.17509/jpki.v4i2.13638. yunitasari, e., sutrisno, i. t., & santoso, b. (2020). the effects of spiritual caring with murottal on stress anxiety, and depression among cervical cancer patients undergoing chemotherapy. eurasian journal of biosciences, 14(june), 1663–1668. yusuf, a., iswari, m. f., sriyono, s., & yunitasari, e. (2020). the effect of combination of spiritual deep breathing exercise therapy on pain and anxiety in postoperative nonpatological orthopedic fracture patients. eurasian journal of biosciences, 14(1), 1625–1631. https://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.210-219 210 assessment of afasia in stroke patients: case study dwi febryanto, retnaningsih, fitria handayani diponegoro university, semarang, indonesia corresponding author: dwifebryanto37@gmail.com abstract background: aphasia is understood as difficulty in understanding or producing language caused by disorders involving the brain hemispheres. early assessment of aphasia is very important to prevent the emergence of telegraphic speech styles, improve welfare, independence, social participation, quality of life, reduce length of stay and care costs, but there is little literature on this subject, especially in stroke patients. purpose: this study aimed to provide an overview of the assessment of aphasia in stroke patients. methods: the design of a case study involving 6 participants and data collection was carried out by conducting an assessment using the language aphasia screening test (last) instrument which was monitored for 3 days, including monitoring errors for naming images, monitoring mismatches repeating words and sentences, monitoring spontaneous pronunciation, monitoring image comprehension, monitoring comprehension of verbal instructions. results: a total of 6 ischemic stroke patients were found wrong in repeating words and sentences. conclusion: in aphasic stroke patients all language modalities are impaired, ranging from spontaneous speech, repetition, naming, language comprehension, reading and writing. keywords: stroke phenomenon, aphasia, assessment received august, 29, 2019; revised december 29, 2019; accepted february 28, 2020 doi: https://doi.org/10.30994/jnp.v3i2.88 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:dwifebryanto37@gmail.com https://doi.org/10.30994/jnp.v3i2.88 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.210-219 211 background the prevalence of stroke in sri lanka in 2015 was 104 per 1,000 population and in china in 2017 was 1,596 per 100,000 population (chang, gajasinghe, & arambepola, 2015; wang et al., 2017). stroke patients in japan were 1,693 patients, 52, 5% experienced aphasia, whereas the prevalence of stroke in indonesia increased from 2013-2018, namely 7.0% to 10.9% (kemenkes ri, 2014). stroke sufferers who experience aphasia due to acute stroke are around 30% (kemenkes ri, 2014; pinzon, 2010). both ischemic and hemorrhagic stroke patients who are treated, are often found to experience paralysis of the limbs, perot face, pelo, and even found aphasia. aphasia is understood as difficulty in understanding or producing language caused by disorders involving the brain hemispheres. in patients with aphasia all impaired language modalities, ranging from spontaneous speech, repetition, naming, language comprehension, reading and writing (lumbantobing, 2000), hysiological changes in aphasia are often found in stroke patients so that the problem of verbal communication disorders should be found in the cppt integrated patient development record but, based on observations this problem is very rarely found. nurses are important to assess stroke aphasia to detect and evaluate patient progress, because nurses often find signs of stroke aphasia patients in the form of speech disability, slowness, and difficulty expressing words so that communication is disrupted (al-khawaja, wade, & collin, 1996; poslawsky, schuurmans, lindeman, & hafsteinsdóttir, 2010) nurses collect subjective and objective data and then establish nursing diagnoses of verbal communication disorders. (ppni, 2016) nurses can intervene in the form of providing support for treatment programs and decision making for care actions (berthier, 2005; ppni, 2016). on the other hand, nurses can carry out their advocacy functions to defend clients if patients do not get proper treatment. the unavailability of a nurse-specific assessment tool for the assessment of stroke aphasia results in the absence of nurses' actions to conduct an aphasia assessment in stroke patients. another factor of nurses who do not do aphasia assessments is the knowledge of nurses related to aphasia assessment. nurses only know the signs and symptoms of aphasia such as speech difficulties experienced by patients, which when examined with instruments can provide good judgment. stroke patients who experience aphasia, they are not able to understand spoken language, difficulty coordinating thoughts, feelings and desires (enderby, wood, wade, & hewer, 1986; flamand-roze et al., 2011) severe stroke aphasia patients are characterized by no there is spontaneous language, however the patient may mention a few repetitive words but is unable to understand pronunciation (enderby et al., 1986; flamand-roze et al., 2011) this can cause a psychological change in the patient's form of anxiety, stress and depression (shehata, 2015) acute stroke aphasia patients have difficulty communicating, making them anxious because they cannot express their desires, hopes and complaints so well that they depend on the people closest to convey their desires and complaints. aphasia strokes also have an impact on well-being, independence, social participation, quality of life and length of stay. stroke patients with aphasia will experience an additional stay of an average of 1-2 weeks. the addition of the length of stay will increase the cost of care (corallo et al., 2017) efforts to prevent the impact of aphasia due to stroke is to recognize aphasia as early as possible. many instruments to assess aphasia due to stroke such as boston diagnostic aphasia examination (bdae), minnesota test for differential diagnosis of aphasia (mttdda), functional communication profile (fcp). all of these tools have their own specifications, and their own scoring system. this measuring instrument takes between 30 minutes to 3 hours to detect aphasia (erdodi & roth, 2017; prins & maas, 2002) this journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.210-219 212 measurement tool is difficult to do in patients who do not tolerate a long time. questions used in the "understanding" sub-test produce answers in the form of "yes and no" so that patients can answer them only by tilting their heads which can lead to bias (erdodi & roth, 2017; prins & maas, 2002) screening tools such as the mobile aphasia screening test (mast), sheffield screening test (sst) and screeling are screening tools for detection of acute stroke aphasia with a time of 3-15 minutes and onset of attack 1-127 days (el hachioui et al., 2017) the measuring devices without sub-tests that require "yes and no" answers, but even without sub-tests that require yes and no answers, the screening tool is only specifically done by a therapist or specialist doctor while other health workers cannot use this (el hachioui et al., 2017; erdodi & roth, 2017) assessment tools for the assessment of stroke aphasia use the language screening test (last) in the form of an image stimulus using instructions and a hint card without a "yes and no" question. this assessment tool is more detailed, easy to use, fast and does not involve writing sub-tests (el hachioui et al., 2017). last is a measuring tool developed for health professionals in detecting stroke aphasia (flamand-roze et al., 2011). last can assess as a whole because it has 5 clinical indicators namely naming images, syllable repetition, sub spontaneous speaking tests, understanding images and verbal commands, without writing subtes. previous measuring instruments are very time-consuming, existing instruments are also still very high from the risk of bias because they involve writing subtests and are difficult to interpret by nurses while a brief, low-bias and easily interpretable assessment is needed (flamand-roze et al., 2011) last is the only fastest tool in detecting aphasia with only 2-3 minutes, low bias and simple and easy to interpret (flamand-roze et al., 2011; flowers, flamand-roze, denier, & roze, 2015; koenigbruhin et al., 2016) last has also been validated in stroke patients. last has a good rating for knowing patients with aphasia. the last assessment instrument is a good aphasia screening and evaluation tool, has high sensitivity, and is an accurate diagnostic instrument with high specificity for aphasia assessment in stroke patients. seeing the importance of knowing aphasia early, it is necessary to do an assessment using easy and efficient tools. objective this study aimed to provide an overview of the assessment of aphasia in stroke patients based on assessment using the last instrument methods participants in this study involved 6 patients who had a stroke. participants were selected according to inclusion and exclusion criteria. the inclusion criteria in this study were men and women aged 40-80 years, declared ischemic or hemorrhagic stroke based on ct scan, indonesian language. exclusion criteria are patients experiencing decreased consciousness, illiteracy, blindness and deafness. the process of data collection is done by first doing licensing by giving informed consent to the family or patient, conducting an aphasia assessment with last measuring instruments that have been translated and monitored for 3 days. the method used is a case study. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.210-219 213 results table 1. demographic data on case studies of patients with stroke aphasia no patient age (years) gender hospitalization day ct scan results 1. mr. f 49 male 3 infarction of the left insula 2. mrs. r 60 female 2 intracerebral hemorrhage in the basal ganglia to the left corona radiata 3. mr.n 50 male 2 intraserebral hemorrhage in the caudatus nucleus to the left corona radiata 4. mrs. p 70 female 2 lunarar infarction of the right external capsule 5. mr. t 50 male 1 lunarar infarction in the right lentiform nucleus 6. mr. s 62 male 2 lakunar infarction in the left lentiform nucleus mr. f, 49 years old, was admitted to the treatment room on august 26, 2019. the patient was assessed for aphasia on the 3rd day care in the ward with a medical diagnosis of non-hemorrhagic stroke + hemiparese dextra. with the results of a ct scan of the head without contrast, namely infarction in the left insula. at present the patient has weak right limbs. composmentis patient awareness, gcs e4m5v5. examination of vital signs temperature 36.5oc, pulse 105 x / minute, blood pressure 190/119 mmhg, rr 20x / minute. the patient has a history of hypertension since 2012 and rarely controls. in the family of the father and sister the patient also suffered the same stroke suffered by the patient at this time. on a physical examination the focus is obtained data that the client's face is not symmetrical, perot mouth. aphasia studies were performed on patients on the third day of treatment, aphasia scores using the last instrument obtained 13, the patient experienced a pronunciation error on the mathematics word sub-test repetition and the postman brought my neighbor's letter. while the naming test, spontaneous pronunciation, understanding of images and verbal instructions can be done appropriately. on the fourth day, a review was conducted and showed that the aphasia score was still the same at 13, while on the 5th day the patient was able to repeat the words and sentences correctly so that the last score was 15. mrs. r aged 60 years entered on august 25, 2019. the assessment was carried out on the second day of treatment at bagsal with a medical diagnosis of intracerebral hemorrhage. the assessment was carried out and found that the patient complained of weak right limbs and difficulty speaking, awareness of patient composmentis, gcs e4m5v5. the patient has a history of hypertension. the patient was put on a 20 drops per minute rl infusion in the left hand. on a physical examination focused on the data that, perot mouth, pelo pronunciation, patients can speak slowly, extremities of the right hand and foot are weak. ct scan results of intracerebral hemorrhage in the basal ganglia to the left corona radiata. on the first day the last score is 10, the client gets a speech therapy program, and the second day the last score is 11, the client can name the picture, the repetition subtest is wrong, the spontaneous speech test is correct, the picture understanding test is still wrong, the verbal instruction test can do correctly. fourth and fifth day evaluations in patients found patients still complained of difficulty moving the right limb, td 145/90 mmhg, right limb muscle strength 4: 4, and speech still pelo with last score 14. the physiotherapy and speech therapy process had actually been carried out, because the patient has weakness in the right limb and there is a speech impediment. evaluation on diagnoses of verbal communication disorders, journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.210-219 214 measured using last instruments. beginning of the study where it was found that there were errors in the pronunciation of mathematical words, the patient was immediately motivated to practice saying mathematics. the patient gets word pronunciation exercises like mathematics, the postman brings my neighbor's letter, always during the shift and every time the nurse visits the patient. the third day after the patient got pronunciation practice, the patient was not able to correctly answer the word mathematics and the postman brought my neighbor's letter. motor speech training is indeed able to restore the patient's speech style and help patients recognize the treatment environment. providing speach motor exercises at least once per shift can enable patients to complete the word repetition sub test well. treatment continues until the patient returns and requires recontrol. finally the patient is allowed to go home and control a week after. mr. n, 50 years old. patients entered the treatment room on september 8, 2019. the assessment was carried out on the second day with the results of a ct scan, namely intracerebral bleeding in the coedetus nucleus to the left corona radiata. client's main complaint based on assessment of the family is a headache with additional complaints namely difficulty speaking and weakness in the right limb. client's blood pressure is 180/107 mmhg. the client has no history of hypertension but has a history of asthma. at present the client is just silent and not talking. the therapy received by the client on september 9, 2019 is infusion of rl 20 drops per minute, citicolin 2x500 mg, tranexamic acid 3x1 gram, ranitidine 3x1 ampoule, mannitol 4x125 cc, amlodipin 1x20 mg, clonidin 2x0.150 mg. last assessment on the first day is obtained last score obtained 0. clients can not speak at all. clients get a speech therapy program. on the second day the last score is still obtained 0. the client is completely unable to speak. speech practice uses the pictures contained in the last instrument. the client cannot say a word, only bow his head. on the third day the evaluation was made again after speech therapy, last score obtained 0. clients can make sounds without meaningful words. the client cannot say a word, only bow his head. mrs. p, 70 years old, for indications of a non-hemorrhagic stroke on september 14, 2019. the patient was assessed for aphasia on the second day of care. the client's main complaints are weakness in the right limbs, difficulty speaking and headaches. clients have a history of hypertension, and rarely do routine control. radiological examination results are lacurer infarction on the right external capsule. the therapy received by the client on september 16, 2019 was infusion of rl 20 drops per minute + vitamin b12, piracetam 4x3 gr, citicolin 2x500 mg, ranitidine 2x1 ampoule. on the first day of the last assessment it is found that the client can only understand the designated image, with a last score of 5. the client gets a speech therapy program. on the second day of development after speech therapy, the client can only say yes, make a sound without meaningful. the client cannot name the picture, the client cannot repeat words and sentences, the client can count 1-10, the client can understand the picture and follow verbal instructions. on day 3 development, the patient has not been able to name the picture, repeat the word, but can count even though the pronunciation is still wrong, can understand the picture and perform verbal instructions. last value 7. mr. t 50 years old, patient entered the treatment room on september 19, 2019. the assessment was carried out on the first day of treatment, the client entered with complaints of pelo speech and weakness of the right limb. the client has no history of hypertension and cholesterol. radiological examination results are right lentiform nucleus lacurer infarction. the therapy received by the client on september 16, 2019 was rl 20 drops per minute, piracetam 4x3 gr, citicolin 2x500 mg, ranitidin 2x1 ampoule, aspilet 1x1 tablet, journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.210-219 215 extra injection of ondansentron 4 mg, then 2x1. on the development of the first day last score was found 13. clients can name pictures correctly, there are pronunciation errors when repeating words and sentences, clients can say spontaneous words, clients can understand images and perform verbal instructions correctly. the development of day 2 and 3 clients can repeat mathematical words correctly, and clients can repeat sentences from the postman carrying a letter to my neighbor appropriately. last score of 15. mr. 62 years old, patient enters the treatment room on october 1, 2019. the assessment is carried out on the second day of treatment, the client enters with complaints of pelo speech and weakness of the right limb. the client has a history of hypertension and is not routine control. the results of radiological examination are lunarar infarction in the left lentiform nucleus. therapy received by clients on october 1 st 2019, namely infusion of rl 20 drops per minute, piracetam 4x3 gr, citicolin 2x500 mg, ranitidine 1 ampoule, amlodipin 10 mg. on the development of the first day last score was found 13. clients can name pictures correctly, there are pronunciation errors when repeating words and sentences, clients can say spontaneous words, clients can understand images and perform verbal instructions correctly. the development of the second day the client is still the same as repeating words and sentences and the third client can repeat the mathematical word correctly, and the client can repeat the postman sent a letter to my neighbor correctly last score of 15. discussion the results of the case study found that six patients experienced aphasia on the first day to the third post-stroke day in the treatment room. this is in agreement with research conducted by flamand roze which states that aphasia in post-stroke usually occurs in the acute phase, which is in the range 1-5 days after the attack (flamand-roze et al., 2011). besides stroke aphasia can also recover spontaneously with a little intervention needed to rehabilitate. all participants with post-stroke both iscemic and hemorrhagic were confirmed by ct scan. the cause of aphasia due to stroke both ischemic and hemorrhagic which causes nerve palsy hypoglossal brain in the temporal fronto lobe of the brain (pinzon, 2010). stroke aphasia patients are unable to understand oral language, difficulty coordinating thoughts, feelings and desires (lumbantobing, 2000). aphasia patients severe strokes are characterized by no more spontaneous language. patients can mention several repeated words but are unable to understand pronunciation (lumbantobing, 2000). in addition, stroke risk factors that cannot be changed are age, gender, family history and previous stroke history. the older a person is, the more susceptible to stroke. this is due to the higher incidence of stroke risk factors such as hypertension in men. the venketasubramanian et al (2005) study of 14906 subjects in singapore showed that the prevalence of stroke over 65 years was 7.67%, and it was significantly higher in the <65 years age group at 4.05%. the prevalence of stroke in men is 1.5 times higher than in women (4.53% vs 2.91%). in addition, according to prof. lumbantobing said that age is a significant factor in evaluating aphasia. normal people under 69 years old will be able to name 20 animals with a standard deviation of 4.5. this ability decreased to 17 in the 70s and to 15.5 in the 80s. if the score is less than 13 in normal people under 70 years, it is necessary to suspect interference in the verbal fluency (lumbantobing, 2000) spontaneous recovery of acute stroke aphasia occurs within 1-3 months. this is supported by research conducted by culton in marshall and campbell (2013) who investigated stroke patients with an onset of less than 30 days tested with a number of measures (campbell & marshall, n.d.) el hachioui in marshall and campbell (2013) also reported 147 aphasia journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.210-219 216 patients at <6 weeks, 3 months, 6 months and 1 year found patterns of recovery in phonology, syntax and semantics. whereas those receiving semantic and syntax aspects of screeling increased up to 6 weeks, and phonology improved up to 3 months (campbell & marshall, n.d.) the largest prospective study of spontaneous recovery is found in sweden. paderson, et al in marshall and campbell (2013) reported that 330 stroke patients were present at admission, hospitalization and outpatient care for up to 6 months. the results showed that language function became stationary at 84% at 2 weeks after onset and 95% of patients at 6 weeks after onset (campbell & marshall, 2013) the largest prospective study of spontaneous recovery is found in sweden. paderson, et al in marshall and campbell (2013) reported that 330 stroke patients were present at admission, hospitalization and outpatient care for up to 6 months. the results showed that language function became stationary at 84% at 2 weeks after onset and 95% of patients at 6 weeks after onset (campbell & marshall, 2013) two participants experienced errors in naming the images. errors in naming images are also closely related to lesions in brain regions. lesions in the temporal lobe in the medial and inferior gyrus areas (angular gyrus). patient talks are generally smooth, it's hard to find the right words for certain objects. this aphasia is known as anomic aphasia (difficulty in naming an object). patients can understand written and verbal language, comprehension and normal repetition (dronkers, 2010) the results of the assessment of aphasia with last showed that 6 participants experienced mismatches and errors in repeating words and sentences. the patient mispronounced a mathematical word and the postman sent with my neighbor's letter. studies show stroke aphasia patients will have trouble repeating words or sentences. this relates to the location of the lesion, if the lesion is at the motor talk center in area 44 and the surrounding area. the repetition of a single word is still good even if done with a variety of efforts. repetition of bad sentences, especially sentences containing short words (such as: if, not, and, or, but (dronkers, 2010; yusiana & suwardianto, 2014; suwardianto & richard, 2017; weiner, 2000) lesions in the posterior temporal gyrus of the auditory association cortex (area 22) or gyrus supramarginalis (area 40). symptoms are that language comprehension will be interrupted and lose the ability to repeat the words spoken by others. spontaneous speech goes smoothly with fast rhythm and normal articulation. submission of information is bad because of circumcollution, the use of words that are meaningless, and incorrect. patients use the wrong words and sounds, and are unable to understand writing, verbal language and naming a bad objec (dronkers, 2010; silbernagl & lang, 2007; weiner, 2001) if the lesion is in the temporal or parietal region which is related to the arctic fascicles which connect the wernicke (sensory) area to the broca (motoric) area. the conversation is smooth even though sometimes paraphrasing and understanding the language is good. patients can understand a speech or written sentence that contains short words, but the ability to repeat words is very disturbed (dronkers, 2010; silbernagl & lang, 2007; suwardianto, 2018; suwardianto & rimawati, 2018; weiner, 2000) studies show normal people are generally able to repeat sentences that contain 19 syllables. generally aphasia patients with impaired repeat ability have pathological abnormalities involving the peri-sylvian region. if the ability to repeat is maintained, the sylvian periarea is free from pathological abnormalities (lumbantobing, 2000) repetition is often ignored in aphasia tests because it is not considered a function of natural language. repetition tests have a significant theoretical and practical journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.210-219 217 contribution to the analysis of aphasic disorders. repetition is important to distinguish between conduction aphasia and transcortical aphasia (kertesz, 2007) the results of the assessment of stroke aphasia with last found that 2 participants experienced spontaneous pronunciation disruption. studies show that extensive infarction in the area of vascularity of the cerebral artery often occurs in the occlusion of the left internal carotid artery or the base of the left cerebral artery. hemiparesis is evident, accompanied by the inability of sufferers in terms of spontaneous speech and understanding of impaired language (dronkers, 2010; silbernagl & lang, 2007; weiner, 2000) the results of the assessment of aphasia with last found that 2 participants did not understand the instructed picture. studies suggest that the ability of aphasia patients to understand is often difficult to assess. simple examination that exists to assess the ability of understanding only gives a rough idea of the disorder and its severity, because the anatomical correlation with comprehension is complex (lumbantobing, 2000) visuals seen by clients are then translated by the brain specifically the occipital lobe region. the largest part of the cortex which is located medially in the primary zone is where visual stimulation is in charge of receiving stimulation from the contralateral visual field of both eyes. visual language symbols are accepted as impulses in the primary center of the second occipital lobe of the hemisphere. information is then forwarded to the visual association area, where the recognition and identification of language symbols occur. the area of visual association that handles language has two paths. first the information from the dominant visual association area goes directly to the word identification area. in the second path, information from the non-dominant area of visual association crosses into the dominant hemisphere through the corpus colosum. information relating to object naming comes from both areas of visual association to the dominant hemisphere word recognition area. at this time the area of impulse recognition associated with naming objects enters the language system and is transmitted to the wernicke area (dronkers, 2010; lumbantobing, 2000; weiner, 2000) the association area is located around the primary cortex. if there is damage in this area, an image can be seen, but not recognized (there is visual agnosia or loss of ability to recognize objects, colors, people, sounds, shapes or smells even though the senses are uninterrupted) (prins & maas, 2002; silbernagl & lang, 2007) the results of the assessment of aphasia with last found that 1 participant could not do verbal instructions correctly. studies show that verbal instructions given can fail in patients with motor disorders, even though their understanding is good (lumbantobing, 2000) conclusion aphasia phenomena can occur in stroke patients in the treatment room. aphasia phenomena in stroke patients in the treatment room include the time of the stroke of aphasia after the attack, monitoring the client's ability to name images, repetition of words and sentences, speaking spontaneously, understanding images, understanding verbal instructions given to patients. the phenomenon that appears can be made a priority for nursing care for nurses after conducting an aphasia assessment with last. last assessment is one of the aphasia studies that can be done by nurses. this tool can monitor the symptoms of aphasia. monitoring is important to find out the immediate condition of aphasia in patients to make prevention or provide appropriate measures. nursing actions that can be given to patients include support for treatment programs and decision making for care actions. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 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2614-3496 (online) vol.3 no.2. april 2020. page.233-243 233 the effectiveness of play therapy in hospitalized children with cancer: systematic review hajaratul azwaningsih ibrahim, arbiyaningsih, andi adriana amal, huriati uin alauddin makassar, indonesia corresponding author: azwaningsih@yahoo.co.id abstract background: play therapy in cancer children is a major intervention that can meet the needs of playing in children who are hospitalized. purpose: this study aimed to determine an effective play therapy model given to children with cancer undergoing hospitalization. methods: the research design used is quantitative descriptive with a systematic review approach. data collection techniques using article search sources in this study are pubmed, science direct, google schoolar, portal garuda, join, ijsr, and emerald. articles published from 2015-2019 and focus on play therapy interventions in children suffering from cancer. results: the results of the analysis of nine articles in accordance with the inclusion criteria about play therapy in children with cancer proved effective in reducing hospitalization of children. the play therapy used in the selected article is drawing, painting, puzzle, storytelling, cognitive behavior and therapeutic play with 20-60 minutes of execution time. conclusion: the play therapy is recommended for use because the technique is simple, does not require a lot of tools and materials, is easy, affordable and can be done by children with preschool and school-age cancer who are hospitalized. keywords: children, hospital, cancer, play therapy. received december, 29, 2019; revised february 10, 2019; accepted march 28, 2020 doi: https://doi.org/10.30994/jnp.v3i2.92 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. mailto:azwaningsih@yahoo.co.id https://doi.org/10.30994/jnp.v3i2.92 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.233-243 234 background cancer is a disease that is the leading cause of death worldwide. cancer is a leading cause of death for children, with 300,000 new cases diagnosed each year. children with cancer in low and middle income countries have a four times greater risk of death than high income countries (who, 2018). the most common cancers in children are acute lymphoblastic leukemia (all) (26%), brain tumors and central nervous system (cns) (21%), neuroblastoma (7%), and non-hodgkin's lymphoma (6%). hodgkin's lymphoma (hl) (15%), thyroid carcinoma (11%), brain and cns tumors (10%), and germ testicular cell tumors (8%) are the 4 cancers most commonly diagnosed in adolescents (ward e, 2014). in indonesia it is estimated that every year there are 4,100 new cases of cancer in children. basic health research (riskesdas) in 2018 states that the prevalence of cancer per mile at the age of less than 1 year is 0.03%, ages 1 to 4 years by 0.08% and ages 5 to 14 years by 0.31% (ministry of health republic of indonesia, 2018). preschool children are ill and the need for children to be hospitalized creates a crisis in their lives. data from dharmais cancer hospital states that cases of childhood cancer in dharmais ssr are likely to increase. the highest increase occurred in 2011, from 63 cases in 2010 to 122 cases in 2011. in 2014, 163 cancer cases were found in children in the dharmais ssr with the most cancers, leukemia, with 46 cases (ministry of health republic of indonesia, 2013). efforts to improve child health are supported by the indonesian government through law no. 23 of 1992 in article 17 which emphasizes that children's health is organized to realize the growth and development of children. efforts to improve children's health starts from the time in the womb, infancy, infancy, pre-school age and school age (health law no. 23 of 1992). children with cancer who undergo hospitalization have effects including separation from family and friends, undergoing painful treatment, being in an unfamiliar environment, and missing out on playing opportunities. children with cancer will experience pain related to the disease process and treatment, visible side effects such as hair loss, weight loss, physical disability, negative impact on the child's social, and psychological adjustment. children with cancer may experience very severe anxiety, withdrawal, behavioral problems, excessive somatic complaints, stress, frustration around them, and difficulty in relationships with peers (elfira, 2011). preschoolers' responses to illness and hospitalization can cause them to see that both things are a punishment and cause children to fear invasive actions (adriana, 2013). preschoolers see hospitalization as a frightening experience. when the child is undergoing treatment in the hospital, usually the child will be prohibited from moving a lot and must rest a lot. this disappoints the child so that it can increase anxiety in children (saputro, 2017). various strategies can be used to help children adjust to the hospital environment, one of them with play therapy. playing in the hospital besides being an effective media to adapt can also provide several benefits, which can improve the relationship between children, families and nurses, can restore feelings of independence in children, provide feelings of pleasure, and help children express feelings of anxiety, fear, sadness, tension and pain (suza, 2015). playing for children is a necessity. when a child is ill and must be treated in a hospital, the need to play should still be facilitated. but in children with cancer not all types of games can be done. to support the treatment process, playing in a hospital must meet the requirements including a child not using much energy to avoid fatigue, playing journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.233-243 235 time is shorter, playing instruments used are simple, relatively safe, do not interfere with children's rest and do not conflict with the therapeutic program (yuliastati, 2016). play is an activity that can be done by children as an effort to stimulate their growth and development and playing in children in the hospital becomes a medium for children to express feelings, relaxation and distraction of uncomfortable feelings. nurses can help parents deal with problems related to the care of their children in the hospital because the nurse is beside the patient for 24 hours. the focus of nursing interventions is to minimize psychological support in child family members. one nursing intervention in overcoming the impact of hospitalization on children is by providing play therapy. play therapy can be done before performing a procedure on a child, this is done to reduce the tension and emotions felt by the child during the procedure. one alternative to divert the attention of children who are hospitalized is by supporting the means of play that can facilitate children to reduce anxiety and fear preschoolers who are hospitalized, because preschoolers still enjoy playing (huda, 2014). many play media to reduce the impact of hospitalization on children. in this study, we want to explain further how effective game media are used by nurses in hospitalized children with cancer and the extent to which outcomes are generated using systematic review as an analysis tool. objective this study aimed to determine an effective play therapy model given to children with cancer undergoing hospitalization methods the design in this research was / the design of this research is quantitative descriptive with a systematic review approach. the research strategy of this research article by using relevant keywords and terms that are mostly used and referring to the terms contained in mesh (medical subject headings) are “hospitalization, play therapy, child, children, cancer, hospitalized, child hospitalized, children hospitalized, hospitalized child, anxiety, pediatric cancer” the source of the search database used in this research are pubmed, science direct, google schoolar, portal garuda, and join, ijsr, dan emerald. the study included for this literature review is an article published in the last 5 years of 2015-2019, there is volume or issn, using experimental design and focusing on play therapy interventions in children suffering from cancer. 9 articles were obtained that fit the criteria, and based on the evaluation with duffy's research appraisal checklist approach 9 articles were included in the category of superior paper (score 205-306). results 1. respondents’ characteristics table 1. respondents’ characteristics play therapy age gender pre school school male female draw √ √ √ paint √ √ √ puzzle √ √ √ storytelling √ √ √ cognitive-behavior √ √ √ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.233-243 236 play therapeutic √ √ √ a. play therapy obtained 1) of the 9 articles found, there were 3 articles that used drawing play therapy to reduce hospitalization in children with cancer. 2) from 9 existing articles, there were 2 articles that used painting play therapy to reduce hospitalization in children with cancer. 3) of the 9 articles found, 1 article that uses puzzle play therapy to reduce hospitalization in children with cancer. 4) of the 9 articles found 1 article that uses storytelling play therapy to reduce hospitalization in children with cancer. 5) of the 9 articles found, 1 article that uses cognitive behavioral play therapy to reduce hospitalization in children with cancer. 6) of the 9 articles found, 1 article uses therapeutic play therapy to reduce hospitalization in children with cancer. b. drawing play therapy 1) the duration of therapy playing drawing is 30 minutes during one game. 2) the procedure of providing drawing therapy is to first measure anxiety in children before bermian therapy is given. after that given the play drawing therapy then the child coloring the picture that has been made. after that, measuring the level of anxiety in children again. c. playing painting therapy 1) the duration of playing therapy is 25 minutes to 60 minutes. 2) the procedure of providing play therapy by painting is to first measure anxiety in children before being given play therapy. after that, he was given therapy to play painting using watercolors and then after painting the children explained their paintings to researchers and other children. after that, measuring the level of anxiety in children again. d. puzzle play therapy 1) the duration of therapy playing puzzle is 20 minutes. 2) the procedure of providing puzzle play therapy is to first measure anxiety in children before being given play therapy then to be given a puzzle play therapy with a type of jigsaw puzzle. after that, measuring the level of anxiety in children again. e. storytelling play therapy 1) the duration of therapy to tell storytelling is 20 minutes. 2) the procedure of giving play therapy with storytelling is to first measure anxiety in children before playing therapy. after that, play therapy is told by storytelling to other children. after that, measuring the level of anxiety in children again. f. cognitive-behavior playing therapy 1) the duration of therapy to play storytelling is 60 minutes. 2) the procedure for providing cognitive behavioral play therapy is to first measure anxiety in children before playing therapy. after that the therapist builds a good relationship with the child to eliminate fear and stress on the child, then identifies the child's emotions through a smiley game then the child is asked to express negative emotions and make positive emotions through the guessing game the puppet emotions then the therapist makes the child laugh and joke together. after that, measuring the level of anxiety in children again. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.233-243 237 g. therapeutic play therapy 1) the duration of therapeutic play therapy is 20 to 30 minutes. 2) the procedure for providing therapeutic play therapy is to first measure anxiety in children before playing therapy. after that the first game uses a chemo duck doll that uses a bandana, iv catheter, arm bandage and a surgical scrub then the children play by practicing treatments or procedures at the hospital using the doll. the second game uses a booklet which is a coloring book with caricature drawings shaped like a syringe and an infusion set that has been modified so that the shape does not make the child feel scared, then the child plays with coloring the caricature picture. after that, measuring the level of anxiety in children again. discussion the results of 9 articles on play therapy in handling hospitalization in children with cancer prove that play therapy is effective in overcoming the problem of hospitalization in cancer patients. the 9 articles show that play therapy can be done at preschool and school age, although different types of age of the child but the results of the study still say that play therapy is effective given. if there are studies using different methods and ages, it is possible that the results found can be different and can be the same. the sampling technique used in the article is the average using purposive sampling. the sampling technique is in accordance with the studies in the article because to determine the sample there must be criteria related to the study. the size of the sample used an average of 14-65 respondents who were then divided into the intervention group and the control group. however, there were 4 journals which had no control group given treatment, so there were differences between the control group and the intervention group. there are 5 journals that use 1 group, namely the intervention group. based on statistical tests in the article using the wilcoxon test and independent test t-test which shows there is an effect of play therapy in dealing with hospitalization in children with cancer. these results indicate that effective play therapy is given to children because it can reduce hospitalization problems that are common in pediatric patients suffering from cancer. in the intervention group given play therapy with a time of 20-60 minutes. according to adriana (2013) which states that the time for playing therapy is 30-35 minutes consisting of the 5 minute preparation stage, the 5 minute opening stage, the 20 minute activity stage and the 5 minute closing stage. meanwhile, according to vanfeet (2011) the time needed for play therapy in children who are hospitalized is 15-20 minutes. 15-20 minutes can make closeness between parents and children and does not cause children to fatigue due to play. based on selected journals effective play therapy is used to overcome hospitalization in children with cancer, namely: 1. drawing play therapy based on the analysis results of drawing play therapy proved to be effective in reducing anxiety in children with cancer. from the results of this study prove that playing with drawing can make children become comfortable and provide a relaxing and distracting effect on children. this is in line with ningsih's research (2015) which states that before being given playing therapy the patient's anxiety level is higher than after being given play therapy. in addition, this study is also in line with research conducted by elfira (2011), namely the anxiety of children who are hospitalized decreases after being given play journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.233-243 238 therapy. play activities undertaken by nurses in children in the hospital will provide benefits to improve the relationship between patients and nurses and will also help express thoughts, anxiety, fear, sadness, tension and pain. according to susanti (2017) play is an activity that children can do as an effort to stimulate their growth and development. play activities are a reflection of physical, intellectual, emotional and social abilities. play is a good medium for learning because by playing, children will speak or communicate, learn to adapt to the environment, do what they do and recognize time, distance, and sound so that it will stimulate and will reduce anxiety. anxiety is the most common response occurring in children with cancer and undergoing treatment. normally anxiety can occur as part of the disease and treatment in cancer sufferers. anxiety can be reactive and situational related to fear after being diagnosed with the disease and during treatment. besides anxiety in children can arise as an impact that occurs from treatment and during treatment procedures such as anemia, stomatitis, malaise, nausea, vomiting, lethargy, weakness, inactivity, skin discoloration, pain, fear, hair loss, changes in body image patient, even anxious about death (saputro, 2017). this anxiety disorder involves anatomical structures in the brain, an aspect that explains anxiety disorders is the influence of the hormone ephineprin. the ephineprin hormone is an adrenaline hormone, this hormone is released in response to stress through the synthesis of catecholamines such as ephineprin. children who experience stress or anxiety the hormone ephineprin in their body will increase due to an increase in oxygen and glucose to the brain and muscles by increasing heart rate (ningsih, 2015). children who experience anxiety can be given play therapy to reduce the hormone ephineprin which increases, after given play therapy there is a decrease in anxiety. the author assumes that play drawing therapy plays an important role in reducing children's anxiety because playing children can express feelings, anxious thoughts, fear, sadness, tension, and pain. this is consistent with the theory that play therapy is the use of games as an effective medium to help patients prevent or resolve psychosocial difficulties achieving optimal growth and development through exploration and self-expression. 2. playing painting therapy based on the research results of playing painting therapy proved effective in reducing anxiety in children with cancer. this is in line with research chari (2013) shows that play therapy is effective in reducing anxiety in children with cancer and play can be used as an effective intervention by health workers to help children diagnosed with cancer in reducing anxiety. anxiety in young children can have an impact on aspects of the child's personal social development. this is consistent with the opinion of the american cancer society (2016) where in clients with a young age, this anxiety will affect the child's relationship with others. there are several ways to overcome anxiety one of which is by playing. in children playing is a daily activity that they always do so that playing is a suitable means of therapy to reduce anxiety in children. playing in the hospital besides being an effective media to adapt can also provide several benefits, which can improve the relationship between children, families and nurses, can restore feelings of independence in children, provide feelings of pleasure, journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.233-243 239 and help children express feelings of anxiety, fear, sadness, tension and pain (a'diilah, 2016). the author assumes play for children is a necessity. when a child is ill and must be treated in a hospital, the need to play should still be facilitated. but in children with cancer not any type of game can be done. one of the games that can be given is to play with painting because children do not use much energy to avoid fatigue, play time is shorter and the instruments used are simple. 3. puzzle play therapy based on the research results, puzzle play therapy has proven to be effective in reducing anxiety in children with cancer. this can be caused because the child feels happy after doing puzzle play therapy so that the child feels comfortable in the hospital environment. this is in line with research conducted by kaluas (2015) which states that puzzle play therapy has a significant effect in reducing the impact of hospitalization on children. the implementation of puzzle play therapy is carried out jointly with other children so that when the child begins to not be interested in continuing to play puzzle, the child will feel challenged when he sees the child next to him almost finished compiling the puzzle. this is evidenced when the other child is almost finished putting together the puzzle pieces, the child will be back excited to continue compiling his puzzle. some children who at first did not greet each other will eventually interact when one of them first finishes the puzzle game. the child who feels defeated will challenge his friend again to rearrange the puzzle. along with this the child will unwittingly interact with friends his age. based on this, it is expected that children will not just be quiet anymore in the room but can invite other children to talk when they start to get bored so that the stage of psychosocial development of children can walk even if the child is being treated. one of the games that can be done in preschoolers is by playing puzzles. according to ball et. al (2012) puzzle is a play tool that can help psychosocial development in preschool children. puzzle games have a distracting effect on children so that children will focus more on puzzle games rather than the anxiety they feel. the benefits of playing puzzles in reducing anxiety have been proven from several studies. one example is a study by ramdaniati (2016) where after being given an anxiety puzzle playing therapy in preschool children who are undergoing hospitalization has decreased. according to the authors of puzzle play therapy can be used as a play option to reduce levels of anxiety in preschoolers who undergo chemotherapy. besides having the benefit of reducing anxiety levels, puzzles can also help the child's psychosocial development, and mental development and creativity of children. playing puzzles also does not require excessive effort so that children will not be tired when playing. 4. storytelling play therapy based on the results of analysis of play therapy with storytelling proved effective in reducing anxiety in children with cancer. storytelling will help children with cancer reduce their anxiety. based on research conducted by susanti (2017), children's anxiety can be reduced by using play activities, one of which is by telling stories. after the intervention is given, children become more comfortable, cooperative, and willing to work together. anxiety in children also decreases, and this can help the healing process in children. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.233-243 240 this is in accordance with research conducted by a'diilah & somantri (2016), with children's storytelling activities able to develop their coping abilities to deal with new things and make children stressed. potter (2016) explains that storytelling is one strategy to shift the focus of children to negative emotions. storytelling is also a reframing technique. this technique can change negative emotions in children with more positive emotions. in addition, storytelling can also be used as a relaxation technique to reduce anxiety. the storytelling method is a method that is non-pharmacological, easy, inexpensive, and is an activity that is liked by children. with storytelling activities, children who experience anxiety show changes in the feelings they experience. the change from loneliness, worry, sadness, fatigue, fear, anger, and crying turned into happy and relaxed after being given storytelling activities (kanchan, 2015). another study conducted by zarei (2013) found that by storytelling, researchers could reduce all aspects of physical anxiety, worries, and social anxiety experienced by children of age schools that are undergoing treatment at the hospital. according to the authors effective storytelling activities are given to children with cancer as an alternative activity for children playing while in hospital, because storytelling is an activity that is easy, affordable, accessible, and is one of the methods favored by children. 5. behavioral cognitive play therapy based on the results of cognitive behavioral play therapy research proven effective in reducing anxiety in children with cancer. identifying emotions and expressing emotions makes children more able to recognize and manage their emotions. moreover, it can reduce anxiety in children while in hospital. this is in line with research conducted by tjahjono (2015) which says that children who receive play interventions in hospitals show fewer negative emotions and experience lower levels of anxiety than children who receive usual care. linnardpalmer (2015) states, play is very important for the mental, emotional, and social welfare of children. like their developmental needs, the need for play does not stop when children are sick or in the hospital. conversely, playing in a hospital provides the main benefits of minimizing the emergence of child development problems, besides the goal of play therapy is to create a safe atmosphere for children to express themselves, understand how things can happen, learn social rules and overcome their problems and provide opportunity for children to express and try something new. meanwhile, according to vanfleet, et al (2011) play therapy is a form of children's play, where they can relate to others, get to know each other, so that they can express their feelings according to their needs. according to the authors of effective behavioral cognitive play therapy given to children because it can help children in expressing negative emotions and building positive emotions so as to eliminate fear and stress in children who are cared for in hospital. 6. therapeutic play therapy based on the results of therapeutic play therapy research proved effective in reducing anxiety in children with cancer. this is in line with research conducted by william (2005) which says that training through therapeutic games can reduce anxiety levels in children aged 7 to 12 years who will perform surgery. the same study was also conducted by saputro (2017) where research conducted on 33 children aged 5 to 12 years showed that playing can reduce anxiety in children journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.3 no.2. april 2020. page.233-243 241 who will undergo a medical examination. play therapy is a therapy that is given and used by children to deal with fear, anxiety and get to know the environment, learn about the treatments and procedures carried out as well as existing hospital staff. play therapy is one of the important aspects of a child's life and one of the most effective tools for dealing with a child's stress when hospitalized, because hospitalization creates a crisis in a child's life and is often accompanied by excessive stress, so children need to play to express fear and anxiety they experience as a coping tool in the face of stress. according to the authors, therapeutic play can help children deal with anxiety due to medical measures they get while undergoing treatment in the hospital. because the game that has been modified by researchers can make children more calm in undergoing various medical actions in the hospital. conclusion based on the results of research from 9 articles stated that effective play therapy in reducing hospitalization in children with cancer including play therapy drawing, painting, puzzle, storytelling, cognitive behavior and therapeutic play that can reduce the impact of hospitalization (reducing anxiety, increasing cooperative behavior, and reduce fear) in children. the play therapy is recommended for use because the technique is simple, does not require a lot of tools and materials, is easy, affordable and can be done by children with preschool and school-age cancer who are hospitalized. suggestion based on the results of the systematic review that has been done about effective play therapy given to children with cancer who are undergoing hospitalization, play therapies like this should be developed in the hospital so that children who are hospitalized can feel calm in a new environment, can be cooperative nurses or doctors who are met every day, besides this therapeutic game can also be carried out at home in order to improve fine motor skills, gross motor skills, language development, and social in children. journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 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(avsar g, kas¸ikçi m, 2011). patient education is a dynamic process, including formal and informal interactive activities, which influences patients’ behavior and produces changes in knowledge, attitudes and skills for better health care outcomes (oyetunde & akinmeye, 2015; avs¸ar g, kas¸ikçi m, 2011; ghorbani et al., 2014). educating the patient also helps to improve the motivation of patients in terms of maintaining their health and improving health outcome (abbasi m, rabiei l & masoudi. r 2018). moreover, patient education is a significant component of high-quality healthcare services (yael l, ilana p & janna s.,2017) and is an important and an essential aspect of nursing (hui-lian che, et al., 2016). during this process, nurse takes the role of a resource provider, mobilizes and teaches patients how to use resources, and improves their sense of control (hui-lian che et al., 2016). in addition, patient education should be carried out from the time of patients’ admission till the time of discharge from the health facility (abbasi m, rabiei l & masoudi. r 2018). more than 28% of nurses reported they have primary responsibility for patient education and almost 64 % perceive they have a great deal of responsibility for overall patient education activities. although nurses consider patient education as an integral part of their care, they fail to implement patient education as much as they desire in the face of work constraints (park, m. y. 2005). although, educating patient and their relatives are a source of satisfaction for the nurses, they felt powerless to deliver patient education consistently due to some obstacles (hui-lian che et al., 2016). several quantitative studies on barriers to patient education showed that excessive workload, inadequate staffs and lack of time were few of the major factors hindering patient education (oyetunde, m. o., & akinmeye, a. j. 2015; livne, y., peterfreund, i., & sheps, j.,2017; karimi moonaghi, h., emami zeydi, a., & mirhaghi, a.,2016 ; abdi, a., izadi, a., vafaeei, k., & lorestani, e. 2014 ; abbasi, m., rabiei, l., & masoudi, r. 2018; ghorbani et al., 2014; ). similarly, a qualitative study among the tawanese nurses also revealed that excessive workload was one of the factors hindering patient education (hui-lian che et al., 2016). in addition, abdi and his colleagues reported mismatch of personnel to patients, job dissatisfaction and lack of managerial attention to patient education as the main barriers of patient’s education (abdi, a., izadi, a., vafaeei, k., & lorestani, e..2014). similarly, bergh and the colleagues also reported lack of support from the managers as the obstacles faced by hospital nurses in attempting to educate patients (bergh et al., 2012). the other obstacles to implementation of patient education were lack of evaluation and documentation of what patients learned. 59% of the nurses and 69.6% of the students reported that lack of consideration of patient education activities in their work appraisal discouraged them to perform patient education as it was time consuming (ghorbani et al., 2014). ). moreover, alternating between patients, not knowing who to provide patient education, difficulty in communication and disrupted confidence and work rhythm were some of the factors which hindered delivery of patient education (hui-lian che et al., 2016). lack of educational materials and environmental factors such as overcrowded patient rooms and lack of educational facilities were also few of the factors hindering patient education (ghorbani et al., 2014). few studies conducted among nurses and nursing student in iran showed that patient’s related factors such a lack of demand to receive education, severe illness, lower educational levels, inability to communicate with the nurse, patients’ attitudes and length of hospital stay, and patient’s lack of interest in provided knowledge were few of the barriers to patient https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.221-229 223 education. (abbasi, m., rabiei, l., & masoudi, r. 2018; ghorbani, r., soleimani, m., zeinali, m. r., & davaji, m. 2014; karimi moonaghi, h., emami zeydi, a., & mirhaghi, a. 2016). quick discharge of the patients from the hospital also poses challenges for the nurses to incorporate patient education as a consequence of busy routine (hui-lian che et al., 2016). patient education has been considered as an important part of nursing for years. however, it is unknown how the bhutanese nurses perceive about patient education. understanding nurses’ perceptions on factors influencing the delivery of patient education may provide healthcare and educational managers with information to develop strategies to promote nursing engagement in patient educational activities. therefore, this qualitative study is conducted in order to understand and explore barriers towards patient education among nurses and also to understand the perceptions of nurses in delivering health education during covid pandemic. methods study design the study design is qualitative and the study is conducted using semi-structured interview. the inclusion and exclusion criteria for the selection of participants are based on the following criteria: inclusion criteria: 1. all categories of nurses (clinical, staff, and assistant nurses) 2. having at least 1 year experience working as a nurse 3. having experience in dealing and providing care to the patients. exclusion criteria 1. other health professionals besides nurses. 2. less than 1 years of working experience. 3. having no experience dealing or providing care to patients. recruitment of participants in order to have a representative sample, equal number of nurses from all the 3 different categories, different age groups, and equal number of male and female nurses were selected. recruitment of participants for the interview was based on purposive sampling in order to gain broad range of perspective. results nurses agreeing to participate in the study were asked to thoroughly read the information sheet, besides delivering detailed additional oral briefings on the points in the information sheet and then they were asked to sign in the consent form prior to the conduction of interview. interviews were conducted with a maximum of 12 participants or until the point of saturation has reached. interviews were recorded, transcribed and read exhaustible on the day of conducting the interview in order to not to miss on any minute details. the data collection was carried out from the first week of october 2021 till the first week of november 2021. data analysis thematic analysis technique was used in order to analyze the data. the first step was to familiarize with the data. the data transcribed was read repeatedly in order to identify themes or patterns among data. after this, the researcher identified the chunks of data (words/phrases/sentences/paragraphs) and started ascribing oneor two-words summary to the chunks of data (open coding). these common themes, statements and ideas were then analyzed for common relationships. central themes and relationships were exhaustibly searched for until https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.221-229 224 they emerged. central themes were identified and open codes were then grouped under different central themes (closed coding). the researcher then interpreted the perceptions of nurses towards patient education and the factors which influence patient education delivery in order to develop narrative description of the meaning the researcher assigned to the quotation of the participants by interweaving the exact quotations from the participants. preparation of interview guide interview questions were developed based on what the research questions were and checking if the questions could extract the answers for the overall research questions. a set of openended questions were developed to direct the interviewer/researcher and these questions usually ask for explanations such as “how” and “why” with regard to nurses’ perceptions towards patient education and factors which hindered the delivery of patient education. open ended follow-up questions were also prepared and were used in order to obtain rich and detailed information of the perceptions and barriers towards patient education. the interview guide was presented to two qualitative research experts and feedbacks/ suggestions were taken into consideration. legal and ethical aspect the study protocol was submitted to the research ethics board of heath, ministry of health, prior to the conduction of the study for the ethical approval. participation in the study was voluntary. participants can withdraw from the study at any point of time without the need to state reasons and on the time of withdrawal, the collected data will be destroyed or the participant will be asked if he/she gives his/her consent to use his/her data. nurses agreeing to participate in the study will be asked to thoroughly read the information sheet, besides delivering additional oral briefings on the points in the information sheet and after all of this is done, they will be asked to sign in the consent form prior to the interview the names and all other personal information will be maintained with confidentiality. the information will be recorded under a pseudonym (if need be) and the data will be secured from unauthorized access. even if the results are published, the findings will be presented anonymously. the names of the participant will be kept anonymous and will not appear in the study. implication of the study understanding nurses’ perceptions on patient education and the factors influencing patient education may provide healthcare and educational managers with information to develop strategies to promote nursing engagement in patient educational activities during ordinary and pandemic times limitation of study this study will be conducted on in jdwnrh. therefore, it may not study the perceptions and factors towards patient education of the nurses in other districts. sponsor/study funding this particular study has received no funding from any organization. the researcher declares no conflict of interest in this study. findings/results three themes on factors hindering patient education delivery to patients and two themes on perceptions on health education delivery during pandemic emerged from the study 1. themes on factors hindering patient education delivery 1.1. nurses related factors 1.2. patient related factors 1.3. inadequate infrastructure https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.221-229 225 2. theme on perception on delivery of health education 2.1. only health education which require patients’ co-operation for undergoing procedure is delivered 3. themes on perceptions on delivery of patient education during pandemic 3.1. change in hospital policy has an impact on patient education delivery during pandemic 3.2. covid related education strengthened 1.1. nurse related factors 1.1.1. time constraints, excess workload and inadequate staffing nurses reported that time constraints, excess workload and busy shift with inadequate number of nursing staff was one of the obstacles in delivering education to the patients. they reported that they were more focused on completing the nursing procedures/tasks first. due to limited staffs and more workload, they did not have time to deliver health education to the patients. “when there are few staffs in a shift, we would prefer to do the procedures fast and then go to the next patient to do the procedure as there is less time to explain everything to the patients. when the tasks in the ward are not complete, we do not have enough time to explain to the patients. when there are only one or two staffs in a shift and when there are lots of procedures to carry out, we do not get time to explain to the patient. we do not feel like explaining to the patient when the tasks are not complete.” participant 8. “i also feel that we do not do much of health education. it is because of time constraints. i do not see nurses communicating to the patients. it is because of lot of work load” participant 2 “we do not have lot of time to sit and talk to them. we do it but it is very brief. we have to do nursing procedures such as intravenous cannulation and change intravenous fluid bottle every now and then. we have lots of procedures for only one patient” participant 3. 1.1.2. lack of knowledge among nurses the participants also attributed lack of knowledge among the nurses as the factor for not imparting health education to the patients. “nurses working in the unit or ward should know about all types of surgery and then only the delivery of health education will be easier and can be delivered to the patient in a proper manner. all types of surgery do not have the same types of education because different types of surgery will have different types of dos and don’ts to follow during post operative period for few weeks. nurses should be well acquainted with knowledge according to the types of surgery and types of disease” participant 1. “due to lack of knowledge among nurses, health education is not being imparted” participant 9. 1.1.3. difficulty in converting /interpreting technical term the participants reported that their inability to explain the technical term to the patients and attendants was one of the reasons hampering the delivery of patients’ education. the other reason was there was no substitute for the technical term in the local language. “the technical terms are difficult to be converted to local language and explained to patients. this is quite difficult. we cannot convey the scientific term to the patients.” participant 8. ‘there are certain english terms for which our native language does not have any term for that. in this kind of scenario, we are not able to explain the scientific term to the patient. this is also one of the challenges” participant 10. 1.2. patient related factors 1.2.1. illiteracy and language barriers https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.221-229 226 participants reported illiteracy and language barriers among the patients and attendants as one of the obstacles for patient education delivery. “sometimes, there is little bit of communication gap. when patient party is illiterate, it is difficult for the patient to comprehend and we have to keep our health education session at halt especially when there is no other nurse colleague who can explain and make the patient party understand” participate 9. “language is a problem. only if we talk to them in their native language, they are able to understand. sometimes we do not speak their language. therefore, we cannot deliver health education to them and our other colleagues who can speak the language will be engaged with other patients” participant 10. 1.2.2. non-receptive patients and attendants the other hindering factor for delivery of patient education, as reported by the nurses, was non-receptive patients and attendants. patients and attendants do not listen to the teachings/suggestions provided by the nurses as the patient party is tired or not interested. “patient attendant are not receptive. this maybe because they have problem at home or they are weak or tired after taking care of the patient for the whole night” participant 3. “some patients have only one attendant. the attendant is busy and not able to sleep at night, they are not able to concentrate and listen to heath education. in cases with two attendants, one attendant listens to health education and they concentrate properly during delivery of health education” participant 8. “sometimes, the patients are not interested in health education” participant 8. “health education is not delivered because our patients are not responsiveness and not very eager to know about their disease condition. they usually do not ask questions. if there are 10 patients in the ward, there will be only one or two patients who will be eager to know about the disease condition. they usually do not ask the health professionals as to how it is done and why it should be done etc.” participant 10. 1.3. inadequate infrastructure participants expressed that limited or non-availability of infrastructure was also one cause of non-delivery of health education. “i think there should be health education delivery room in each ward where you can sit with your patient and provide health education. in our setting we have six patients in one cubicle and when we explain to one patient, it is not comfortable for us or for the patient as well and there are lots of interruption and noise disturbances from other patients and attendants. similarly, there are disturbances from other patients and attendants even when we try to educate the patient at the nurse’s station or in the co-corridor. so, in such scenario, we will need a room where we can sit with the patient and attendants for delivery of patient education using educational material” participant 10. “we do not have a cme room so we provide in the ward. in my opinion i feel that facilities like cme room, videos or projectors should be there to facilitate health education delivery” participant 5. 2. perceptions on health education delivery 2.1 only health education which require patients’ co-operation for undergoing procedure is delivered health education which requires the cooperation of the patient when carrying out a procedure is usually imparted to the patients so that there is proper compliance to the procedure. in addition, health education is also imparted on the time of discharge on medication intake and follows up. on the contrary health education of disease condition of the patients is not usually imparted. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.221-229 227 “nurses are busy and they are involved in task most of the time. so, health education delivery happens only when it is mandatory like when the patient in the ward has to undergo surgery/ct/mri, then you provide health education so that he/she is ready for the procedure” participant 10. “health education is usually given on the time of discharge regarding medication and follow up as per the discharge document. however, health education on specific disease condition is not usually given to patients. when there is procedure that the patient has to undergo, then the health education is given. health education on disease condition is usually not given. nurses educate the patient only if the procedure is compulsory and has to be done and if health education is not delivered, the procedure may fail. participant 8. in our wards, for patients coming with conservative treatment, we are not able to provide health education. our focus is more on pre-operative patients because when we educate them on how to prepare for the surgery, they are able to comply with it. recently we had tonsilitis patient who came for tonsillectomy and it was during my second night shift that i provided health education during that time. participant 3. 3. perceptions on health education delivery during covid pandemic 3.1. change in hospital policy has an impact on delivery of health education one participant expressed that due to the change in policy of the hospital related to the strict prohibition of opd patients in the ward in order to keep the health facility free of covid, the opportunity to provide health education has declined. “i think the patient after discharge is not allowed during in the ward during covid pandemic. otherwise, patient used to come for follow up in the ward after surgery. patients used to come here for post-operative review and nurses used to do the wound dressing and educate patient on the medication usage and follow up”. participant 1. another participant expressed that not allowing excess attendants and visitors in the ward/ unit has given them opportunity to provide health education to their patients. “during the pandemic, the hospital is less crowded, we are able to provide better health education. for example, in my unit before pandemic many attendant/ visitors were allowed in the unit and it was difficult to provide health education. now it is quite better for providing health education” participant 8. health education delivery to the patients is a challenge during the time of lock down during pandemic. “i think the delivery of health education before covid is quite different than now. during pandemic when there is lockdown, patient education is almost forgotten because the number of staff in a shift is decreased to half and therefore, we have two staffs catering to the needs of 14 to 16 patients for a duration of 12 hours. during such time, majority of us are not able to provide health education to the patients though we know that it is very important for the patients. this is also because we try to limit the contact with the patient and secondly the number of nurses is reduced to half and therefore, it is difficult to provide health education participant 10. 3.2. covid related education has strengthened participants also expressed that the health education related to covid or educating patients on covid protocols were initiated during the pandemic. “we can also educate patient more on hand washing and all as it is pandemic. before we also used to provide health education for the sake of it but now, we tell them you are more immunosuppressant patient so you have to take care of hand washing, usage of mask wherever you go you have to use mask. i think that is the only difference” participant 3. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.221-229 228 “now we inculcate covid topics while giving health education. we club covid topics along with other health education topics”. participant 5. “i think the covid related education has improved”. participant 6 “i did not notice any differences in the health education delivery before pandemic and during pandemic. however, explanation of covid protocol has come up. apart from that there are not much changes to health education”. participant 7. discussion barriers to patient education the study explores the factors hindering health education delivery by the nurses to the patients. the challenges are categorized as nurse related factors, patient related factors and limited infrastructure. the nurse related factors include time constraints, excess workload and inadequate staffing, lack of knowledge among the nurses and the inability of nurses to explain the technical terms to the patients. this finding is in line with a qualitative study among the taiwanese nurses also revealed that excessive workload was one of the factors hindering patient education (huilian che et al., 2016). similarly, several quantitative studies on barriers to patient education that showed that excessive workload, inadequate staffs and lack of time were few of the major factors hindering patient education (oyetunde, m. o., & akinmeye, a. j. 2015; livne, y., peterfreund, i., & sheps, j.,2017; karimi moonaghi, h., emami zeydi, a., & mirhaghi, a.,2016 ; abdi, a., izadi, a., vafaeei, k., & lorestani, e. 2014 ; abbasi, m., rabiei, l., & masoudi, r. 2018; ghorbani et al., 2014; ). moreover, alternating between patients, not knowing who to provide patient education, difficulty in communication and disrupted confidence and work rhythm were some of the factors which hindered delivery of patient education (hui-lian che et al., 2016). the patient related factors were illiteracy and language barriers, non-receptive patients and attendants. this is also in line with the studies conducted among nurses and nursing student in iran which showed that patient’s related factors such a lack of demand to receive education, severe illness, lower educational levels, inability to communicate with the nurse, patients’ attitudes and length of hospital stay, and patient’s lack of interest in provided knowledge were few of the barriers to patient education .(abbasi, m., rabiei, l., & masoudi, r. 2018; ghorbani, r., soleimani, m., zeinali, m. r., & davaji, m. 2014; karimi moonaghi, h., emami zeydi, a., & mirhaghi, a. 2016). the other factor which hindered education delivery was lack of infrastructure. this is in line with the study conducted by ghorbani and the colleagues. it was found out that lack of educational materials and environmental factors such as overcrowded patient rooms and lack of educational facilities were also few of the factors hindering patient education (ghorbani et al., 2014). conclusion perceptions on health education delivery health education which requires the cooperation of the patient when carrying out a procedure and education at the time of discharge regarding medication usage and follow ups are usually imparted to the patients. however, health education on disease condition of the patients is not usually imparted. perceptions on health education delivery among nurses during covid pandemic the policy related to covid pandemic has influenced the health education delivery to the patients by the nurses. the covid related health topics were introduced and health education https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.221-229 229 was delivered more on these topics than ever before. due to the restriction of visitors/attendants in the hospital during the time of pandemic in order to keep the health facility free of covid cases, this has resulted in less crowding and favorable environment for the nurses to provide health education to their patients as it is less noisy. as per the author’s knowledge there is no study which has explored the health education delivery to the patients during the covid pandemic. at the same time delivering of health education was still a challenge during the pandemic as the number of nurses working per shift was reduced during lock down and nurses used to maintain distance from patient admitted in the ward as they feared of contracting covid. references abbasi, m., rabiei, l., & masoudi, r. (2018). experience of nursing students about the barriers to patient education: a qualitative study in iran. korean journal of medical education, 30(4), 327. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6288616/. abdi, a., izadi, a., vafaeei, k., & lorestani, e. (2014). assessment of patient education barriers in viewpoint of nurses and general physicians. international research journal of applied and basic sciences, 8(12), 2252-2256. https://irjabs.com/files_site/paperlist/r_2451_150108160608.pdf. avşar, g., & kaşikçi, m. (2011). evaluation of patient education provided by clinical nurses in turkey. international journal of nursing practice, 17(1), 67-71. che, h. l., yeh, m. y., jiang, r. s., & wu, s. m. (2016). taiwanese nurses’ experiences of difficulties in providing patient education in hospital settings. nursing & health sciences, 18(1), 113-119. https://onlinelibrary.wiley.com/doi/abs/10.1111/nhs.12266. ghorbani, r., soleimani, m., zeinali, m. r., & davaji, m. (2014). iranian nurses and nursing students' attitudes on barriers and facilitators to patient education: a survey study. nurse education in practice, 14(5), 551-556. https://doi.org/10.1016/j.nepr.2014.06.003. moonaghi, h. k., hasanzadeh, f., shamsoddini, s., emamimoghadam, z., & ebrahimzadeh, s. (2012). a comparison of face to face and video-based education on attitude related to diet and fluids: adherence in hemodialysis patients. iranian journal of nursing and midwifery research, 17(5), 360. karimi moonaghi, h., emami zeydi, a., & mirhaghi, a. (2016). patient education among nurses: bringing evidence into clinical applicability in iran. investigacion y educacion en enfermeria, 34(1), 137-151. https://doi.org/10.17533/udea.iee.v34n1a16. karimi moonaghi, h., emami zeydi, a., & mirhaghi, a. (2016). patient education among nurses: bringing evidence into clinical applicability in iran. investigacion y educacion en enfermeria, 34(1), 137-151. http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=s012053072016000100016. livne, y., peterfreund, i., & sheps, j. (2017). barriers to patient education and their relationship to nurses’ perceptions of patient education climate. clinical nursing studies, 5(4), 65. https://www.scilit.net/article/f86e66ebdde4f9d8ce9eb79e7299d9ce. oyetunde, m. o., & akinmeye, a. j. (2015). factors influencing practice of patient education among nurses at the university college hospital, ibadan. open journal of nursing, 5(05), 500 https://www.scirp.org/html/11-1440428_56519.html. park, m. y. (2005). nurses' perception of performance and responsibility of patient education. journal of korean academy of nursing, 35(8), 1514-1521. https://thejnp.org/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6288616/ https://irjabs.com/files_site/paperlist/r_2451_150108160608.pdf https://onlinelibrary.wiley.com/doi/abs/10.1111/nhs.12266 https://doi.org/10.1016/j.nepr.2014.06.003 https://doi.org/10.17533/udea.iee.v34n1a16 http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=s0120-53072016000100016 http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=s0120-53072016000100016 https://www.scilit.net/article/f86e66ebdde4f9d8ce9eb79e7299d9ce https://www.scirp.org/html/11-1440428_56519.htm journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.281-293 281 the influence of workload factors, work stress and health personnel competency on the implementation of hospital occupational safety and health management systems (smk3rs) alfian yoga wiratna1*, nway eint chei2 1magister of public health program, institute of health science strada indonesia, kediri, indonesia 2immunization officer-covid vaccination & response (unv), unicef-yangon, myanmar *corresponding author: alfianyogawiratna@gmail.com abstract background: accident prevention in the workplace cannot be separated from the influence of behavior and application by health workers in its implementation which prioritizes the interests of patient safety. the behavior and abilities of health workers play an important role in the implementation of patient safety. several factors that influence the behavior of nurses in implementing the hospital occupational health and safety management system (smk3rs) are influenced by motivation, perceptions, attitudes, organizational culture, knowledge and experience. purpose: the purpose of this study was to determine and analyze how the description influence and relationship between workload, work stress and implementation of hospital occupational health and safety management system (smk3rs) at lira medika hospital karawang. methods: the sampling technique used is purposive sampling with a total sample of 100 people. this type of research is descriptive verification research. the statistical instrument used is regression analysis using validity, reliability, normality tests. results: an influence of workload, work stress and competence on the assessment of the implementation of hospital occupational health and safety management system (smk3rs) by 19.05% because the rest is influenced by other variables or factors such as training, education level, motivation, leadership and others. conclusion: based on the results of the study, it appears that the workload parameters have no effect on the implementation of hospital occupational health and safety management system (smk3rs) for medical service/supporting staff at lira medika hospital. meanwhile, the direct effect is work stress and work competence. keywords: competence, smk3rs, workload, work stress received march 10, 2022; revised april 1, 2022; accepted april 29, 2022 doi: https://doi.org/10.30994/jnp.v5i2.220 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:alfianyogawiratna@gmail.com https://doi.org/10.30994/jnp.v5i2.220 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.281-293 282 background health workers and workers in the medical sector are at risk of occupational diseases, including covid19, as a result of their work. managers need to work to protect the health of their employees. all workers need to understand the risks of their job and work according to safety procedures. because health facilities are high-risk workplaces, work accident compensation insurance is important for the health and safety of health workers and workers in the medical field (mustikawati, 2020). hospitals as medical service companies have various problems, one of which is occupational safety and health (k3). various types of potential hazards in hospitals are caused by biological, chemical, ergonomic, physical, and psychosocial factors, including health workers, visitors, patients, and the surrounding environment. kak), which can cause illness and work accidents in the area as well as other implications. there should be a standard of protection for hospital workers. aspects of knowledge, attitude and involvement of k3 which are part of the behavior of nurses also play an important role in the successful implementation of k3 in hospitals and efforts to overcome accidents in the workplace (rifai et al., 2020). lira medika hospital is a type c private general hospital, and has been operating since june 5, 2014, in karawang, west java to maximize the needs of the karawang community and its surroundings. lira medika hospital has introduced the k3rs management system since its inception. rs. lira medika has been trying to achieve zero accidents during its implementation since the k3rs program was first implemented. based on k3rs 2020 report data, there are still cases of occupational illness (pak) and work accident (kak). the data obtained indicate that the main cause of pak and kak is the behavior of employees who tend to be negligent. the hospital strives to create a workplace that is healthy and safe from work accidents, such as changing the hazardous behavior of employees into safe behavior. initial observation results. revealed that lira medika hospital has a relatively high number of services per day, with an average of more than 50% of the available beds, and of course is a hospital with a high risk of work accidents for employees, patients and visitors. from initial observations, lira medika hospital has implemented a comprehensive k3rs management system for employees to comply with standard precautions. it's like when you want to dispose of used toxic and hazardous waste (b3) for medical purposes that are infected with used syringes, i know there are. in the process of disposal, there are still employees who neglect to use personal protective equipment (ppe) in the form of gloves, so that employees are infected with syringes used by patients. accident prevention in the workplace cannot be separated from the influence of behavior and application by nurses. the implementation should prioritizes the interests of patient safety (zahiri harsini et al., 2020). 36 of 2014, a health worker is every person who devotes himself to the health sector and has knowledge and or skills through education in the health sector which for certain types requires the authority to carry out health efforts. health workers are grouped into 13 groups, medical personnel, clinical psychology staff, nursing staff, midwifery staff, pharmaceutical personnel, public health workers, environmental health workers, nutritionists, physical therapy personnel, medical technical personnel, biomedical engineering personnel, traditional health workers, and other health workers. minister of health regulation number 52 of 2018 states that the occupational health and safety management system in health facilities includes: ohs plans in health facilities. implementation of the ohs plan in health facilities. ohs performance monitoring and evaluation in health facilities review and improvement of ohs performance in medical https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.281-293 283 facilities. meanwhile, the implementation of k3 standards for health facilities include the application of standard precautions carried out by health workers (indonesia ministry of health, 2018). from the inhibiting factors for the implementation of the occupational safety and health management system here in after referred to as smk3 proposed by konradus (2012), it can be seen that the inhibiting factors that caused the implementation of smk3 at lira medika hospital were not on target due to the quality of human resources (hr) which was low k3 awareness and knowledge and safety behavior are still relatively low, there is no commitment from management and workers to the implementation of k3, low supervision of k3, less than optimal law enforcement against k3 violations (konradus, 2012). problems in this study based on the facts above, the authors are encouraged to conduct further research on personal factors that can affect the implementation of smk3rs, especially in terms of the application of k3 standard precautions. the author chose the research title "analysis of the effect of workload factors, work stress and competence of health workers on the implementation of hospital occupational health and safety management system (smk3rs) at lira medika hospital karawang".the variables used in this study are the result of a combination of several empirical studies, which differ in the object of research, which of course will give different results. objective the purpose of this research is to analyze the effect of workload, work stress, and competency of health workers on the implementation of the hospital occupational safety and health management system at lira medika hospital. methods this research is an associative research, where this study aims to determine the relationship between two or more variables (sugiyono, 2015). this research was conducted at lira medika hospital karawang, indonesia at november 2021. the research was conducted toward health workers in lira medika hospital karawang, indonesia. the population in this study was employees of medical and nursing services/support who served in the lira medika hospital, amounting to 442 people. from the total population of health workers, 442 people were re-selected based on the status of permanent employees or working years of more than one year so that the total population according to the criteria above became 169 people, the number of samples taken was 100 respondents. analysis of the data used in this study is multiple linear regressions. this model was chosen to determine how much influence the independent variables have on the dependent variable either partially or jointly. it is expected that the hypothesis that includes: h1: the workload affect the implementation of hospital occupational safety and health management system at lira medika hospital karawang. h2: work stress affects the performance of the companion the implementation of hospital occupational safety and health management system at lira medika hospital karawang. h3: competence affects the performance the implementation of hospital occupational safety and health management system at lira medika hospital karawang. h4: workload, work stress and competence affects the performance the implementation of hospital occupational safety and health management system at lira medika hospital karawang, it can be validly tested. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.281-293 284 results validity and reliability test results the stages of testing the questionnaire were carried out as an effort to measure the extent to which the questionnaire made had a level of validity and reliability. a valid questionnaire is a questionnaire that has a good level of readability so that respondents are able to fill out the questionnaire easily without any confusion in providing the answers to the questionnaire. while a reliable questionnaire is a questionnaire that can be used to measure different objects in different timescales on the same research subject. this test is carried out to see whether the data obtained in the field are really worthy of research or not. this test uses validity and reliability tests. validity test results validity test is used to measure whether or not a questionnaire is valid. the questionnaire is said to be valid if the questions on the questionnaire are able to reveal something that will be measured by the questionnaire. validity testing was carried out with the help of a computer using the spss program with a significance level of 5% or 0.05. if r count > r table, then it is said to be valid and vice versa. reliability test results the reliability test is to measure a questionnaire which is an indicator of a variable or construct. a questionnaire is said to be reliable if a person's answer to a statement is consistent or stable from time to time. a variable is said to be reliable if it gives a cronbach alpha value > 0.60. table 1. reliability test results no. variabel cronbach apha role of thumb description 1. workload (x1) 0.470 0.6 reliable 2. work stress (x2) 0.476 0.6 reliable 3. competence (x3) 0.378 0.6 reliable 4 implementation of smk3rs 0.614 0.6 reliable source: data processed questionnaire based on table 1, the test was carried out in a variable manner, not in question items on each variable, which can be seen the result is the cronbach's alpha value is greater than 0.6, it can be concluded that workload, work stress, competence and implementation of hospital occupational safety and health management system (smk3rs) are said to be reliable. classic assumption test results normality test results the results of the normality test of the data from the residuals with the kolmogrovsmirnov normality test using spss v.25.0 can be seen in the table below: https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.281-293 285 source: data processed questionnaire figure 1. picture of normality test results based on figure 1, we can see that the plotting points in the picture "normal p-p plot of regression standardized residual" always follow and approach the diagonal line. therefore, as the basis or guidelines for decision making in the normality test of the probability plot technique, it can be concluded that the residual value is normally distributed. thus, the assumption of normality for the residual value in linear regression analysis is fulfilled. heteroscedasticity test results heteroscedasticity test is used to determine whether or not there is an inequality of residuals in the regression model. in this discussion, a heteroscedasticity test was carried out using the spearman's rho test, which correlated the residual value (unstandardized residual) with each independent variable. if the correlation significance is less than 0.05, then the regression model has heteroscedasticity problems (widiawati, 2017). the test results are as follows: source: data processed questionnaire figure 2. scatterplot of heteroscedasticity testing results https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.281-293 286 from the figure 2, it can be seen that the dots do not form a clear pattern, and the points spread above and below the number 0 on the y axis. so it can be concluded that there is no heteroscedasticity problem in the regression model. multicollinearity test results the multicollinearity test aims to test whether there is a correlation between the independent variables in the regression model. a good regression model should not have a correlation between the independent variables. to find out the existence of multicollinearity in the regression model, it can be seen from the value of variance inflation factor (vif). table 2. multicollinearity test results no . variabel tolerance vif <10 description 1. workload (x1) 0,980 1,020 does not experience multicollinearity 2. work stress (x2) 0,249 4,015 does not experience multicollinearity 3. competence (x3) 0,249 4,014 does not experience multicollinearity source: data processed questionnaire based on the results of table 1, it shows that workload and work stress and competence have a tolerance value of < 1, so referring to the basis for decision making in the multicollinearity test, it can be concluded that there is no multicollinearity in the regression. while the vif value has a value of < 10, it refers to the basis for making decisions. the vf value in the multicollinearity test can be concluded that there is no multicollinearity in the regression. data analysis data analysis is a description of data analysis or testing based on data obtained by distributing questionnaires that can be realized in hypotheses. where the hypothesis is a temporary answer to the problems that are formulated and will be investigated in research. with the formulation of the problem, it is necessary to prove by analysis. in this study, the data analysis technique was multiple regression analysis. the results of the data analysis can be seen as follows: table 3. data analysis results variabel β std error t hitung sign constant 15.584 7.509 2.075 0.041 workload (x1) 0.709 0.100 7.098 0.000 work stress (x2) -0.159 0.220 -0.727 0.469 competence (x3) 0.297 0.200 1.484 0.141 r 0.611 f count 19.054 r square 0.373 probability f 11.699 adjusted r2 0.354 source: data processed questionnaire https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.281-293 287 regression equation multiple linear regression equation with three independent variables, namely b1 = 0.709, b2 = -0.159, b3 = 0.297. the values at the output are then entered into the multiple linear regression equation as follows: y' = a + b1x1 + b2x2 + b3x3 y' = 15.584 + 0.709x1 + (-0.159x2) + 0.297x3 y' = 15.584 + 0.709x1-0.159x2 + 0.297x3 (y' is the predicted dependent variable, a is a constant, b1, b2, and b3 is the regression coefficient, and x1, x2, and x3 are independent variables). based on the multiple linear regression equation above, it can be described as follows: 1) the constant value of is 15.584, it means that if the independent variable (free) is zero, then the dependent variable (bound) has a negative value of -6.522. 2) the value of the workload variable coefficient (x1) is positive at 0.709, this gives an illustration that the workload has a positive and significant influence on performance the implementatiton of hospital occupational safety and health management system at lira medika hospital karawang. this means that for every 0.1 unit increase in workload, the workload will increase performance on the implementatiton of hospital occupational safety and health management system at lira medika hospital karawang. 3) the coefficient of work stress variable (x2) has a negative value of -0.159, this illustrates that the work stress factor has no significant and significant effect performance on the implementatiton of hospital occupational safety and health management system at lira medika hospital karawang. this means that any increase in work stress will not increase the implementation of the implementatiton of hospital occupational safety and health management system 4) the coefficient of competency variable (x3) has a positive value of 0.297, this illustrates that the competency factor has a positive and significant influence on performance the implementatiton of hospital occupational safety and health management system at lira medika hospital karawang. this means that every increase in work competence will increase the implementation of the implementatiton of hospital occupational safety and health management system. coefficient of determination r2 the analysis of the coefficient of determination or r square is used to find out how big the pe rcentage of the contribution given by the independent (free) variable together to the dependent (bound) variable. based on the value of the coefficient of determination (r2) of 0.373. it shows that the variables of workload, work stress, competence can affect the implementation of the implementation of hospital occupational safety and health management system by 37.3% and the remaining 62.7% is influenced by other independent variables of. f test the results of the analysis show that the value of f count is 19,054 with a significance level of 0.000 or the significance obtained is less than <0.01, meaning that h0 is rejected. ha is accepted. so it can be concluded that the model used is accepted. this means that workload, work stress, work competence have a significant influence on the implementation of hospital occupational safety and health management system (smk3rs). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.281-293 288 discussion effect of workload on the implementation of the hospital occupational health and safety management system (smk3rs) based on the results of data analysis, it is known that the sig value for the effect of workload (x1) variable on smk3rs is 0.000> 0.05 while the value of count is 7.098> t table 1.985 so it can be concluded that the workload has no influence on the implementation of smk3r so it can be concluded that the workload does not has a positive and significant impact on the implementation of smk3rs for medical service/supporting staff at lira medika hospital. it can be concluded that h1 is rejected. result shows that most of the respondents' answers are in the moderate category with a total of 56 respondents (55%). these results provide an illustration that in general the workload of the service/medical support staff at lira medika hospital is medium. however, it was also found that respondents with a high workload category were 3 people or 9%, and 41 respondents or 36% of respondents were in the high workload category. the workload is something that arises from the interaction between the demands of the tasks of the work environment which is used as a place of work, skills, behavior and perceptions of workers. workload can sometimes also be defined operationally on various factors such as the demands of the task or the efforts made to measure the work. however, it is not wise to only consider the workload from one aspect only, as long as the other factors are interrelated in complex ways. in general, the optimum level of workload intensity will be achieved if there is excessive pressure and tension both physically and mentally. what is meant by pressure here is with regard to several aspects of human activity, tasks, organization, and from the environment that occur as a result of individual worker reactions because they do not get the appropriate desires. while tension is a logical consequence that must be accepted by the individual concerned as a result of the pressure received (campbell et al., 2013). an organizational system consists of many interdependent and interrelated subsystems that work together to complement each other to facilitate the achievement of organizational goals in all categories, both large and small. employees in every organization have varying levels of workload that they face on a daily basis. if for any reason the workload changes, the change changes employees' stress levels as well as their perception of fairness in the workload balance, especially when the change is positive. but is it positive, as in the case of increased workload; or negative, such as a reduction in workload; it has implications for employee job satisfaction and ultimately, work performance (ali & farooqi, 2014). this is in line with the opinion of research i. rukmana (2020) which obtained the result that workload has no effect on employee performance at pt xyz (rukmana, 2020). the results of this study indicate that the workload level of 55% of respondents is at a moderate level or can still be called balanced so that it has not been able to have a significant impact on the implementation of the smk3rs program. the effect of work stress on the implementation of the occupational health and safety management system (smk3rs) https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.281-293 289 based on the results of data analysis, it is known that the sig value for the effect of the work stress variable (x2) on smk3rs. is 0.469 <0.05 while the value of t count -0.727 < t table 1.985 so it can be concluded that work stress has an influence on the implementation of smk3r. medicine. it can be concluded that h2 is accepted. table 4.6 shows that most of the respondents' answers are in the moderate category with a total of 70 respondents (70%). these results illustrate that in general the work stress of medical service/support workers at lira medika hospital is moderate. however, it was also found that respondents with a high work stress category were 11 people or 11%, and 19 respondents or equal to 19% of respondents are in the category of high work stress. this is in accordance with the theory according to stranks (2005), work stress experienced by workers is not only detrimental to workers but also to the company (strank, 2005). the impact of job stress experienced by workers can affect organizational performance in achieving company targets. stress is a universal element that cannot be avoided and people from almost every culture and demographic must face levels of stress (robbins, 1999). employees belief that their company does not value them, and sometimes employees do not even want to work with their organization for reasons that the organization does not offer them a part in decision making, no control over the work environment and lack of relaxation in the workplace, which are some of the main factors causing employee stress (bhui et al., 2016). from the results of this study, it can be concluded that the work stress of employees at lira medika hospital karawang is mostly at moderate results as much as 66%. employee work stress is becoming a plus for the implementation of the k3rs program in order to prevent pak and kak. therefore, it is necessary to improve management efforts to reduce work stress on employees as an effort to support the implementation of the k3rs program. influence of competence on the implementation of occupational health and safety management system (smk3rs) based on the results of data analysis, it is known that the sig value for the influence of the work competency variable (x3) on the implementation of smk3rs is 0.141>0.05 while the value of t count is 1.484>t table 1.985 so it can be concluded that work competence has an influence on the implementation of smk3rs. this means that the level of competence will have an impact on the implementation of smk3rs. so it can be concluded that work competence has a positive and significant influence on the implementation of smk3rs for medical service/supporting staff at lira medika hospital. it can be concluded that h3 is accepted. result shows that most of the respondents' answers are in the moderate category with a total of 66 respondents (66%). these results provide an illustration that in general the competence of the service/medical support personnel at lira medika hospital is medium. however, it was also found that respondents with low competency categories were 25 people or 25%, and 9 respondents or 9% respondents. are in the category of high competence. these results are in line with the theory of robbins (2003) which states that if employees have the ability or competence at work, they can help employees to handle stress https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.281-293 290 carefully which will form an exciting work situation so that it has an impact on increasing employee safety behavior, this will greatly support the occupational safety and health management system (k3rs) program. is a variable that can have an influence on the safety behavior of health workers. one way to measure the level of competence of nurses is to look at the level or level of education, most of the health workers at the lira medika hospital karawang have an undergraduate education level and the profession is the standard and benchmark that nurses already have fairly good competence. through good competence nurses will be able to provide the best service to patients (robbins, 2003). from the results of the study, it can be concluded that the competence of employees at lira medika hospital karawang is mostly on average results. high employee competence will be an advantage for the implementation of the k3rs program in order to prevent pak and kak. therefore it is necessary to improve employee competence so that it is better to support the achievement of the k3rs program; efforts to increase competence can be through employee education and training. effect of workload, work stress, competence on the implementation of the occupational health and safety management system (smk3rs) the results of the analysis show that the calculated f value is 19.054 with a significance level of 0.000 or the significance obtained is less than <0.01, meaning that h0 is rejected. ha is accepted. based on kmk ri no. 1087 / menkes / sk / vii / 2010 occupational health and safety (k3) is an effort to provide safety guarantees and improve the health status of workers by preventing occupational diseases (pak), occupational accidents (kak) and controlling hazards in the workplace. occupational health and safety in the hospital itself as an effort to improve and maintain guaranteed health for all hospital staff positions, patients, patient companions, hospital visitors, and the hospital environment so as to reduce the number of accidents and occupational diseases, so that can create a hospital environment that is safe, comfortable, healthy, and prosperous. k3rs management efforts are supported by the role of health workers and non-health workers who work in hospitals. the results of previous research from the journal of nurse behavior in the application of occupational health and safety management in aceh (2017), concluded the importance of disciplined behavior from health and non-health workers who work in hospitals that support the implementation of k3 in hospitals. it is necessary to develop knowledge and skills in the field of nursing management, especially related to k3 so that the services provided are more optimal and quality without forgetting the level of health and safety for nursing care providers. from the journal of factors relating to the implementation of ohs applications in health workers at rsia permata sarana husada for the period of february 2015, it can be concluded that the implementation of k3 at rsia permata sarana husada has been implemented, but is still not good. there are still many workers who have not received knowledge and information about k3rs policies. there is a relationship between the level of knowledge about k3rs with efforts to implement k3 at rsia permata sarana husada, https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.281-293 291 the results of this study indicate that the model used is acceptable. this means that workload, work stress, work competence has a significant influence on the implementation of smk3rs. variable workload, work stress, work competence on the implementation of the occupational safety and health management system (smk3rs). this finding is in accordance with the prediction of hypothesis 4 which predicts that workload, work stress, work competence have a significant influence on the implementation of smk3r. /medical support at lira medika hospital. hospitals have a role in promoting occupational safety and health among workers, employers and the public. in particular, the promotion of k3rs through an approach with humans, namely the workforce so that they can improve safe behavior at work and employees can always remember and understand more about the k3 aspects that are conveyed. some of the osh promotion activities carried out by the hospital include osh training, ohs supervision and communication. from the results of the study it can be concluded that the implementation of smk3rs at lira medika hospital karawang is in the good enough category. this means that some employees have been exposed to messages in k3 promotions which are part of the k3rs program. workload and work stress are still within normal limits and can be tolerated, the competencies possessed by employees are good according to hospital standards. this becomes a resource for the k3 manager and for the implementation of the k3rs system. conclusion based on the results of the study, it appears that the workload parameters have no effect on the implementation of smk3r for medical service/supporting staff at lira medika hospital. meanwhile, the direct effect is work stress and work competence. this shows that the condition of a person's ability, whether experiencing work stress or having good work competence, has an effect on every work performance, this will greatly support the optimization of the implementation of the k3rs program. self-confidence makes people able to do a job better, and vice versa, emotional disturbances such as fear and shame can also reduce a person's work performance or appearance, so that competence will decrease. in an effort to implement the optimal k3rs program, routine evaluations are needed to always remind the importance of working in a healthy and safe condition such as carrying out a cycle of k3 handling activities periodically daily, weekly, and monthly evaluations can be started from the internal work unit that handles similar work, led directly by the head of the working group. the level of risk can be reduced by making standard operating procedures clear and easy to understand for each part of the work and monitoring the implementation of work safety standards on a regular basis. it is known that employees already understand the importance of ohs regulations and implementation. however, in reality, it is not fully maximized. it is hoped that employees can change their perception to become professionally oriented, so that the implementation of k3 can be realized to the maximum. the implementation of socialization of k3 policies and various information about k3 is carried out repeatedly and continuously by the management https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.281-293 292 by involving all elements within the company so that the implementation of smk3 in the company can achieve optimal value. acknowledgments the author is thankful to respondents in lira medika hospital, karawang for their valuable information and their awareness to participate in this research. references ali, s., & farooqi, y. a. 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(2020). aspek keselamatan dan kesehatan kerja pada fasilitas pelayanan kesehatan di instansi kesehatan wilayah kerja puskesmas banguntapan iii. jurnal pemberdayaan: publikasi hasil pengabdian kepada masyarakat, 4(1), 91–98. https://doi.org/10.12928/jp.v4i1.2020. robbins, s. p. (1999). prinsip-prinsip perilaku organisasi edisi ke 5. jakarta: erlangga. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.2. april 2022. page.281-293 293 robbins, s. p. (2003). perilaku organisasi. jakarta: pt. indeks kelompok gramedia. rukmana, i. j. (2020). the influence of leadership and motivation on employee performance. almana : jurnal manajemen dan bisnis, 4(2), 190–196. https://doi.org/10.36555/almana.v4i2.1352. strank, j. w. (2005). stress at work: management and prevention. amsterdam: elsevier publishing. sugiyono. (2015). metode penelitian manajemen. bandung: alfabeta. widiawati, k. (2017). peran standar kompetensi karyawan sebagai upaya meningkatkan pelayanan prima pada bisnis perbankan di indonesia. jurnal ilmiah ilmu administrasi dan sekretari, 1(2), 1–15. http://journal.wima.ac.id/index.php/vocatio/article/view/1638. zahiri harsini, a., ghofranipour, f., sanaeinasab, h., amin shokravi, f., bohle, p., & matthews, l. r. (2020). factors associated with unsafe work behaviours in an iranian petrochemical company: perspectives of workers, supervisors, and safety managers. bmc public health, 20(1), 1192. https://doi.org/10.1186/s12889-020-09286-0. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.183-194 183 the effectiveness of visual art on the psychological response in stroke survivors : a systematic review yoga ayom pangestu*, yurike septianingrum, imamatul faizah department of nursing and midwifery, nahdlatul ulama university, surabaya, indonesia *corresponding author: ayom.ns16@student.unusa.ac.id abstract background: stroke causes disability and has an impact on the psychological needs of patients who are often not met so they are at risk for depression, anxiety, stress, isolation, and other negative impacts. purpose: this study is a systematic literature review aimed at identifying and discussing the benefits and effectiveness of visual arts interventions on psychological responses in post-stroke patients. methods: article searches are performed from pubmed, proquest, sage, and other search results databases. results: a total of 8 articles were selected and a discussion was carried out regarding visual art interventions on psychological responses in post-stroke patients. visual arts therapy (drawing, painting, and digital) has been to be effective for psychological responses in stroke survivors. conclusion: the benefits and effectiveness of therapy can be felt from 7 to >20 sessions with varying durations for each session. apart from having a positive impact on psychology, visual arts therapy can also train motor, cognitive, and memory functions in post-stroke patients. keywords: psychological response, stroke, visual art received february 10, 2023; revised march 12, 2023; accepted april 3, 2023 doi: https://doi.org/10.30994/jnp.v6i2.308 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attribution-non commercialsharealike 4.0 international license. https://thejnp.org/ mailto:ayom.ns16@student.unusa.ac.id https://doi.org/10.30994/jnp.v6i2.300 journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.183-194 184 background stroke is a cerebrovascular disease that can cause physical disabilities such as paralysis to death if not treated quickly and appropriately (ting lo et al., 2018). stroke does not only cause physical problems, but all aspects of the patient's life including psychosocial well-being and quality of life (chan et al., 2021). psychosocial needs that are not met can cause stressful conditions in post-stroke patients. these conditions can be in the form of negative feelings, achievement of reality, increased risk of health problems, and can cause depression (mare et al., 2019). mare et al (2019) said that 1 in 3 post-stroke patients tend to experience depression in the first 1 year. the prevalence of depression in post-stroke patients is 31.1% (schottke & giabbiconi, 2015 in mare et al., 2019). whereas frey et al (2020) said that the prevalence of depression in post-stroke patients can reach 33%.gu & chang (2017)said that 50% of poststroke patients experience depression. in a cohort study involving 12,000 post-stroke patients, approximately more than all post-stroke patients with depression had poor adherence to antidepressants. so the results of treatment in post-stroke patients with depression are inadequate (wijeratne et al., 2022). post-stroke patients should be suspected of having depression if there is a delay in recovery from the estimated estimate, the patient's cooperative level with therapy, and unstable emotions. depression in post-stroke patients can reduce the effectiveness of therapy and the recovery process (mare et al., 2019). previous studies have shown that depression that persists after a stroke can predict a decrease in quality of life in the long term (wijeratne et al., 2022). art is one of the interventions that can be applied in health services and has been carried out in various international articles. patient participation in artistic activities is a model of psychological treatment, especially in stroke rehabilitation patients. this intervention allows for increased well-being, preventing increased psychological problems, self-esteem, selfefficacy, and self-confidence. previous research using a randomized controlled trial (rct) design with a total of 118 patients showed that interventions by making visual arts actively improve depression, quality of life, and self-awareness when compared with post-stroke care in general (jh morris et al., 2019). art therapy can help post-stroke patients to vent conflicts and emotions thereby reducing mental and emotional problems. the benefit of art interventions, especially drawing, is neurorehabilitation based on the hebbian principle of neuroplasticity. this principle explains that the existence of multimodal stimulation will result in the activation of neurons. activation of such neurons leads to increased synaptogenesis. creative arts therapy or creative art therapy (cat) improves mood, physical function, quality of life, concentration, and self-motivation in post-stroke patients. a cohort study in korea on post-stroke patients using color in art interventions showed an increase in life goals variables (wijeratne et al., 2022). art therapy in the context of visual art interventions in the form of drawing or painting in post-stroke patients with psychological problems is rarely studied. so this article aims to conduct a systematic literature review on the use of visual arts interventions in post-stroke patients on psychological responses. methods this study is a systematic literature review that aims to find, analyze, and conduct a discussion on the literature on the effectiveness of drawing art interventions on psychological responses in stroke patients. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.183-194 185 search strategies and data sources article searches were performed on the pubmed, sciencedirect, and other search results databases. the search uses “and” and “or” to find articles with the keywords “art therapy” or “creative art” and “stroke” or “after stroke” or “aphasia”. keyword search based on the title and abstract of the article. the total number of articles is 306, 424 from the mentioned database. the results of the search articles were selected by selecting full text, reviews, and publications between 2008 and 2022 with a total of 24,253 articles. a total of 24,245 articles were excluded because they were not relevant to the study objectives and did not have access to the full text, so they received 8 articles for review. selection criteria of the studies the inclusion criteria in this study were research studies conducted from 2008 to 2022, studies involving the effectiveness of the art of drawing or painting on psychological responses and/or post-stroke patients, as well as quantitative studies with empirical designs, qualitative studies, and case reports. while the exclusion criteria in this study were experimental studies on animals, and literature review. the search result data is entered into mendeley and identified based on the prisma 2020 flow diagram using microsoft word. several items were cataloged to be presented in the results, namely: article title, author, year of publication, type of research, subject, variable, intervention, analysis, and results. this study uses the pico conceptual framework to define the clinical question or problem of the study. the pico conceptual framework in this study is as follows: p (population): post-stroke patients or stroke survivors i (intervention): art therapy (drawing or painting) c (comparison): none o (outcome): psychological response quality appraisal study articles were selected using an article quality assessment. quality appraisal or quality assessment of various included studies uses the joana briggs institute (jbi) critical appraisal tools. the selected articles were then entered into the mendeley program for review. results search results for articles from various databases with prisma guidance resulted in 306,424 articles for inclusion in the study. after the selection process was carried out, there were 8 articles to be included in the study. records identified from*: pubmed (n = 650) proquest (n = 300,351) sage (n = 5,423 ) records removed before screening: duplicate records removed (n = 282,068 ) records marked as ineligible by automation tools (n = 83,501 ) records removed for other reasons (n = 103 ) identification of studies via databases and registers id e n ti fi c a ti o n https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.183-194 186 records screened (n = 24,253) records excluded** (n = 24,230) reports sought for retrieval (n = 23) reports not retrieved (n = 5) reports assessed for eligibility (n = 18) reports excluded: different study designs (n = 3) literature reviews (n = 4) different interventions (n = 3) studies included in review (n = 7) reports of included studies (n = 1) s c re e n in g in c lu d e d figures1prisma 2020 flow diagrams https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.183-194 187 table1 literature review no. title and author method results 1. creative art therapy to enhance rehabilitation for stroke patients: a randomized controlled trial (kongkasuwan et al., 2016) design rct with blinded assessor subject there are 113 stroke inpatients aged ≥50 years who can communicate verbally variable a. creative arts therapy b. rehabilitation of stroke patients intervention treatment group: conventional physical therapy program 5 days/week (20 sessions) for 1-2 hours/day and creative art therapy 1.5-2 hours with 5-10 patients in 1 group (total 8 sessions) control group: physical therapy only analysis differences between the two groups using unpaired t-test and chisquare analysis for categorical data. the mean difference for the intervention group was significantly higher than for the control group on depression(-4.5, 95% ci 6.5, -2.5, p<0.001), physical function (1.2, 95% ci 0.1, 2.3, p=0.043), and quality of life (8.9, 95% ci 3.8, 13.8, p< 0.001). when compared to baseline measurements, both groups experienced improvements in cognition, physical function, and quality of life and decreases in anxiety and depression. 85% of respondents were satisfied with creative art therapy and reported an increase in concentration (68.5%), emotion (79.6%), selfconfidence (72.2%), and motivation (74.1%). 2. art participation for psychosocial wellbeing during stroke rehabilitation: a feasibility randomized controlled trial (jh morris et al., 2019) design single blind randomized controlled trialor randomized controlled trials subject patients diagnosed with stroke during the rehabilitation period were in the treatment group n = 41 and the control group n = 40 variable a total of 81 participants (29%) took part in the study from 315 populations. 88% (n=71) of participants completed the session, and 77% (n=62) followed up. completion of study results varies from 97% and 77%. the level of effectiveness cannot be determined from this study but the impact size shows that participation in the arts https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.183-194 188 no. title and author method results a. participate in activities to create works of art b. psychosocial well-being intervention art interventions (drawing, collage, printing, painting, and mixed media techniques). the number of sessions is 8 analysis covariance analysis to analyze group variability, magnitude, and mean is capable of providing benefits to emotional wellbeing, positive and negative affect, and selfefficacy towards art. 3. fight like a ferret: a novel approach of using art therapy to reduce anxiety in stroke patients undergoing hospital rehabilitation (ali et al., 2014) design pilot study subject a total of 6 stroke patients are in rehabilitation at the sussex rehabilitation center (src), princess royal hospitalhaywards health. subjects aged >16 years, have the ability to give informed consent in the study, medically stable condition. variable a. art therapy b. anxiety and depression intervention art therapy by drawing and painting using white paper, pencils, crayons, making figures with clay, digital art using an ipad, and doing photography using a camera. subjects were intervened for 6 weeks, with 2 sessions/week with a duration of 50 minutes/session. six male subjects with an average age of 69 years (38-85). group discussions help the subject to express feelings openly, namely frustration and hopes for physical and emotional rehabilitation: "fight like a ferret", an expression used by the group. the group in the study produced several art and photographic objects to be made into a film. the median score for the hospital anxiety and depression scales (had) in the group was 8 (abnormal) at the start of the study, and changed to 6 at the end of the study (normal). https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.183-194 189 no. title and author method results analysis thematic analysis, crossreferenced. 4. social context, art making processes and creative output: a qualitative study exploring how psychosocial benefits of art participation during stroke rehabilitation occur (j. morris et al., 2016) design the exploratory qualitative approach study uses an in-depth semi-structured interview subject subjects consisted of 3 artists and 11 non-artists participants (n=14) variable a. psychosocial benefits of art b. stroke rehabilitation intervention tayside creative engagement intervention(tcei): identifying and generating ideas, working with materials and creating works of art about something lost during a stroke. the intervention was carried out for 8 weeks, 8 sessions, 40 minutes/session. analysis interview data were recorded in audio and transcribed, a systematic approach to data management and using vivo 9.2, thematic analysis. the framework approach is used to identify themes and develop a conceptual scheme. non-medical and social contexts in art facilitate social interaction, provide pleasure, distraction from stroke, and rebuild social identity thereby elevating mood. the process of making art creates selfconfidence and selfefficacy, creative attainment, communication, and physical recovery and control over experienced situations and expectations. creative output involves completing a work of art and displaying the work. it maximizes self-esteem and elevates mood, creating a new identity through positive judgment. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.183-194 190 no. title and author method results 5. promoting holistic wellbeing in chronic stroke patients through leisure art-based creative engagement (sit et al., 2017) design this study uses a qualitative design subject a total of 24 post-stroke patients participated in the study using purposive and snowball sampling variable a. holistic wellbeing in stroke patients b. leisure art-based creative engagement intervention leisure art-based creative engagementfor 7 weeks, 7 sessions, 2.5 hours/session. analysis the analysis was carried out by qualitative content manually through an iterative process a total of 24 participants completed the study: 4 themes emerged from the study subjects' experiences with lace: 1) appreciation of opportunity; 2) appreciation of yourself; 3) appreciation of others; 4) appreciation of life. from the perspective of the participants, it shows that lace maximizes the process of self-expression and enjoyment. furthermore, lace creates affirmations for life and empowers the process of strengthening connection and appreciation with oneself and others. 6. the effects of art and craft activities on anxiety and stress of stroke patients (hoons, 2019) design experimental study with intervention group and control group subject patients diagnosed with stroke, 9 patients received interventions for making art, and 9 patients as a control group received conventional occupational therapy. variable a. effects of arts and crafts activities b. anxiety and stress in stroke patients intervention the intervention was carried out for 30 minutes/session, the results of the study based on the comparison of the two groups showed that the intervention group had more significant results on anxiety and stress (p<0.05). these results demonstrate that arts and crafts activities can reduce anxiety and stress in stroke patients https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.183-194 191 no. title and author method results 3x/week, for a total of 8 weeks. analysis the study uses the t-test 7. art therapy outcomes in the rehabilitation treatment of a stroke patient: a case report (kim et al., 2008) design case report subject patients with subarachnoid hemorrhage due to ruptured cerebral aneurysm variable a. drawing therapy b. stroke rehabilitation patient intervention drawing therapy for 10 weeks, 2x/week, 40 minutes/session analysis descriptive drawing therapy assists patients in increasing emotions and meanings, as well as monitoring emotions and meanings that cannot be detected with conventional rehabilitation therapy. the results of the mmse, mvpt, and psychological tests showed an increase in visual perception and meaning, motor activity, and function as a secondary effect. studies conclude that art therapy can have a positive effect on chronic stroke patients. 8. without words: relational neuropsychology and creative arts therapies with people managing aphasia (chilcote, 2021) design case studies with quantitative and qualitative approaches subject two post stroke participants with aphasia variable a. creative arts therapy b. cognitive and clinical therapeutics intervention creative arts psychotherapy 5-6 sessions (weekly), 75 minutes/session. materials use crayons, paper, watercolors, pencils, etc. analysis wab-r aq program, linguistic inquiry and wird ciunt (liwc), creative arts therapyon cognitive impact shows significantly that there are perceptual-motor changes, executive function, memory, differences in limitations on language production. meanwhile, the clinical therapeutic results show an increase in mood, involvement, and relational experiences. https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.183-194 192 discussion the results of the article search found 8 studies to be reviewed. this study aims to identify and discuss the benefits and effectiveness of visual arts interventions on psychological responses in stroke survivors. kongkasuwan et al. (2016) conducted a study of 113 patients with the intervention group receiving conventional therapy and creative arts therapy and the control group only receiving conventional therapy. the study showed that art therapy 2 times a week in combination with conventional physical therapy 5 times a week for 4 weeks reduced depression, improved function and quality of life. art therapy can affect patient well-being, combat and prevent self-isolation, and improve stroke patient expectations. jh morris et al. (2019)conducted a single-blind study with a randomized controlled trial in the form of a visual art intervention for 1 session/week with artists and 1 session with other respondents and the intervention was carried out in 8 sessions. the results show that art interventions in stroke patients during the rehabilitation period can be carried out and can improve post-stroke patient welfare, positive affect, and self-efficacy. however, the challenges of art interventions require adjustments and ensuring that participants are really interested in participating in research until the final stage. research results byjh morris et al. (2019) also corroborated by previous studies conducted byali et al. (2014) that art therapy can and should be done in hospital rehabilitation for stroke patients. art therapy has been shown to facilitate emotional support for participants, assist them in expressing themselves, and socializing with other participants. participants in the study also received safe facilities in expressing their worries and fears about the future, engaging in creative and memorable activities. respondents also learned new things such as using an ipad to create digital images. j. morris et al. (2016) in his qualitative study shows that participation in art for stroke rehabilitation patients stimulates positive mood, gets pleasure through the process of making art, and regenerates his social identity. art therapy also provides distraction from the effects of illness, increases self-esteem, helps in communicating through art, trains the upper extremities that are affected through art, and increases confidence in creating works of art and in life. art therapy for stroke patients can also be performed by nurses on the basis of jean watson's caring theory. the theory is proved by sit et al. (2017) that creative art-based activities are a suggestion in providing caring to stroke patients. this arts-based intervention maximizes patients' self-expression, enjoyment, strengthening self-appreciation, connection with others, and affirmation of life. creative art therapy can also be a caring modality to restore harmony between one's mind and body, especially in stroke patients. brain damage in patients often results in anxiety, depression, decreased self-esteem as a result of a person's decreased capabilities. based on study studies by hoons (2019) showed that arts and crafts activities can reduce anxiety and stress in stroke patients. this is reinforced by previous studies by kim et al. (2008) that art therapy provides strong motivation for patients to increase capacity in daily life and through art-making activities that involve motor function, visual perception, and cognitive function. in addition to the positive impact on psychology, other benefits of art therapy have been proven by chilcotes (2021) that such therapy train cognitive function, perceptual-motor, executive function, and memory. conclusion visual arts therapy with various methods such as drawing, painting, and digital has proven to be effective for psychological responses in stroke sufferers. the benefits and effectiveness of visual arts therapy can be felt from 7 to >20 sessions. visual arts therapy can https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.183-194 193 and/or is appropriate in the hospital for post-stroke patients. apart from having a positive impact on psychology, visual arts therapy can also train motor, cognitive, and memory functions in post-stroke patients. references ali, k., gammidge, t., & waller, d. (2014). fight like a ferret: a novel approach of using art therapy to reduce anxiety in stroke patients undergoing hospital rehabilitation. medical humanities, 40(1), 56–60. https://doi.org/10.1136/medhum-2013-010448. chan, c. k. p., lo, t. l. t., wan, a. h. y., leung, p. p. y., pang, m. y. c., & ho, r. t. h. (2021). a randomised controlled trial of expressive arts-based intervention for young stroke survivors. bmc complementary medicine and therapies, 21(1), 1–10. https://doi.org/10.1186/s12906-020-03161-6. chilcote, a. m. (2021). without words: relational neuropsychology and creative arts therapies with people managing aphasia. proquest dissertations and theses, 141. https://www.proquest.com/dissertations-theses/without-words-relationalneuropsychology-creative/docview/2562842608/se-2?accountid=15083. frey, j., najib, u., lilly, c., & adcock, a. (2020). novel tms for stroke and depression (notsad): accelerated repetitive transcranial magnetic stimulation as a safe and effective treatment for post-stroke depression. frontiers in neurology, 11(august), 1–7. https://doi.org/10.3389/fneur.2020.00788. gu, s. y., & chang, m. c. (2017). the effects of 10-hz repetitive transcranial magnetic stimulation on depression in chronic stroke patients. brain stimulation, 10(2), 270– 274. https://doi.org/10.1016/j.brs.2016.10.010. hoon, k. j. (2019). the effects of art and craft activities on anxiety and stress of stroke patients. journal of digital convergence, 17(11), 251–258. kim, s. h., kim, m. y., lee, j. h., & chun, s. (2008). art therapy outcomes in the rehabilitation treatment of a stroke patient: a case report. art therapy, 25(3), 129– 133. https://doi.org/10.1080/07421656.2008.10129593. kongkasuwan, r., voraakhom, k., pisolayabutra, p., maneechai, p., boonin, j., & kuptniratsaikul, v. (2016). creative art therapy to enhance rehabilitation for stroke patients: a randomized controlled trial. clinical rehabilitation, 30(10), 1016–1023. https://doi.org/10.1177/0269215515607072. mare, a. c. b., pudjonarko, d., & sujianto, u. (2019). art therapy on anxiety and depression in post-stroke patients. proceeding of the international nursing conferen e on chronic disease management, 8, 223–227. morris, j. h., kelly, c., joice, s., kroll, t., mead, g., donnan, p., toma, m., & williams, b. (2019). art participation for psychosocial wellbeing during stroke rehabilitation: a feasibility randomised controlled trial. disability and rehabilitation, 41(1), 9–18. https://doi.org/10.1080/09638288.2017.1370499. morris, j., toma, m., kelly, c., joice, s., kroll, t., mead, g., & williams, b. (2016). social context, art making processes and creative output: a qualitative study exploring how psychosocial benefits of art participation during stroke rehabilitation occur. disability and rehabilitation, 38(7), 661–672. https://doi.org/10.3109/09638288.2015.1055383. sit, j. w. h., chan, a. w. h., so, w. k. w., chan, c. w. h., chan, a. w. k., chan, h. y. l., fung, o. w. m., & wong, e. m. l. (2017). promoting holistic well-being in chronic stroke patients through leisure art-based creative engagement. rehabilitation nursing, 42(2), 58–66. https://doi.org/10.1002/rnj.177. ting lo, t. l., lee, j. l. c., & ho, r. t. h. (2018). creative arts-based therapies for stroke https://thejnp.org/ journal of nursing practice https://thejnp.org/ issn: 2614-3488 (print); 2614-3496 (online) vol.6 no.2. april 2023. page.183-194 194 survivors: a qualitative systematic review. frontiers in psychology, 9(sep), 1–12. https://doi.org/10.3389/fpsyg.2018.01646. wijeratne, t., sales, c., & wijeratne, c. (2022). a narrative review on the nonpharmacologic interventions in post-stroke depression. psychology research and behavior management, 15(july), 1689–1706. https://doi.org/10.2147/prbm.s310207. https://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.77-88 77 determinant factor of childhood basic immunization compliance during the covid-19 pandemic in jambi city, jambi province, indonesia anita rezeki carolina1, defi efendi2,3*, maria dyah kurniasari4 1faculty of nursing, universitas indonesia, west java, indonesia 2pediatrics department, faculty of nursing, universitas indonesia, west java, indonesia 3neonatal intensive care unit (nicu), universitas indonesia hospital, west java, indonesia 4faculty of medicine and health science, universitas kristen satya wacana, central java, indonesia corresponding author: defiefendi@ui.ac.id abstract background: the coverage of immunization among children in jambi city decreased during covid-19 pandemic. purpose: this study aimed to identify the factors that might be associated with basic vaccination compliance among mothers in jambi, indonesia. methods: this study uses a case control design in 5 jambi city regions in march-may 2021. the sample in this study is mothers who have children in age 9-24 months. the sampling that is used in this study is cluster sampling with total sample of 506 mothers. the data analysis used in this study is descriptive statistical analysis of univariate, bivariate using chi square test. results: the results of data analysis showed that the variables related to compliance were perceptions of receiving immunization, attitudes, knowledge, husband's support with p value < 0.01, and distance traveled with p value < 0.05. conclusion: effort to improve compliance in the pediatric immunization pandemic are needed to strengthen mother’s perception, knowledge, attitudes during covid-19. analysis with predictive models is highly recommended to determine the odd-ratios and adjusted oddratios between factors related to the complying for basic vaccination. keywords: childhood basic immunization, compliance, covid-19 pandemic, factor. received june 29, 2021; revised july 12, 2021; accepted july 17, 2021 doi: https://doi.org/10.30994/jnp.v5i1.154 the journal of nursing practice, its website, and the articles published there in are licensed under a creative commons attributionnoncommercial-sharealike 4.0 international license. http://thejnp.org/ mailto:defiefendi@ui.ac.id https://doi.org/10.30994/jnp.v5i1.154 journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.77-88 78 background since the covid-19 outbreak was declared as global pandemic by who on march 11, 2020, immunization coverage for children around the world has been affected (andrews, et al 2020). who stated, 5.7 million babies did not get complete basic immunization, in the first four months of 2020 (irawati, 2020). this is supported by the research of macdonald, et al (2020) which stated that the covid-19 pandemic caused disruption of routine immunization programs, including reduction in visits and timeliness immunization for children. a quick survey conducted by unicef and the ministry of health of 7558 parents in indonesia, stated that 84% of immunization services were disrupted due to the covid19 pandemic. disruption to immunization services is caused by various reasons, such as a lack of understanding of the ministry of health guidelines, the number of health facilities that close immunization services, and the high risk of covid-19 transmission in health facilities (kartini, et al 2021; mukhi & medise, 2021; kemenkes & unicef, 2020; aji patriawati, 2020). the immunization coverage rate in indonesia in january-august 2020 showed a significant reduction starting from 0.5%-87% (nurhasanah, 2021). according to the badan pusat statistik ri (2020) the percentage of children aged 12-23 months who received complete basic immunization in jambi province in 2018-2020 sequentially, namely: 2018 (65.09%), 2019 (52.57%), 2020 (50.44%) , this shows that the coverage rate is low and has decreased significantly every year. the percentage of basic immunization coverage in 2020 in jambi city also showed a decrease of 7.1% compared to the same period in 2019, this was influenced by the covid-19 pandemic situation which required the termination of services at posyandu and a reduction in the frequency of services in various health facilities (dinas kesehatan provinsi jambi, 2020). the decline in immunization services occurred in almost all health facilities serving immunizations, one of which was the work area of the jambi city coffee garden health center. the number of children under two years old (baduta) who received complete basic immunization in 2020 in this work area was 620 baduta (48%), this shows that the achievement rate is still far from the set performance target of 1,287 baduta (data internal puskesmas kebun kopi kota jambi, 2020). a study conducted in one of the provinces in indonesia reported that education level, socioeconomic status, and ability to access health facilities were significantly associated with higher immunization coverage (maharani & kuroda, 2018). however, information about factors related to complete basic immunization status in children aged 12-23 months in indonesia is still very minimal, especially during the covid-19 pandemic (efendi et al., 2020). in addition, investigating the link between maternal compliance in immunization can be a strategy to increase immunization coverage rates. therefore, this study aims to examine factors related to maternal compliance in providing basic immunization to children aged (924 months) in jambi city. objective this study aims to explain the factors that influence maternal compliance in providing basic immunization to children aged 9-24 months during the covid-19 pandemic. methods research design this study is a community-based retrospective case-control study to identify the distance of their living home to the health facility center, perception, attitude, knowledge, husband support on basic vaccination compliance among mother in indonesia. http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.77-88 79 sample and setting the study was conducted in jambi city, indonesia, between march-may 2021. there were five region from two community health centers in jambi city, which were randomly selected. we recruited 506 eligible participants based on the study criteria. the inclusion criteria of mothers who meet basic immunizations include: 1) respondents are able to write and read. 2) respondents are mothers aged under two years (9-24 months) in jambi city. 3) have a complete history of giving basic services to children at local health services (puskesmas or hospitals). 4) respondents have a health card (kms) or kia book. the inclusion criteria of mothers who did not comply with basic vaccination as controls in this study were: 1) mothers did not monitor their child's monitoring and did not have records. 2) the child suffers from a disorder that cannot be immunized, such as malignancy or hiv aids. research instrumen demographic data were collected using a self-designed questionnaire survey containing participant’s demographic characteristics, including total number of their children, religion, educational level, family income, transportation access, health insurance, history of experience for child basic immunization, health protocol facility, health professional support (molan, 2020; buffarini et al., 2020; kemenkes ri, 2020; herliana & douiri, 2017; eb et al., 2016; nainggolan, 2014; hu et al., 2014; waluyanti, 2009). parity was the amount of maternal history in child birth (fiandany erynda et al., 2020). the measuring instrument used was a questionnaire adapted by research molan (2020), buffarini et al., (2020), eb et al., (2016), and hu et al., (2014) with the classification of birth order as follows: first, second, third or more. family income was the total amount of husband and wife income earned for the type of work done in each month (fiandany erynda et al., 2020). the division of categories in family income, based on the jambi provincial minimum wage (ump) value of rp. 2.630.162 (setiawan, 2021). the measuring instrument used was a questionnaire. the scale of the data was continuous, to facilitate analysis, the data was converted into dichotomous coded 0= < ump (<rp 2.700.000); 1= > ump (≥ rp 2.700.000). based on the mother's ease of access to health facilities which consists of two categories, namely (nainggolan, 2014): 0 = easy (cars, bicycles, motorbikes, public transportation, and others); 1 = difficult (walking, bicycle, boat, air transportation, etc.). the questions were adapted from the 2013 riskesdas questionnaire on households and individuals. insurance coverage represented any health insurance provided through social security or local government, by employer, privately purchased or other insurance (herliana & douiri, 2017). the measuring instrument used was a questionnaire with the following classification: 1 = does not have health insurance; 1 = have health insurance (herliana & douiri, 2017; waluyanti, 2009). immunization experience is the experience of giving complete basic immunizations to previous children, where children are given immunizations from the age range of 0-9 months (kemenkes & gavi, 2015). previous immunization experience was explored by asking about the completeness of immunization in previous children which was adapted from research (waluyanti, 2009) with the following categories: 0 = no experience; 1 = complete; 2 = incomplete. health protocol facilities are all forms of health protocol facilities that are used to manage each patient and protect patients and health workers from a dangerous environment (agarwal et al., 2020). this research instrument was compiled based on technical guidelines for services during the covid-19 pandemic by kemenkes ri (2020), which consisted of 5 questions. based on the instrument validity test, all question items were declared valid (r http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.77-88 80 count > r-table = 0.278) with a cronbach alpha value of 0.676, meaning that the questions in this study were declared reliable. based on the number of scores, it is classified into 2 categories: 1) adequate = score > median; 2) inadequate = score < median (median 5). health worker support is one of the social supports, in the form of information support related to health behavior (wau & razella, 2020). the research instrument used is a modified result of waluyanti research (2009) and has been modified according to the covid-19 pandemic situation. the results of the validity and reliability test stated that this item was valid (r count > 0.278) and reliable at an alpha of 0.681. based on the number of scores, classified into 2 categories: 1) support = score > median; 2) not supported = score < median (median 4). potential factors contributes to basic vaccination compliance among mothers, consist of: distance of their living home to the health facility center, perception, attitude, knowledge, and husband support. this study uses a survey questionnaire based on relevant and related studies and literature. distance of their living home to the health facility center calculated based on the distance to the nearest healthcare facility as the straight-line distance from a household to the healthcare facility, based on geographic coordinates, and this as 4 km categorized or 4 km, according to le polain de waroux et al., (2013) assuming that 5 km would roughly corresponds to an hour's walk. perception variable consists of a question regarding religious views on immunization, in this study the instrument used is a modification of the research of rachmawati & putri (2016). the results of the validity test in the research of rachmawati & putri (2016) stated that the item was valid with a calculated r value > r table and cronbach alpha 0.944 (r > 0.444) which stated that this item was reliable. variables were measured using a likert scale and classified according to 2 categories: 1) support = if > median; not support = if < median (median 4). attitude was the mother's response in the form of a statement of agree or disagree with the delivery of immunizations to her baby (fiandany erynda et al., 2020). the research instrument is a modified result of zuliani research (2016) and the instrument has also been modified to assess the attitude of mothers in carrying out immunizations during the covid19 pandemic. based on the validity test of the instrument, all question items were declared valid (r count > r table = 0.278) with a cronbach alpha value of 0.859, meaning that this instrument was declared reliable. knowledge instrument aims to measure the extent to which the mother's level of knowledge about immunization is the result of the information received and understood (fiandany erynda et al., 2020). the instrument used in this study is the result of a modification from the research of zuliani (2016) and matondang (2016). the researcher has also modified the question items by adding questions regarding mother's knowledge regarding immunization service policies during the covid-19 pandemic. mother's knowledge about immunization was assessed by giving 20 questions. a score of 1 was given if the mother answered the questions correctly and 0 if not. the average number of each question is calculated and categorized into three groups: 1) good, if the answer is between 76% 100%; 2) enough, if the answer is between 56% 75%; 3) less, if the answer is between <56% (asfaw et al., 2016: arikunto 2013). based on the validity test of the instrument, all question items were declared valid (r count > r table = 0.278) with a cronbach alpha value of 0.795, meaning that this instrument was declared reliable. husband support is any form of support or assistance provided by husband in providing immunizations to infants (fiandany erynda et al., 2020). this research instrument is a modified result of research conducted by matondang (2016), the researcher has also modified the question item by adding a question regarding husband's support regarding the implementation of immunization during the covid-19 pandemic. husband's support is measured by giving a score or weight with the following details: if the type of question is http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.77-88 81 positive) and the respondent's answer is yes, it is given a weight of 1 and if the answer is not, it is given a weight of 0, on the other hand, if the type of statement is negative and the respondent's answer is yes, it is given a weight of 0. not weighted. the assessments are categorized into three groups: 1) good, if the answer is between 76% 100%; 2) enough, if the answer is between 56% 75%; 3) less, if the answer is between <56% (arikunto 2013). data analysis a x2 test was used to examine the distributions of participant characteristics and the relationship between factors related to the basic vaccination compliance. continuous data such as total number of their children,dan jarak tempuh would be categorized based on the mean if the data was normally distributed. while, if the distribution was not normally distributed, the data would be categorized based on median number. however, since the data of (religion, education, occupation, income, health insurance ownership, previous immunization experience, and means of transportation) were not normally distributed, those data were categorized based on the median as the cut of points [49]. all statistical analyses were performed using the statistical package for the social sciences (spss) vers. 25.0 (chicago, il, usa). ethical consideration the study protocol was reviewed and approved by the institutional review board ethics committee (sk-76/un2.f12.d1.2.1/etik 2021) from faculty of nursing university indonesia and conformed to the provisions of the declaration of helsinki. written informed consent was obtained from each participant after they had received both verbal and written information about the research. results from the total of participants, there were significant differences in distributions between mothers who did not complying for basic vaccination and mother who complying for basic vaccination in the total number their children and education (table 1). as well, significant differences were found in the distributions of perceptiom, attitude, knowlegde and husband support (table 2). table 1. distributions of demographic characteristics between mothers who did not complying for basic vaccination and mother who complying for basic vaccination (n=506). characteristic did not complying for basic vaccination (n=262) (%) complying for basic vaccination (n=244) (%) p value total number of their children 1 104 (39.70%) 67 (27.50%) <0.05 2 87 (33.20%) 78 (32%) >2 71 (27.10%) 99 (40.60%) religion non moslem 22 (8.40%) 23 (9.40%) 0.75 moslem 240 (91.60%) 221 (90.60%) educational level college 198 (75.60%) 161 (66%) <0.05 http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.77-88 82 senior high school or below 64 (24.40%) 83 (34%) health insurance without health insurance 69 (26.30%) 63 (25.80%) 0.92 with health insurance 193 (73.70%) 181 (74.20%) family income < rp. 2.700.00,131 (50%) 118 (48.40%) 0.72 > rp. 2.700.00,131 (50%) 126 (51.60%) history of experience for child basic immunization without experience 81 (30.90%) 87 (35.70%) 0.49 did not complying for basic immunization 28 (10.70%) 22 (9.00%) complying for basic immunization 153 (58.40%) 135 (55.30%) health protocol facility low 47 (17.90%) 36 (14.80%) 0.34 good 215 (82.10%) 208 (85.20%) health professional support low 74 (28.20%) 59 (24.20%) 0.31 good 188 (71.80) 185 (75.80%) transportation difficult to access 11 (4.20%) 7 (2.90%) 0.47 easily accessed 251 (95.80%) 237 (97.10%) note. x2 test was used to compare between groups. table 2. distributions of potential risk factors contributes to basic vaccination compliance among mothers (n=506). characteristic did not complying for basic vaccination (n=262) (%) complying for basic vaccination (n=244) (%) p value distance > 4km 59 (22.50%) 36 (14.80%) <0.05 < 4km 203 (77.50%) 208 (85.20%) perception do not support basic vaccination compliance 96 (36.60%) 60 (24.60%) <0.01 support basic vaccination compliance 166 (63.40%) 184 (75.40%) knowledge low 95 (36.30%) 43 (17.60%) <0.01 good 167 (63.70%) 201 (82.40%) attitute not good 119 (45.40%) 85 (34.80%) <0.01 good 143 (54.60%) 159 (65.20%) http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.77-88 83 husband support low 168 (64.10%) 121 (49.60%) <0.01 good 94 (35.90%) 123 (50.40%) discussion this study concludes that mothers who lives with the distance of < 4km to health facility were had a positive relationship with the complying for basic vaccination with p value < 0.05. in this study, the result showed that distance to the public health facility to get the vaccination site was probably negatively associated with on-time full vaccination. this finding is consistent with studies in burkina faso, china, ethiopia, and tanzania (mekonnen et al., 2020; hu et al., 2014; le polain de waroux et al., 2013). thus, this further strengthened the argument that the time spent to reach the vaccination site expenses a high opportunity cost to caregivers by creating the need for multiple visits (mekonnen et al., 2020). distance also had a strong effect on timely hb-0 and bcg vaccination, where children born in the urban area were significantly more likely to be vaccinated on time. this is most likely explained by the fact that many children in the urban setting were born in health facilities, therefore vaccinations such as hb-0 and bcg-polio 1 will be given immediately after birth (hu et al., 2014). this study concludes that mothers who had the perception to support basic vaccination were complying for basic vaccination with p value < 0.01. the results of this study are related to the research of r. s. putri (2016) and hudhah & hidajah (2018) which stated that there was a significant relationship between perceptions of immunization reception according to the mother's beliefs and maternal compliance in giving immunizations to toddlers (p = 0.002). the influence in the results of this study was due to the fact that most of the respondents believed that immunization had a good impact on children and the beliefs held to provide support for immunization (hudhah & hidajah, 2018). parents who have anxiety about post-immunization events tend to refuse to get immunizations (sriatmi et al., 2019). similar results were also found in a survey conducted by the kementerian agama ri (2021) which showed that public confidence in vaccine safety, effectiveness, and side effects (66.13%) were the determining factors for compliance with the national vaccine program and perceived acceptance factors. immunization based on belief does not affect vaccination adherence. this study concludes that mothers who had good knowledge of vaccination were had a positive relationship with the complying for basic vaccination with p value < 0.01 compared to mother who had low level of knowledge of vaccination. this is in line with the research of dewi lisencia fitri et al., (2018), the results of this study indicate that there is a relationship between the level of knowledge and the completeness of pentavalent immunization. this is in accordance with research conducted by albertina & febriana (2016) in jakarta, latifah (2014) in tegal, luthfi (2014) in boyolali, nurbaya (2014) in kabupaten pangkep, and wijaya et al., (2013) in jakarta, which states that there is a relationship between the level of knowledge and completeness of immunization. the results of this study are also in line with research conducted by kiptoo (2015) which states that poor knowledge of immunization schedules significantly causes low immunization coverage in children aged 12-23 months (or = 9.04; 95% ci = 1.37 to 7.87; p = 0) and research smith et al. (2017) which states that one of the factors that influence immunization coverage is vaccine knowledge. the reason parents do not give vaccines is because they have the wrong knowledge about the vaccination schedule, lack of knowledge about vaccines or where to get it, believe that the previous vaccine dosage is still effective and feel just one vaccine http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.77-88 84 dose is enough. this study concludes that mother's knowledge can influence their beliefs so that mothers will behave in accordance with their beliefs. good knowledge about basic immunization is expected to increase the awareness of mothers on the importance of giving basic immunizations in full to their children (erynda et al., 2020). this study concludes that mothers who had good attitude toward vaccination were had a positive relationship also with the complying for basic vaccination with p value < 0.01 compared to mother who had bad attitude toward vaccination. this is consistent with a study conducted by dewi lisencia fitri et al., (2018) di cipondoh, wijaya et al (2013) in jakarta, hartatik et al (2013) di tulangagung, emilya in padang (2017), and hudhah & hidajah (2018) in jawa timur also stated that there was a relationship between maternal attitude with the completeness of basic immunization. the results of this study are also in line with erynda et al., research (2020) which states that parents who have a negative attitude about immunization are 1.92 times more likely to not provide complete basic immunization to their babies than mothers who have a positive attitude. the researcher analyzed that the mother's attitude towards immunization was influenced by the high level of knowledge, husband's support, and perceptions of immunization reception according to the mother's religion. according to adhayani arda et al., (2018) and erynda et al., (2020) factors that influence respondents to have a negative attitude towards immunization are the mother's lack of knowledge about immunization, the less mother's knowledge about immunization, the greater the impact on the formation of a negative mother's attitude about immunization. a person's attitude is influenced by the knowledge he has, where the higher the level of knowledge a person has of a thing, the better the attitude he has of it (hudhah & hidajah, 2018). alport's theory also states that the formation of a person's attitude is influenced by 3 main components, namely beliefs or perceptions of certain concepts, emotional life or one's evaluation of objects, and the tendency to act (notoatmodjo, 2014), so that a person's attitude cannot stand alone in influencing compliance behavior. , there are other factors that support the occurrence of attitudes, one of which is the belief or perception factor (hudhah & hidajah, 2018). as the results in this study which states that mothers who have a perception of receiving immunization significantly support maternal compliance. in addition, attitudes can be influenced by personal experience factors, the influence of others who are considered important, the influence of culture, mass media, religious institutions and emotional factors (erynda et al., 2020). this study concludes that mothers who were supported by their husband were significantly with p value < 0.01 positively related with the complying for basic vaccination. this is in line with research conducted by erynda et al., (2020), senewe et al., (2017), and arista & hozana (2016) which state that there is a relationship between husband's support and a history of giving basic immunizations to infants. husband's support is an important factor in healthy behavior. husbands who believe in the benefits of immunization for their babies will support their wives to make optimal use of health services. husband's support can be in the form of providing information to mothers about immunization, accompanying mothers to immunize their babies, and helping mothers take care of babies after getting immunizations (senewe et al., 2017). the results of this study concluded that if the husband supports the mother in providing complete immunization for her baby, then the mother tends to have positive attitudes and behaviors in providing complete immunization for her baby. on the other hand, if the husband does not provide support, it will be difficult for a mother to fully immunize her baby (erynda et al., 2020). this is supported by the theory put forward by soekidjo notoatmodjo which states that to realize an attitude into a real action, it is necessary to have supporting factors that come from the family, one of which is the husband's support (igiany, 2020). the support of a husband will facilitate mothers in changes http://thejnp.org/ journal of nursing practice http://thejnp.org issn: 2614-3488 (print); 2614-3496 (online) vol.5 no.1. october 2021. page.77-88 85 in behavior, including compliance in implementing the basic immunization (jayanti et al., 2017). conclusion the results of data analysis showed that the variables related to maternal compliance in basic immunization were perceptions of immunization reception, attitudes, knowledge, husband's support with p value < 0.01, and distance with p value < 0.05. increasing mother's knowledge indirectly has an positive impact on the formation of attitudes and perceptions of mothers towards immunization reception. therefore, researchers suggest that the strengthening of mother's knowledge continues to be carried out, both in the form of health education activities at the family and community levels. in addition, ensuring that all health service providers open immunization services during the covid-19 pandemic can also increase immunization coverage rates, especially in posyandu services while still involving husband's support in its implementation. this study has several limitations by using a case-control research design, making it difficult to produce a causal relationship between predictors and outcome variables. this study did not analyze the relationship factors related to maternal characteristics, such as age, education level, occupation, history of childbirth (antenatal care, birth attendant, health facilities used, etc.) all of which may affect immunization compliance. however, the possibility of information bias on maternal compliance did not occur, because the researchers directly observed and documented the child's immunization records listed in the kms or kia books. analysis with predictive models is highly recommended to determine the odd-ratios and adjusted odd-ratios between factors related to the complying for basic vaccination. acknowledgments the authors would like to thank the participants of this study and to puskesmas kebun kopi dan kebun handil for helping researchers during the data collection process. conflicts of interest the authors declare that there is no conflict of interest. references adedire, e. b., ajay, i., fawole, o. i., ajumobi, o., kasasa, s., wasswa, p., & nguku, p. 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